PA Form Testing Portal

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Failed: 0

Pending: 0

Performance

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Recent Tests

Time	Patient	Drug	Payer	Type	Mode	Status	Duration	Fields	Actions
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Single PA Form Test

Patient Information

Full Name *

Sex

Date of Birth

Phone Number

Email

Address

City

State

Zip Code

Member ID

Insurance Provider

Group Number

Guardian Name

Prescriber Information

Name

NPI Number

Phone Number

Fax Number

Email

Tax ID

DEA Number

Clinic Name

Address

City

State

Zip Code

Specialty

Official Contact Name

Insurance Information

Payer

BV Outcome

Plan Name

Practice Type

Prescription Information

Drug Name

Quantity

Strength

Days Supply

PA Form Upload

Drag & drop your PA form PDF here

or click to browse · PDF files only · Max 20MB

Bulk PA Form Testing

Download Excel Template

Upload an Excel file with patient records and match each row to a PA form PDF. The system will process each pair automatically.

Payer *

Benefit Type *

Step 1: Upload Excel File

Excel optional (use default fields)

Drop your Excel file here (.xlsx or .csv)

Required columns: firstName, lastName, subscriberId, dateOfBirth, drugName, state, planName. For Medical benefit: include jcode/hcpcsCode. For Pharmacy: include ndcCode.

No PDFs uploaded yet

Step 2: Upload & Map PDF Forms

Upload Excel and PDFs to continue

Bulk Jobs

Job ID	Payer	Type	Total	Passed	Failed	Progress	Status
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Match Template

Template Matching

Payer

State

Plan

Practice Type

Manual verification for matched templates.

All Test Results

Time	Patient	Drug	Payer	Benefit	Mode	Filename	Status	Duration	Fields	Error	Actions
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Activity Log

[System] PA Testing Portal started. Ready to receive submissions.