To demonstrate how a Chiro Physio Pre-Determination is submitted and adjudicated when there are multiple insurers involved. A Pre-Determination identifies the products and/or services that may be provided in the future. The purpose of submitting a Pre-Determination with COB is to determine whether and how much of the costs will be covered by each insurer.

To demonstrate how a Generic Pre-Determination is submitted and adjudicated. A Pre-Determination identifies services that may be rendered in the future. The purpose of submitting a Pre-Determination is to determine whether the services will be covered as well as to identify an estimate for potential payment.

Interaction List

Pre-Det Request, Gen	FICR_IN500101UV01
Pre-Det Comp Results Comp, Gen	FICR_IN510101UV01

To demonstrate how a Pharmacy Pre-Determination is submitted and adjudicated. A Pre-Determination identifies services that may be rendered in the future. The purpose of submitting a Pre-Determination is to determine whether the services will be covered as well as to identify an estimate for potential payment.

Interaction List

Pre-Det Request, Rx	FICR_IN500102UV01
Pre-Det Comp Results Comp, Rx	FICR_IN510102UV01

To demonstrate how a Preferred Accommodation Pre-Determination is submitted and adjudicated. A Pre-Determination identifies accommodation that may be provided in the future. The purpose of submitting a Pre-Determination is to determine whether the costs will be covered as well as to identify an estimate for potential payment.

Interaction List

Pre-Det Request, PAccom	FICR_IN500103UV01
Pre-Det Comp Results Comp, PAccom	FICR_IN510103UV01

An application that is responsible for the submission of a Pre-Determination, Chiro Physio for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Generic for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Oral Health for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Pharmacy for pharmaceutical services provided and/or products delivered on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Physician for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Preferred Accommodation for varying types of accommodation on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Vision Care for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination for health care services provided and/or products delivered on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive only the Final Pre-Determination Results with no initial response from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Chiro Physio for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that is responsible for the submission of a Pre-Determination, Generic for health care services provided and/or products delivered by a generic benefits group on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination Results will be forwarded from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Oral Health for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that is responsible for the submission of a Pre-Determination, Pharmacy for pharmaceutical services provided and/or products delivered on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination Results will be forwarded from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Physician for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that is responsible for the submission of a Pre-Determination, Preferred Accommodation for varying types of accommodation on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination Results will be forwarded from the Pre-Determination Manager.

An application that is responsible for the submission of a Pre-Determination, Vision Care for varying services and/or products on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that is responsible for the submission of a Pre-Determinations for health care services provided and/or products delivered on behalf of one or more patients.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Pre-Determination Requestor will receive an initial response, which may contain partial results and an indication when the Final Pre-Determination Results will be forwarded from the Pre-Determination Manager.

An application that responds to a Pre-Determination, Chiro Physio with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Generic with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Oral Health with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Pharmacy with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Physician with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Preferred Accommodation with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Vision Care with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination Invoice by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination with the final Pre-Determination Results only.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

The Final Pre-Determination Results may arrive close to immediate (i.e. in the same query/response interaction) or may lag the Pre-Determination by a period of time (perhaps one or more days).

An application that responds to a Pre-Determination, Chiro Physio with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Generic with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Oral Health with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Pharmacy with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Physician with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Preferred Accommodation with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination, Vision Care with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application that responds to a Pre-Determination with Final Pre-Determination Results if possible. If Final Pre-Determination Results are not possible, then the Pre-Determination Manager may respond with Initial Pre-Determination Results that can include partial or incomplete processing results and an indication of when the Final Pre-Determination Results will be available.

When the Pre-Determination Manager, Initial/Final Results sends the Final Pre-Determination Results, they act as a Pre-Determination Notifier. This Application Role includes the Notifier Application Role.

A Pre-Determination itemizes products and/or services, which may or may not be delivered/performed in the future, in order to determine whether the items will be covered and to identify an estimate for potential payment. The Pre-Determination Manager (adjudicator) processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice. It must be noted that pre-determination results may only be accurate for that specific moment in time.

An application responsible for sending notification of Final Pre-Determination Results to a Pre-Determination Tracker.

An application responsible for sending notification of Final Pre-Determination Results, Chiro Physio to a Pre-Determination Tracker.

