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AETNA REFERRAL
PAYER INFORMATION
Utilization Management: AETNA
Payer ID: 123456789
REQUESTER INFORMATION
Provider: Doe#1, John MD
ETIN: 1234567
SUBSCRIBER INFORMATION
Insured or Subscriber: JONES, JANE J
Member ID: ABCD1000
Diagnosis Code: 78900
REFERRING PROVIDER INFORMATION
Referring Provider: Doe#3, John MD
ETIN: 1234567
SERVICE PROVIDER INFORMATION
Provider Role: Performing
Provider Taxonomy Code: 111XX0100X
Physician/Osteopath Gastroenterology
SERVICE INFORMATION
Request Category: Specialty Care Review
Place of Service: Office
Certification Action: Certified in total
Certification Number: 123456283
Issue Date: 07/29/2004
Expiration Date: 10/26/2004
HCPCS Procedure Code: 99999
Services Delivery: 1 Visit
For: 1 Remaining
The provider understands that receipt or use of this
referral information does not guarantee payment of any
healthcare claim by Aetna, and such information is
subject to change, even retroactively, at any time.
TRANS REF #: 001234567
Due to enhancements made to electronic processing, you
may notice changes to the format/content of your
responses. For further info, please contact your vendor.
Transaction run on 07/29/2004 at 12:31:38 PM CT
by John Doe - Physicians |
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