The main segment for the response is the HCR segment. That is where the information from this screen goes. The first combo box let's us choose a certification action code.
The available action codes.
Next comes a certification or authorization number. This will be listed on a later health care claim.
In case we reject the request for other reasons that listed in the formal reject reason we have choose a reason from the drop down box
Reject reasons
Next to the HCR segment we have additional date information and reference numbers