An application responsible for sending notification of Final Pre-Determination Results, Generic to a Pre-Determination Tracker.

An application responsible for sending notification of Final Pre-Determination Results, Pharmacy to a Pre-Determination Tracker.

An application responsible for sending notification of Final Pre-Determination Results, Physician to a Pre-Determination Tracker.

An application responsible for sending notification of Final Pre-Determination Results, Preferred Accommodation to a Pre-Determination Tracker.

An application responsible for tracking Pre-Determination Results from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

An application responsible for tracking Pre-Determination Results, Chiro Physio from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

An application responsible for tracking Pre-Determination Results, Generic from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

An application responsible for tracking Pre-Determination Results, Pharmacy from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

An application responsible for tracking Pre-Determination Results, Preferred Accommodation from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

An application responsible for tracking Pre-Determination Results, Physician from a Pre-Determination Notifier.

An example of a Pre-Determination Tracker could be a head office, accountant or a payee.

A trigger to send a Pre-Determination-Authorization Request for adjudication of services and/or products.

A Pre-Determination-Authorization itemizes services and/or products, which may be rendered in the future, in order to determine whether the items will be covered as well as to identify an estimate for potential payment. The Adjudicator processes the Pre-Determination-Authorization as if it were a real Invoice.

A Provider may also use a Pre-Determination-Authorization Request to compare alternate treatments to determine the least cost alternative for the patient.

A trigger to send a completed Pre-Determination-Authorization Result.

This trigger may be fired close to immediate (i.e., in the same submission/response interaction as the request) or may lag the request by a period of time (perhaps one or more days).

A Pre-Determination-Authorization identifies services and/or products that may be rendered in the future. The purpose of submitting a Pre-Determination-Authorization is to determine whether the Adjudicator will cover the services and/or products as well as to identify an estimate for potential payment.

These results are not an intent to pay; they are informational only. The results indicate items, which would be paid in full, partially paid or refused, with appropriate reason codes explaining why the item would or would not be paid.

A trigger to send an initial Pre-Determination-Authorization Result when the Adjudicator has completed an initial preprocessing of the Pre-Determination-Authorization Request.

Final results will come later (e.g. next day) as an unsolicited result.

The initial results may include preliminary edits such as patient identifier and date validation as well as patient eligibility validation. The initial results may also indicate when the final results may be expected.

A trigger to send a Pre-Determination Request for adjudication of services and/or products.

A Pre-Determination itemizes services and/or products, which may be rendered in the future, in order to determine whether the items will be covered as well as to identify an estimate for potential payment. The Adjudicator processes the Pre-Determination as if it were a real Invoice. The only difference between a Pre-Determination and a regular Invoice is that the final result (e.g. payment in full, partial pay) will not result in an actual payment. The Pre-Determination is a mock Invoice.

A Provider may also use a Pre-Determination Request to compare alternate treatments to determine the least cost alternative for the patient.

A trigger to send an initial Pre-Determination Results when the Adjudicator has completed an initial preprocessing of the Pre-Determination Request.

Final results will come later (e.g. next day) as an unsolicited result.

The initial results may include preliminary edits such as patient identifier and date validation as well as patient eligibility validation. The initial results may also indicate when the final results may be expected.

A trigger to send a completed Pre-Determination Result.

This trigger may be fired close to immediate (i.e., in the same submission/response interaction as the request) or may lag the request by a period of time (perhaps one or more days).

A Pre-Determination identifies services and/or products that may be rendered in the future. The purpose of submitting a Pre-Determination is to determine whether the Adjudicator will cover the services and/or products as well as to identify an estimate for potential payment.

These results are not an intent to pay; they are informational only. The results indicate items, which would be paid in full, partially paid or refused, with appropriate reason codes explaining why the item would or would not be paid.

A trigger that indicated that the Adjudicator has accepted responsibility for the Pre-Determination Nullify Request and will respond with completed results (accept, reject) at a later point (e.g. next day).

A trigger that indicated successful completion of a Pre-Determination Nullify Request. In other words, the request has been nullified.

A trigger to send a Pre-Determination Nullify Request.

The response to the request may be accepted or rejected, depending on the ability of the Adjudicator to nullify the request.

