RQA^I08
RQA/RPA - Request for treatment authorization information
Patient Referral
This event triggers a message to be sent from a healthcare provider to a payor requesting authorization to perform specific medical procedures or tests on a given patient. The specific medical procedures must be filled out in the PR1 segments. Each repeating PR1 segment may be paired with an AUT segment so that authorization information can be given regarding dollar amounts, number of treatments, and perhaps the estimated length of stay for treatment. The OBR and OBX segments should be used to include any relevant clinical information that may be required to support or process the authorization.
Message Types
Message Type
Trigger Structure
Return Structure
Event Flow
TriggerI08
SendRQA_I08
ReceiveRPA_I08
Worked Examples
11.6.2 RQA message using an I08 event with an immediate response
When the attending physician decides to refer the patient for treatment to another healthcare provider, pre-authorization may be required by the payor. In the following RQA example, Dr. Blake is requesting the appropriate pre-authorization from Washington State Insurance Company for a colonoscopy on Cary Joe Brown. The request includes the diagnosis, in case it is a factor in the approval decision. As shown below, the immediate response indicates approval of the request that was made on 01/10/94 and that expires on 05/10/94. In actuality, most payors require some human intervention in the pre-authorization process and would probably not respond immediately.
HL7 v2
MSH|^~\&|BLAKEMD|EWHIN|MSC|EWHIN|19940110105307||RQA^I08|BLAKEM7898|P|2.3|||NE|AL
PRD|RP|BLAKE^BEVERLY^^^DR^MD|N. 12828 NEWPORT HIGHWAY^^MEAD^WA^99021| ^^^BLAKEMD&EWHIN^^^^^BLAKE MEDICAL CENTER|BLAKEM7899
PRD|RT|WSIC||^^^MSC&EWHIN^^^^^WASHINGTON STATE INSURANCE COMPANY
PID|||402941703^9^M10||BROWN^CARY^JOE||19600309||||||||||||402941703
IN1|1|PPO|WA02|WSIC (WA State Code)|11223 FOURTH STREET^^MEAD^WA^99021^USA|ANN MILLER|509)333-1234|987654321||||19901101||||BROWN^CARY^JOE|1|19600309|N. 12345 SOME STREET^^MEAD^WA^99021^USA|||||||||||||||||402941703||||||01|M
DG1|1|I9|569.0|RECTAL POLYP|19940106103500|0
PR1|1|C4|45378|Colonoscopy|19940110105309|00
MSH|^~\&|MSC|EWHIN|BLAKEMD|EWHIN|19940110154812||RPA^I08|MSC2112|P|2.3|||ER|ER
MSA|AA|BLAKEM7888
PRD|RP|BLAKE^BEVERLY^^^DR^MD|N. 12828 NEWPORT HIGHWAY^^MEAD^WA^99021| ^^^BLAKEMD&EWHIN^^^^^BLAKE MEDICAL CENTER|BLAKEM7899
PRD|RT|WSIC||^^^MSC&EWHIN^^^^^WASHINGTON STATE INSURANCE COMPANY
PID|||402941703^9^M10||BROWN^CARY^JOE||19600301||||||||||||402941703
IN1|1|PPO|WA02|WSIC (WA State Code)|11223 FOURTH STREET^^MEAD^WA^99021^USA|ANN MILLER|(509)333-1234|987654321||||19901101||||BROWN^CARY^JOE|1|19600309|N. 12345 SOME STREET^^MEAD^WA^99021^USA|||||||||||||||||402941703||||||01|M
DG1|1|I9|569.0|RECTAL POLYP|19940106103500|0
PR1|1|C4|45378|Colonoscopy|19940110105309|00
AUT|PPO|WA02|WSIC (WA State Code)|19940110|19940510|123456789|175|111.6.3 RQA message using an I08 event with a deferred response
In the following example of a pre-authorization request, the payor indicates his receipt of the request (a standard acknowledgment message), but defers issuing a pre-authorization to a later time. This response represents a more typical payor transaction sequence. Note the use of the "Accept Acknowledgment Type," requiring the receiving system to respond in all cases to receipt of the message.
HL7 v2
MSH|^~\&|BLAKEMD|EWHIN|MSC|EWHIN|19940110105307||RQA^I08|BLAKEM7898|P|2.3|||AL|AL
PRD|RP|BLAKE^BEVERLY^^^DR^MD|N. 12828 NEWPORT HIGHWAY^^MEAD^WA^99021| ^^^BLAKEMD&EWHIN^^^^^BLAKE MEDICAL CENTER|BLAKEM7899
PRD|RT|WSIC||^^^MSC&EWHIN^^^^^WASHINGTON STATE INSURANCE COMPANY
PID|||402941703^9^M10||BROWN^CARY^JOE||19600301||||||||||||402941703
IN1|1|PPO|WA02|WSIC (WA State Code)|11223 FOURTH STREET^^MEAD^WA^99021^USA|ANN MILLER|(509)333-1234|987654321||||19901101||||BROWN^CARY^JOE|1|19600309|N. 12345 SOME STREET^^MEAD^WA^99021^USA|||||||||||||||||402941703||||||01|M
PR1|1|C4|45378|Colonoscopy|19940110105309|00
MSH|^~\&|MSC|EWHIN|BLAKEMD|EWHIN|1994011015315||MCF|MSC2112|P|2.3|||ER|ER
MSA|AA|BLAKEM7888
MSH|^~\&|MSC|EWHIN|BLAKEMD|EWHIN|19940111102304||RPA^I08|MSC2113|P|2.3|||ER|ER
MSA|AA|BLAKEM7888
PRD|RP|BLAKE^BEVERLY^^^DR^MD|N. 12828 NEWPORT HIGHWAY^^MEAD^WA^99021| ^^^BLAKEMD&EWHIN^^^^^BLAKE MEDICAL CENTER|BLAKEM7899
PRD|RT|WSIC||^^^MSC&EWHIN^^^^^WASHINGTON STATE INSURANCE COMPANY
PID|||402941703^9^M10||BROWN^CARY^JOE||19600301||||||||||||402941703
IN1|1|PPO|WA02|WSIC (WA State Code)|11223 FOURTH STREET^^MEAD^WA^99021^USA|ANN MILLER|509)333-1234|987654321||||19901101||||BROWN^CARY^JOE|1|19600309|N. 12345 SOME STREET^^MEAD^WA^99021^USA|||||||||||||||||402941703||||||01|M
PR1|1|C4|45378|Colonoscopy|19940110105309|00
AUT|PPO|WA02|WSIC (WA State Code)|19940110|19940510|123456789|175|1