For draft authorization request:
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No.
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Control Name
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Type
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Description
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Activity Details
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Fig. 1 New authorization request
Fig. 2 Approved / rejected authorization request
Control Name | Type | Default Value / State | Mandatory | Description |
Type | drop-down list |
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| preselected (3 - CPT code) / enabled | Yes | Procedure type. Possible values:
The latest saved Type will be preselected by default in new requests and |
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claims. |
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2
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Procedure
Procedure | text field + [...] selection button | empty / enabled | Yes | Procedure (or activity) from the list of the specified type. |
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Format: code: description. |
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The user can type it manually (e.g. a |
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trade drug code) and press Enter key or they can select it from the list which opens by pressing […] button. |
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3
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Ordering Clinician
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text field
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| Rx number | text field | empty / enabled | Yes | Prescription number. Visible for an activity with Type = 5 - Trade Drug code if setting IsRxNumberMandatorySetting = true. |
| Fill counter | text field | empty / enabled | Yes | Fill Counter. Visible for an activity with Type = 5 - Trade Drug code if setting IsRxNumberMandatorySetting = true. Possible values: >=0, integer. |
Ordering clinician | text field + [...] selection button | empty / enabled | Yes | The doctor who ordered a procedure or prescribed a drug. |
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Format: clinician license: clinician |
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name (Clinicians list). The user can type it manually (e.g. a clinician license) and press Enter key or they can select it from the list which opens by pressing […] button. The latest saved Ordering |
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clinician will be preselected by default in new requests and |
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claims. |
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4
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Performing Clinician
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text field
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Ordering clinician is mandatory if Encounter start >= 1-Jun-2014. Ordering clinician must be empty if Encounter start < 1-Jun-2014. | ||||
Performing clinician | text field + [...] selection button | empty / enabled | Yes | The doctor who performed a procedure or dispensed a drug. |
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Format: clinician license: clinician name |
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(Clinicians list). The user can type it manually (e.g. a part of clinician name) and press Enter key or they can select it from the list which opens by pressing […] button. The latest saved Performing |
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clinician will be preselected by default in new requests and |
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claims. |
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5
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Start Date
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date picker
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Performing clinician is optional if Encounter start >= 1-Jun-2014. Performing clinician is mandatory if Encounter start < 1-Jun-2014. | ||||
Start date | date picker | checked (today) / enabled | Yes | Activity start date. The latest saved Start Date will be preselected by default in new requests and claims. Possible values: between Encounter start and Encounter end. If the user changes the visit period and the activity Start date becomes outside its boundaries, it adjusts to the new value |
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of Encounter start / Encounter end. | ||||
Quantity | text field | empty / enabled | Yes | How many items of selected procedure clinician prescribes. |
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Possible values: 0.0001-999.9999 |
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7
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Comments
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text field
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. |
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8
Add PDF attachment |
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link | enabled | - | On clicking Add PDF attachment |
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a window opens to search for the necessary file. After the file is selected, the link label changes to View PDF attachment. On clicking View PDF attachment link attached file opens for viewing. |
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| View PDF attachment | link | hidden | - |
Update observations |
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link label
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link | enabled | - | On clicking Update observations Observations form opens where the user can set observations of LOINC or |
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Text type |
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Requested Price Per One Unit
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10
. For a sent request (that cannot be edited) the link name is View observations. | ||||
| View observations | link | hidden | - | |
Discount | text field | empty / enabled | No | Price discount in percent. |
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Possible values: 0-100%. |
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Copay | text field | empty / enabled | No | Patient copay in percent. |
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Possible values: 0-100%. If the user enters/modifies Copay, |
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then Patient |
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share recalculates: |
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Patient |
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share = |
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Gross |
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price x Copay / 100. If the user modifies |
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Patient |
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share, Copay value clears. |
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12
Gross |
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price | text field | empty / enabled | Yes | Gross price for one unit of the procedure. |
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If the user sets Type = 5 - Trade Drug Code and selects any trade drug in Procedure, |
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Gross |
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price fills with Price value for this drug but still can be changed to another value. |
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13
Patient |
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share | text field | empty / enabled | No | Patient share for one unit of the procedure. |
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Patient share = Gross price x Copay / 100. |
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Net |
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price | text field | empty / enabled | Yes | Net price for one unit of the procedure. |
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Payer Reply*
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15
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Payment Amount
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text field
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Amount approved by payer for activity.The value is auto filled from payer reply and is not editable.
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16
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Patient Share
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text field
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Patient share for activity as per payer reply.The value is auto filled from payer reply and is not editable.
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17
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List Price
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text field
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Activity list price as per payer reply.The value is auto filled from payer reply and is not editable.
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18
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Denial Code
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text field
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Denial code as per payer reply for activity.Format: denial code - denial description.The value is auto filled from payer reply and is not editable.
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19
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Authorization no
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text field
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Authorization number. This value is the same as Prior Authorization No on Request Details tab.The field is not editable.
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20
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Selected Procedures
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grid
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Net price = Gross price - Patient share. If the user modifies Net price, then Gross price adjusts. If the user modifies Gross price or Patient share, then Net price adjusts. | ||||
| Comments | text field | empty / enabled | No | Comments on the activity left by the provider. It is sent as an observation. |
| Patient instructions | text field | empty / enabled | No | Instructions to the patient left by the provider. It is sent as an observation. |
Selected procedures | grid | empty / disabled | - | All procedures for a request, one procedure per line. The grid contains the following columns: |
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|
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|
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The grid is not editable. |
Add new procedure (Ctrl + N) |
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link | enabled | - | On clicking the link |
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(or pressing Ctrl + N), an empty row adds to the Selected |
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procedures grid. |
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Remove this procedure (Ctrl + D) |
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link | enabled | - | On clicking the link |
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(or pressing Ctrl + D), the highlighted row removes from the Selected |
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23
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Gross Price
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text field
procedures grid. |
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Requested Totals
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Total gross (requested) | text field | empty / disabled | - | Total gross price for all procedures (activities) in the request. |
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24
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Patient Share
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Total patient share (requested) | text field | empty / disabled | - | Total patient share for all procedures (activities) in the request. |
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25
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| ||||
Total net (requested) | text field | empty / disabled | - | Total net price for all procedures (activities) in the request |
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Approved Totals*
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26
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Gross Price
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text field
. | ||||
| Payer reply | ||||
| Payment amount | text field | disabled | - | Amount approved by the payer for activity. The value is auto-filled from the payer reply. |
| Patient share | text field | disabled | - | Patient share for activity as per the payer reply. |
| List price | text field | disabled | - | Activity list price as per the payer reply. |
| Denial code | text field | disabled | - | Denial code as per the payer reply. Format: denial code - denial description |
| Authorization no | text field | disabled | - | Authorization number. This value is the same as Authorization no on Encounter Details tab. |
| Total gross (approved) | text field | disabled | - | Total gross price for all procedures (activities) in the payer reply |
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| . |
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27
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Patient Share
| Total patient share (approved) | text field | disabled | - | Total patient share for all procedures (activities) in the payer reply. |
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28
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Net Price
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| Total net (approved) | text field | disabled | - | Total net price for all procedures (activities) in the payer |
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| reply |
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| . |
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