A trigger that indicated unsuccessful completion of a Pre-Determination Nullify Request. In other words, the request has NOT been nullified.

A trigger to send a Pre-Determination Query Request to determine the existence and status of a Pre-Determination Request.

For example, a chiropractor may wish to render a service similar to one submitted on a Pre-Determination the previous day. A Pre-Determination Query Request can be submitted to determine if the service item has been adjudicated and the processing results of the adjudication.

A Pre-Determination Query Request can be submitted during any stage of Pre-Determination processing: pre-adjudication, post-adjudication. The extent of information provided in the Pre-Determination Query Response will be impacted by the extent to which the Pre-Determination has been processed.

A trigger to send a Pre-Determination Query Response indicating the existence and status of a Pre-Determination Request.

Pre-Determination Query Response will be impacted by the processing stage of the Pre-Determination: pre-adjudication, post adjudication. The response will inform the Provider of the processing stage of the Pre-Determination and any available adjudication results. The closer the Pre-Determination processing is to completion, the more information will be provided in the response.

This model represents a message used to submit a Pre-Determination Request message from a healthcare product or services Provider (e.g. individual healthcare practitioner, healthcare facility, pharmacy, medical goods and supplies purveyors, etc.) to an Insurance Carrier (e.g. jurisdictional medical services plan, insurance organization, workers compensation organization and/or their agents).

An Insurance Carrier may delegate performance of this function to an Adjudicator (agent of the Insurance Carrier). Subsequent discussions only note Provider and Adjudicator (not Insurance Carrier).

The request is for the adjudication of possible future services (or supply of goods) to determine whether they would be covered and to obtain an estimate for the potential payment amount.

The 2 core classes referenced in the RMIM are the FinancialTransaction, cloned as the FinancialTransactionOrderPaymentRequest and the InvoiceElement, cloned as the InvoiceElementOrderGroup and InvoiceElementOrderDetail. As in an invoice, the Pre-Determination Request message can be made up of components that are independent requests for payment and adjudication.

A Pre-Determination Request is sent to the recipient identified in the message control wrapper, an Adjudicator. The Payor is identified through the DebitPayor to the A_Account CMET It is communicated as an FinancialTransactionIntentPayment (a FinancialTransaction in INT:intent mood) and an EventAdjudicationResults (an InvoiceElement in EVN:event mood).

To generate an Invoice (request for payment and adjudication), a FinancialTransactionOrderPaymentRequest (a FinancialTransaction in ORD:order mood), InvoiceElementOrderGroup (an InvoiceElement in ORD:order mood) and an InvoiceElementOrderDetail (an InvoiceElement in ORD:order mood) are created and related through Act Relationships and supported by a number of participations (e.g. patient, Provider, Payor, Payee).

The FinancialTransactionOrderPaymentRequest allows for a grouping of InvoiceElements and reflects the request for payment of a specified monetary amount. The FinancialTransactionOrderPaymentRequest indicates "Please Pay". The leaf level FinancialTransactionOrderPaymentRequest ties to an InvoiceElementOrderGroup; the items below the line (ReasonPaymentRequest) must be adjudicated together. In other words, each ReasonPaymentRequest separates independent billable items.

The InvoiceElement (both group and detail) are the elements of an Invoice that need to be adjudicated in order to determine any payment. There are 2 types of InvoiceElements: a group and a detail. The InvoiceElementOrderDetail identifies the pricing for a line item such as a drug, medical procedure, durable good or other billable item including adjustments (e.g. taxes, discounts, surcharges). The InvoiceElementOrderGroup allows for the grouping/collection of InvoiceElementOrderDetail's to make up a logical billable item. For example, a Pharmacy dispense may have a group with 2 details, one for the drug cost and the other for the dispense fee. Both must be present and can be grouped with an InvoiceElementOrderGroup.

Concluding, an Invoice is made up of one or more FinancialTransactionOrderPaymentRequest (Please Pay), connected to an InvoiceElement grouping, which contains one or more InvoiceElementOrderGroups and InvoiceElementOrderDetails. An Invoice may have multiple FinancialTransactionOrderPaymentRequests, with multiple InvoiceElementOrderGroups and InvoiceElementOrderDetails.

