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Letters Metadata Information

LETTERS (PADL/RRL)

Prior Authorization Decision Letters (PADL) are formal communications sent by insurance companies, health plans, or third-party administrators to inform patients and healthcare providers about the outcome of a prior authorization request. A prior authorization is a process where a healthcare provider must obtain approval from the insurance company before providing certain treatments, medications, or services to a patient. This is done to ensure the requested treatment or service is covered by the patient's insurance plan and is deemed medically necessary.

Review Result Letter (RRL) is an official communication that informs the recipient of the outcome of a review process. Whether it involves approval, denial, or partial approval of a request, it provides the necessary details and rationale for the decision. If applicable, the letter will also outline the next steps, including how to appeal a decision. These letters play a crucial role in maintaining transparency, clarity, and effective communication between insurance companies, healthcare providers, and patients.

esMD Functional Specifications Submission Set and Metadata Attributes for Letters

Data Element	Value	Datatype/Format	Required (R) / Optional (O)	Length	Repeatable Element (Y/N)
LocalizedString	PA Decision Letters or Review result letters	String	O	Variable	N
mimeType	application/xml	String	R	Variable	N
contentTypeCode	20	Numeric	R	2	N
RequestType	LETTERS	String	R	Variable	N
Clinical document mediaType	application/json	String	R for RRL metadata	Variable	N
esMDTransactionId	ID	Alphanumeric	R	50	N
Letter Id	ID	Alphanumeric	R	60	N
ProviderNPI	NPI	Numeric	R	10	N
HIH OID	Format: "urn:oid:1.3.6.1.4.1.101420.6.1"	Alphanumeric	R	64	N
Sender OID	Format: "urn:oid:1.3.6.1.4.1.101420.6.1"	Alphanumeric, Colon and Period	R	50	N
totalNumberOfDocuments	Number	Numeric	R	3	N
creationTime	Timestamp	DateTime	R	25	No
documentID=LetterId_Indexnumber	ID	Alphanumeric	R	50	No

eSMD TO HIH LETTERS JSON Structure Data Elements

Letter Classification Section

Data Element	Value	Datatype/Format	Required (R) / Optional (O)	Length	Repeatable Element (Y/N)
Letter id	A unique id for a letter generated by RC system	String	R	60	N
Letter Date	Date of the Letter	mm/dd/yyyy	R	10	N
Category	Default Value “LETTER”	String	R	60	N
Subcategory	Default Value “OTHER”	String	R	60	N
Enclosures	For Future Use	String	O	NA	N
Input Field	Data Input field/ Date input field (For Future Use)	String	O	NA	N

ADR Level Info (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Type of eMDR	Type of eMDR	Character Constant Value: 'POST-PAY-OTHER' (One Constant Value)	14	R
Unique Letter Id	Unique identifier for the letter	Character	60	R
Letter Date	Date of the letter	Character Format: mm/dd/yyyy	10	R

RC System Identifier Details (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
RC System Identifier	Identifier for the RC system	Character	60	R
Medicare Appeal #	Medicare appeal number	Character	60	O
CSE #	CSE number of RC System	Character	60	O

Sender RC Details (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Organization Name	Name of the sender RC organization	Character	100	R
Address 1	Primary address of the sender RC	Character	75	O
Address 2	Secondary address of the sender RC	Character	75	O
City	City of the sender RC	Character	50	O
State	State of the sender RC	Character Values: All standard 2-character US states value (Postal Code for state Ex: VA, MD, CA, AZ etc.)	2	O
Zip Code	Zip code of the sender RC	Character Formats: 99999-9999	10	O
Telephone (with Extension)	Telephone number and extension of the sender RC	Character Format: 9999999999-9999	18	O
e-Mail Address	Email address of the sender RC	Character	100	O
Web Site Address	Website address of the sender RC	Character	80	O

Provider Details (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Last Name / Organization Name	Provider's last name or organization name	Character	100	R
Provider NPI	National Provider Identifier of the provider	Character Formats: 9999999999	10	R
First Name	First name of the provider	Character	50	O
Middle Name	Middle name of the provider	Character	30	O
Address 1	Primary address of the provider	Character	75	O
Address 2	Secondary address of the provider	Character	75	O
City	City of the provider	Character	50	O
State	State of the provider	Character Values: All standard 2-character value representation for US states	2	O
Zip Code	Zip code of the provider	Character Formats: 99999-9999	10	O
Provider Number/ PTAN	Provider number or PTAN	Character	13	O
Fax	Fax number of the provider	Character Format: 9999999999	10	O

Letter Details (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Respond By	Response due date	Character Formats: mm/dd/yyyy	10	R
Jurisdiction / Zone of the RC	Jurisdiction or zone of the RC	Character Examples: 'QIC Area 1', 'SMRC', 'CERT', 'UPIC Mid-Western', etc.…	50	O
Program name (Line of Business)	Name of the program or line of business	Character Values: (suggested) Part A, Part B, DME, HHH	10	O
Letter Sequence	Sequence number of the letter	Character Values: (suggested) First, Second, etc.…	30	O
Previous Letter Date	Date of the previous letter	Character Formats: mm/dd/yyyy	10	O
Appeal # Cross Reference	Cross-reference number for the appeal	Character	60	O
Redetermination	Redetermination details	Character	80	O
Reconsideration	Reconsideration details	Character	80	O

Submission Contacts (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Contact Name	Name of the contact person	Character	100	O
Contact Tel and Extension	Telephone number and extension of the contact person	Character	18	O
Contact Fax	Fax number of the contact person	Character	10	O
Contact E-Mail Address	Email address of the contact person	Character	100	O

Review Level Detail (Occurs ONE Time)

Data Element	Short Description	Format / Values	Length	Usage
Document Code	Code for the document	Character Formats: (999999), (999999999999), (999999999999999999), or -1E+24	24	O
Document Code	Code for the document	Character Formats: (999999), (999999999999), (999999999999999999), or -1E+24	24	O
Inquiry Text 1	First inquiry text	Character	1000	O
Inquiry Text 2	Second inquiry text	Character	1000	O
Inquiry Text 3	Third inquiry text	Character	1000	O
Inquiry Text 4	Fourth inquiry text	Character	1000	O

Claim Details (Can Repeat More Than Once)

Data Element	Short Description	Format / Values	Length	Usage
Beneficiary ID	Identifier for the beneficiary	Character	12	O
Claim ID	Identifier for the claim	Character	23	O
Date Of Service (From)	Start date of the service	Character	10	O
Date Of Service (To)	End date of the service	Character Format: mm/dd/yyyy	10	O