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prior-authorization.pdf

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JSON

authorization_number

PA-2024-789012

request_date

2024-03-15

determination_date

2024-03-18

payer

name: UnitedHealthcare, plan_name: Choice Plus PPO, phone: 1-800-555-1234

member

name: Richard A. Stevens, member_id: UHC987654321, group_number: GRP-100500, date_of_birth: 1962-07-30

provider

name: Dr. Amanda Collins, MD, npi: 1234567890, practice: Orthopedic Specialists of Boston, phone: (617) 555-4567

request

service_type: Outpatient Surgery, procedure_code: 27447, procedure_description: Total Knee Arthroplasty, diagnosis_codes: ["M17.11","M17.12"], diagnosis_description: Primary osteoarthritis, bilateral knees, place_of_service: Ambulatory Surgery Center, requested_date: 2024-04-15, units_requested: 1

clinical_justification

Patient has failed conservative treatment including physical therapy (12 weeks), NSAIDs, and corticosteroid injections. X-rays show bone-on-bone arthritis. Functional limitations include inability to walk more than 1 block.

determination

status: Approved, approved_units: 1, effective_date: 2024-04-01, expiration_date: 2024-06-30, conditions: Must be performed at in-network facility

appeal_deadline

null

{ "authorization_number": "PA-2024-789012", "request_date": "2024-03-15", "determination_date": "2024-03-18", "payer": { "name": "UnitedHealthcare", "plan_name": "Choice Plus PPO", "phone": "1-800-555-1234"}, "member": { "name": "Richard A. Stevens", "member_id": "UHC987654321", "group_number": "GRP-100500", "date_of_birth": "1962-07-30"}, "provider": { "name": "Dr. Amanda Collins, MD", "npi": "1234567890", "practice": "Orthopedic Specialists of Boston", "phone": "(617) 555-4567"}, "request": { "service_type": "Outpatient Surgery", "procedure_code": "27447", "procedure_description": "Total Knee Arthroplasty", "diagnosis_codes": [ "M17.11", "M17.12"], "diagnosis_description": "Primary osteoarthritis, bilateral knees", "place_of_service": "Ambulatory Surgery Center", "requested_date": "2024-04-15", "units_requested": 1 }, "clinical_justification": "Patient has failed conservative treatment including physical therapy (12 weeks), NSAIDs, and corticosteroid injections. X-rays show bone-on-bone arthritis. Functional limitations include inability to walk more than 1 block.", "determination": { "status": "Approved", "approved_units": 1, "effective_date": "2024-04-01", "expiration_date": "2024-06-30", "conditions": "Must be performed at in-network facility"}, "appeal_deadline": null }