An Authorization may have been obtained for an InvoiceElementOrderDetail or InvoiceElementOrderGroup that is specified by the ConfirmationEventCoverage.

Included are the identification data for each of the participants, including Providers organization, practitioner organization, patient(s), insured party, Payor, Payee, Invoice author and target recipient individuals/organizations. The Payor is the party specified as financially responsible for the Invoice and the Payee the party that will receive any payment. Both of these participations are noted against the FinancialTransactionOrderPaymentRequest.

Patient(s) are identified as the Patient role for the InvoiceElementOrderGroup. There may be a single patient or an itemized group with individual insurance information.

Insurance information is included in the CoverageEventPolicyOrAccount and CoverageDefinition acts. Two major roles for an insurance policy are the PolicyHolder and CoveredPartyRole. There may be multiple CoveredPartys for a single insurance policy, with the CoveredParty role describing why the patient is covered by the insurance policy (e.g. spouse of PolicyHolder). Also, the IncidentEvent, LocationIncident and the R_LocationServiceDelivery CMET classes identify the accident (workplace, motor vehicle, etc. and its location) that is the basis for the coverage being referenced. The ObservationEventInjuryCoding is to specify the injuries related to the accident.

Specific data about the billable act (what was performed such as treatment procedures, practitioner identification, service location, etc.) are modeled separately and inserted into the appropriate message types created from this model. See the A_Billable CMET for the specific types of billable acts that can be inserted into the generic Invoice structure. Healthcare products and their packaging type and quantity are included through the Product participation against the InvoiceElementOrderDetail.

The Invoice may optionally reference a contract under which the billing is done (FinancialContractEvent), accident information (IncidentEvent, including incident type, location and nature of injuries) and attachments (ObservationEventAttachment) containing any form of supporting information.

When the claimant has multiple insurance coverages (own and through spouse or a child with both parents having coverage, etc.), the Invoice is sent in priority sequence based on insurance rules to each Payor with subsequent Payors receiving the Adjudication Results from the previous Payors. Each Payor is sent identical Invoice elements to adjudicate.

Multiple insurance coverages may be prioritized for coordination of benefits submissions. The EventAdjudicationResults from each Payor are forwarded to the next Payor to explain the outstanding amounts being claimed.

This model represents the message used to respond to a Pre-Determination Request from a healthcare product or services Provider (e.g. individual healthcare practitioner, healthcare facility, pharmacy, medical goods and supplies purveyors, etc.) to an Insurance Carrier (e.g. jurisdictional medical services plan, insurance organization, workers compensation organization and/or their agents).

An Insurance Carrier may delegate performance of this function to an Adjudicator (agent of the Insurance Carrier). Subsequent discussions only note Provider and Adjudicator (not Insurance Carrier).

A Pre-Determination results is communicated as a PaymentIntent (a FinancialTransaction in INT:intent mood) and one or more AdjudicationResults (an InvoiceElement in EVN:event mood). These are supported by participations for the Payor and Payee.

The Adjudicator responds to a FinancialTransactionOrderPaymentRequest (What might you Pay?) with an FinancialTransactionIntentPayment (I estimate that I would pay) that includes a set of EventAdjudicationResults explaining how each InvoiceElementOrderGroup and InvoiceElementOrderDetail on the Pre-Determination has been adjudicated indicating what they would cover (e.g. pay as submitted, pay as adjusted, reject, provide information). The EventAdjudicationResults may also indicate an estimated monetary amount if the item(s) were covered. Changes to Payor, Payee and insurance information, if applicable, may also be returned with the adjudication responses.

An EventAdjudicationResults may also reference related adjudication observations such as drug utilization reporting (DUR) information for drug interactions. This is specified using the A_AdjudicationObservation CMET; the CMET allows for multiple types of Adjudicator initiated adjudication observations to be included in an adjudication response to a Provider.

A reference to a ActOrderRequired to be performed by the provider organization, may also be made. This could be a requirement to print an Explanation of Benefits (EOB) to be supplied to the patient/covered party. Associated with this may be the specification of a print form to be used. This is done by using the RoleEOBPrintForm and ManufacturedMaterialForm classes.

