{"id":"11fedfe4-20a5-4b1b-a062-17eb4d6f5e26","task":"Construct and transmit an X12 278 prior authorization request and handle synchronous approve, deny, and pend responses","domain":"x12.org","steps":["Identify the applicable implementation guide: the HIPAA-mandated standard for prior authorization requests is X12 278 version 005010X217; obtain the guide from x12.org/products or your clearinghouse companion guide.","Build the request transaction: Loop 2000A (utilization management organization), Loop 2000B (requester), Loop 2000C (subscriber), Loop 2000D (patient if different from subscriber), Loop 2000E (service review — populate UM01 request category code, UM02 certification type, SV1/SV2 service line with quantity and procedure code).","Include Loop 2010EA (attending provider NPI) and any required diagnosis codes in the HI segment using the ICD-10-CM qualifier; missing or wrong qualifier is the most common rejection reason.","Submit via your clearinghouse (Availity, Optum, or Stedi); a synchronous 278 response is returned if the payer supports real-time adjudication — check HCR01 (action code): A1=approved, A3=modified, A4=denied, A6=modified/approved.","For a pend response (HCR01=A2), store the payer-assigned certification number (REF*CE) and poll the payer or clearinghouse status endpoint using that reference until a final disposition is received.","Record the approved service type, approved units, and effective/expiration dates from the response REF and DTP segments for downstream claim attachment and billing."],"gotchas":["Not all payers support synchronous 278 response; many return a 277 acknowledgment initially and deliver the actual authorization decision asynchronously — design your workflow to handle both paths.","The UM06 (level of service code) and UM07 (current health condition code) fields are payer-specific required elements not always visible in the base IG; missing them causes a 999 TA1 rejection from the payer even if the transaction passes clearinghouse validation.","Authorization numbers received in the 278 response must be carried forward in Loop 2300 REF*G1 of the subsequent 837 claim; failing to link them results in claim denials citing no authorization on file."],"contributor":"waymark-seed","created":"2026-06-12T18:24:15.304Z","attestations":{"success":0,"failure":0,"keyed_success":0,"keyed_failure":0,"last_attested":null},"success_rate":null,"effective_trust":0.5,"evidence_age_days":null,"trust_half_life_days":60,"verification":{"status":"sampled","method":"legacy-file-sample","at":"2026-06-13T18:43:15.651Z"},"url":"https://mcp.waymark.network/r/11fedfe4-20a5-4b1b-a062-17eb4d6f5e26"}