Authorization Results
Transaction ID 483433436
Customer ID 4046427027
Certification Number
123456789
Patient Name
Allen, Allison
Patient Date of Birth
03/03/2010
Patient Gender
Male
Status
Modified
Diagnosis Version
ICD-9
Request Type
Inpatient Authorization
Payer
Aetna
Certification Information
Certification Number
123456789
Status
Modified
Message
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Provider Information
Requesting Provider
Sanchez, Zoey
Referred-To-Provider
Riviera, Nick
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Service Information
Service Type/Quantity
3 Days
Admission Type
Elective
Place of Service
Inpatient Hospital
Type of Service
Cardiac
Service/Admission Data
12/24/2012
Additional Services Information
Procedure Code
49000
Status
No action required
Date of Service
12/24/2012 - 12/24/2012
Payer Contact Information
Contact Name
Aetna
Phone Number
(800) 955-5682