This model represents a message used to submit a Pre-Determination Nullify message from a healthcare product or services Provider (e.g. individual healthcare practitioner, healthcare facility, pharmacy, medical goods and supplies purveyors, etc.) to an Insurance Carrier (e.g. jurisdictional medical services plan, insurance organization, workers compensation organization and/or their agents).

An Insurance Carrier may delegate performance of this function to an Adjudicator (agent of the Insurance Carrier). Subsequent discussions only note Provider and Adjudicator (not Insurance Carrier).

This message is a request to remove a specified previous request for Pre-Determination adjudication

The referenced Pre-Determination message was made up of one or more FinancialTransactionOrderPaymentRequests (What might you Pay?), connected to an InvoiceElement root grouping, which contains with one or more InvoiceElementOrderGroups and InvoiceElementOrderDetails. Each one of these root groups must be referenced in a separate nullify message. Only the identification data for the Providers organization, practitioner organization, Payor (the party specified as financially responsible for the Invoice) and the Payee (the party that will receive any payment) are required.

Other data that was included with the referenced Pre-Determination message is already in the possession of the recipient.

This model represents a message used to send a Pre-Determination Query Request message from a Provider (e.g. individual practitioner, healthcare facility, medical goods and supplies purveyor) to an Insurance Carrier (e.g. jurisdictional medical services plan, insurance organization, workers compensation organization).

An Insurance Carrier may delegate performance of this function to an Adjudicator (agent of the Insurance Carrier). Subsequent discussions only note Provider and Adjudicator (not Insurance Carrier).

It is used to request the status of a specific Pre-Determination Request.

A submitted Pre-Determination Request message is processed by an Adjudicator and the response communicated as an Invoice Adjudication Results message.

The Pre-Determination Query is a single parameter, the Invoice Element root Group identifier, from the Pre-Determination Request being queried.

This message is a specialization of the Pre-Determination that includes one or more Chiro Physio billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is a generic health care products/services Pre-Determination that includes one or more Clincal Product or Clinical Service billable act(s) identifying products/services that may be rendered in the future. The purpose of submitting a Pre-Determination is to determine whether the products/services will be covered as well as to identify an estimate for potential payment.

Base Hierarchical Message Description   

This message is a specialization of the Pre-Determination that includes one or more Oral Health billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is a specialization of the Pre-Determination that includes one or more Pharmacy billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is a specialization of the Pre-Determination that includes one or more Physician billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is a specialization of the Pre-Determination that includes one or more Preferred Accomodation billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is a specialization of the Pre-Determination that includes one or more Vision Care billable act(s) identifying products and/or services that may be rendered in the future.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Chiro Physio Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Chiro Physio message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Chiro Physio message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results Chiro Physio message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when pre-determination is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Generic Pre-Determination.

This message is returned to a Provider each time an Generic Pre-Determination message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Generic message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Detemrination on-line, the Pre-Determination Results, Generic message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when adjudication is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Oral Health Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Oral Health message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Oral Health message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results Oral Health message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when pre-determination is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Pharmacy Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Pharmacy message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Pharmacy message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results, Pharmacy message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when adjudication is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Physician Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Physician message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Physician message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results Physician message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when pre-determination is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Preferred Accommodation Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Preferred Accommodation message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Preferred Accommodation message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results Preferred Accommodation message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when pre-determination is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to send pre-determination results for a Vision Care Pre-Determination.

This message is returned to a Provider each time a Pre-Determination, Vision Care message is successfully processed by an Adjudicator Application. As a minimum, the Pre-Determination Results, Vision Care message will contain the Adjudicator Applications' Invoice number, status codes for each Invoice Element Detail Item in the Invoice and optionally, a tracking number for the Adjudicator Application.

If the Adjudicator Application is able to process the Pre-Determination on-line, the Pre-Determination Results Vision Care message will contain the A_Adjudication_result indicating the results of the pre-determination (e.g., paid as submitted, paid as adjusted, etc.). Otherwise an acknowledgement of receipt of the Pre-Determination will be sent and when pre-determination is completed, this message will be sent.

Base Hierarchical Message Description   

This message is used to Nullify an entire root group of a Pre-Determination that has previously been submitted to a Adjudicator for processing and payment. A Pre-Determination that is Nullified must be marked as Nullified only and not purged from the Adjudicator Application's database.

