Workflow Codes
The address a message is sent to does not say which step of a claim it is. A new preauthorisation, a resubmission, an enhancement and an answer to a query all go to the same place, in the same kind of bundle. The workflow code in the message header is what tells them apart. Each code also comes with a status that says whether the message starts a request, answers one, or refuses it. The official Workflow Status Sheet is the authority, and new codes appear there first.
Every workflow code
Search by code, name or status, and switch between the codes a provider sends, the codes a payer sends, every row of the Workflow Status Sheet, and the lettered families.
Spellings are as published, such as Initimation, Reimburstment and protocal, so that searching for what you saw in a payload finds the row.
12Preauth Request Initiatedrequest.initiated121Preauth Reprocess(Resubmission) Initimationrequest.initiated13Enhancement Request Initiatedrequest.initiated131Enhancement Query Ack Successresponse.partial131Enhancement Query Ack Failedresponse.error131Enhancement Query Response Submittedresponse.complete18Preauth Query Ack Successresponse.partial18Preauth Query Ack Failedresponse.error19Preauth Query Response Submittedresponse.complete20Preauth Ack Successresponse.partial20Preauth Ack Failedresponse.error21Preauth Request Approvedresponse.complete22Enhancement Request Approvedresponse.complete23Preauth Request Rejectedresponse.complete231Enhancement Denyresponse.complete24Preauth Request Queriedrequest.initiated241Enhancement Query Raiserequest.initiated251Preauth Reprocess Ackresponse.complete41Preauth Arbitration Intimationrequest.initiated42Preauth Arbitration Acknowledgementresponse.completePC01Preauthorization Cancellationrequest.initiatedPC02Preauthorization Cancellation Accomplishedresponse.complete10Patient Registeredrequest.initiated11Patient Admittedrequest.initiated14Discharge Submittedrequest.initiated28Claim Request In Processresponse.partial29Claim Forwardedresponse.partial31Payment Processedrequest.initiated33Payment Settledrequest.initiated141Discharge Query Response Submittedresponse.complete151Claim Query Response Submittedresponse.complete252Reprocess Request Approvedresponse.complete253Reprocess Request Rejectedresponse.complete254Reprocess Request Queriedrequest.initiated261Discharge Request Approvedresponse.partial262Discharge Request Rejectedresponse.complete263Discharge Request Queriedrequest.initiated45Final Bill Initimationrequest.initiated45Final Bill Ack Successresponse.partial45Final Bill Ack Failedresponse.error15Claim Request Initiatedrequest.initiated181Final Bill Query Responseresponse.complete161Claim Doc Query Responseresponse.complete17Payment Notice Recivedresponse.complete25Claim Doc Ack Successresponse.partial25Claim Doc Ack Failedresponse.error46Final Bill Approveresponse.complete26Claim Request Approvedresponse.complete47Final Bill Query Raiserequest.initiated47Final Bill Query Ack Successresponse.partial47Final Bill Query Ack Failedresponse.error27Claim Request Queriedrequest.initiated27Claim Request Queriedresponse.partial/complete491Final Bill Denyresponse.complete291Claim Doc Denyresponse.complete30Payment Notice Initmationrequest.initiated30Payment Notice Ack Successresponse.partial30Payment Notice Ack Failedresponse.errorR122Reimburstment Claim Reprocess Requestedrequest.initiatedR15Reimburstment Claim Submittedrequest.initiatedR151Reimburstment Claim Query Response Submittedresponse.completeR252Reimburstment Claim Reprocess Request Approvedresponse.completeR253Reimburstment Claim Reprocess Request Rejectedresponse.completeR254Reimburstment Claim Reprocess Request Queriedrequest.initiatedR26Reimburstment Claim Approvedresponse.completeR27Reimburstment Claim Queriedrequest.initiatedR28Reimburstment Claim Evaluation In Processresponse.partialR291Reimburstment Claim Rejectedresponse.complete34Wallet Upgrade Intimationrequest.initiated36Claim Arbitration Intimationrequest.initiated38Fraud Alertrequest.initiated35Wallet Upgrade Acknowledgementresponse.complete37Claim Arbitration Acknowledgementresponse.complete39Fraud Alert Acknowledgementresponse.completeG11Grievance Intimationrequest.initiatedG12Grievance Acknowledmentresponse.completeG13Grievance Intimation Failureresponse.errorRP1Return Payment Intimationrequest.initiatedRP2Return Payment Acknowledgementresponse.completeRP3Return Payment Failureresponse.errorN01Notifications Intended To Payerrequest.initiatedN02Notifications Intended To Providerrequest.initiatedN03Notifications Intended To Beneficiaryrequest.initiatedN04Acknowledgement Of The Notificaionresponse.completeDC01Discharge Correction Intimationrequest.initiatedDC02Acknowledgement For Discharge Correctionresponse.complete
Mainline Cashless State Machines
In the diagrams below, each arrow carries the workflow code of the message that moves the case.