The Adjudicator may/may not be able to Nullify the Pre-Determination Invoice Element root group, and will indicate processing results in the response message.

This message cannot be used to Nullify or remove ancillary information for a Pre-Determination and/or Invoice Element Detail item such as Contact information or any referenced health documents.

Base Hierarchical Message Description   

This message is used by a Provider to request previously submitted Pre-Determination invoice processing information.

The Pre-Determination Query is used to query against an entire Pre-Determination Request.

The Pre-Determination Query is a single parameter, the Invoice Element root Group identifier, from the Pre-Determination Request being queried.

The Invoice Adjudication Results message is returned in response to this query in the same way it would be returned to the Pre-Determination Request message.

This information may have previously been sent to the submitter but must be resent in response to a Pre-Determination Query message.

Base Hierarchical Message Description   

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Chiro Physio services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Generic services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Oral Health services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Pharmacy services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for medical services and/or products rendered by a physician. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Preferred Accommodation services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the inital Pre-Determination Results for Vision Care services and/or products. Completed results will follow at a later point in time (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Chiro Physio services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Generic services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Oral Health services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Pharmacy services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for medical services and/or products rendered by a physician.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Preferred Accommodation services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Vision Care services and/or products.

The receiver will provide completed Pre-Determination Results, NOT initial results.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Chiro Physio services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Generic services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Oral Health services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Pharmacy services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for medical services and/or products rendered by a physician.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Preferred Accommodation services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Request message for Vision Care services and/or products.

The receiver will attempt to return completed Pre-Determination Results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Chiro Physio services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Generic services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Oral Health services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Pharmacy services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for medical services and/or products rendered by a physician.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Preferred Accommodation services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Vision Care services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Chiro Physio services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Generic services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Oral Health services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Pharmacy services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for medical services and/or products rendered by a physician.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Preferred Accommodation services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the completed results of a Pre-Determination Request for Vision Care services and/or products.

This notification follows on initial results sent previously.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Chiro Physio services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Generic services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Oral Health services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Pharmacy services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for medical services and/or products rendered by a physician.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Preferred Accommodation services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Vision Care services and/or products.

The receiver will provide completed nullify results only. The receiver does NOT return an initial response.

Nullify results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Chiro Physio services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Generic services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Oral Health services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Pharmacy services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for medical services and/or products rendered by a physician.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Preferred Accommodation services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Nullify Request message to request the nullification of a previously submitted Pre-Determination Request for Vision Care services and/or products.

The receiver will attempt to return completed nullify results, but where this is not possible, initial results will be returned, with the completed results to be sent unsolicited to the sender at a later point (e.g. next day).

The completed results indicate that the receiver was successful or not in nullifying the Pre-Determination Request.

Description 

The sender sends a Pre-Determination Query message to determine the status of a previously submitted Pre-Determination Request for Chiro Physio services and/or products.

Query response uses the Pre-Determination Results message.

Description 

The sender sends a Pre-Determination Query message to determine the status of a previously submitted Pre-Determination Request for Generic services and/or products.

Query response uses the Pre-Determination Results message.

Description 

The sender sends a Pre-Determination Query message to determine the status of a previously submitted Pre-Determination Request for medical services and/or products rendered by a physician.

Query response uses the Pre-Determination Results message.

Description 

The sender sends a Pre-Determination Query message to determine the status of a previously submitted Pre-Determination Request for Preferred Accommodation services and/or products.

Query response uses the Pre-Determination Results message.

Description 

The sender sends a Pre-Determination Results message containing the processing status (e.g. active, complete) and/or results of a Pre-Determination Request for Chiro Physio services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the processing status (e.g. active, complete) and/or results of a Pre-Determination Request for Generic services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the processing status (e.g. active, complete) and/or results of a Pre-Determination Request for Pharmacy services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the processing status (e.g. active, complete) and/or results of a Pre-Determination Request for services and / or products rendered by a physician

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.

Description 

The sender sends a Pre-Determination Results message containing the processing status (e.g. active, complete) and/or results of a Pre-Determination Request for Preferred Accommodation services and/or products.

Pre-Determination Results indicate adjudication results for specified services and/or products, but does not generate a payment.