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For draft eligibility 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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1

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Fig.1 New eligibility request


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Fig.2 Approved / rejected eligibility request


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Fig.3 New authorization request


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Fig.4 Approved / rejected authorization request



Control Name

Type

Default Value / StateMandatory

Description

Request Type

drop-down list

preselected (Authorization) / enabledYes

Type of a prior request.

Default value:

-

 

  • Authorization if the request is opened by
clicking on Create
  • clicking New Prior Request
button
  •  below the menu or by selecting
E-
  • Prior Requests > New Authorization from the menu;
-
  • Eligibility if the request is opened by selecting
E-Your
  • Prior Requests > New Eligibility from the menu.

Possible values: Authorization, Eligibility.

2

Request IDtext field

Request number.Default value: empty. Format: [Provider ID]-[ID Prefix]-[auto-generated value].Request ID is not editable, it is assigned when the request is saved as draft or sent.

3

Date Ordered

text field

Date of ordering.Default value: today.

 

Visit Info

 

 

4

Visit Type

drop-down list

Patient visit type.Default value:

Yes
Date ordereddate picker
Yes

Encounter start

date picker

checked (today) / enabledYes

Visit start date. The latest saved Encounter start is preselected by default in new requests and claims.

Encounter end

date picker

unchecked (today) / enabled

Yes, if Encounter type = 3 or 4

No, otherwise

Visit end date. Encounter end must be greater than or equal to Encounter start. If the user sets Encounter start > Encounter end, then Encounter end adjusts to Encounter start automatically.

The field becomes mandatory if the user selects Encounter type = 3 or 4).

Encounter type

drop-down list

preselected (1 - No bed + No emergency room) / enabledYes

Patient visit type.

Possible values:

  • 1 - No bed + No emergency room;
  • 2 - No bed + Emergency room;
  • 3 - Inpatient bed + No emergency room;
  • 4 - Inpatient bed + Emergency room;
  • 5 - Daycase bed + No emergency room;
  • 6 - Daycase bed + Emergency room;
  • 7 - National screening;
  • 8 - New visa screening;
  • 9 - Renewal visa screening;
  • 12 - Home;
  • 13 - Assisted living facility;
  • 14 - Mobile unit;
  • 41 - Ambulance - land;
  • 42 - Ambulance - air or water.
The latest saved Visit Type will be preselected by default in new requests and e-claims.

5

Visit Start

date picker

Visit start date.Default value: today.

The latest saved

Start Date

Encounter type will be preselected by default in new requests and

e-

claims.

Visit Start is mandatory for inpatient requests and must be empty for outpatient requests.

6

Visit End

date picker

Visit end date.Default value: unchecked.End Date must be greater than or equal to Start Date. If User sets Start Date > End Date, then End Date adjusts to Start Date automatically.Visit End is mandatory for inpatient requests and must be empty for outpatient requests.

 

Diagnoses

 

 

7

Type

Diagnosis type

drop-down list

empty / enabledYes

Diagnosis type.

Default value: empty.

Possible values:

  • Principal
,
  • ;
  • Secondary
, Admitting.
  • ;
  • Admitting;
  • Reason For Visit.

A request may have:

-

  • the principal diagnosis only;
-
  • the principal diagnosis and from one to several secondary
/ admitting
  • diagnoses.

8

ICD9 Diagnosis

text field

ICD10 diagnosis

text field + [...] selection button

empty / enabledYes

Diagnosis from

ICD9

ICD10 code set.

Default value: empty.

 

Format: code: description.

User grid

The user can type it manually (e.g. a code) and press Enter key or they can select it from the list which opens by pressing […] button.

9

Selected Diagnoses

If Diagnosis Effective Date <= 31 December 2016, the label becomes ICD9 diagnosis: and ICD9 code set is used.

Selected diagnoses

grid

empty-

All diagnoses added to the request. The grid contains the following columns:

  • Type -
Type,
  • shows the value selected from
Type
  • Diagnosis type drop-down list;
  • Code -
Code,
  • shows the value set in
ICD9 Diagnosis
  • ICD10 diagnosis field.
10

Add this diagnosis to your favourites

link label

link 

hidden-

The link

label

appears when

ICD9 Diagnosis

ICD10 diagnosis is set and this diagnosis is not in Favourites list yet. On clicking the link the diagnosis adds to Favourites list and the link disappears.

11

Search for your favourite diagnosis

link label

link 

enabled-

On clicking the link

label

Your Favourite Diagnoses form opens where all diagnoses once added to

favourites

favorites are listed. If the user selects any of them and

clicks on

clicks Select button, the form closes and the diagnosis appears in

ICD9 Diagnosis

ICD10 diagnosis field.

12

Add new diagnosis (Ctrl + N)

link label

link 

enabled-

On clicking the link

label

(or pressing Ctrl + N) an empty row adds to the Selected

Diagnoses

diagnoses grid.

13

Remove this diagnosis (Ctrl + D)

link label

link 

enabled-

On clicking the link

label

(or pressing Ctrl + D) the highlighted row removes from the Selected

Diagnoses

diagnoses grid.

 

Payer reply*Prior Authorization No

 

 

14

Authorization notext fielddisabled-Authorization number. This value is the same as Authorization
No
no on Procedure Details tab.
The field is not editable.

15

Authorization
Start
starttext fielddisabled-Authorization start date as per the payer reply.
The field is not editable.

16

Authorization
End
endtext fielddisabled-Authorization end date as per the payer reply
.The field is not editable.

17

Authorization
Result
resulttext fielddisabled-Authorization result as per the payer reply.
The field is not editable.

18

Limittext fielddisabled-Limit value as per the payer reply.
The field is not editable.19
Denial
Code
codetext fielddisabled-Denial code as per the payer reply.
The field is not editable.

20

Commentstext fielddisabled-Comment left by
payer.The field is not editable.

* When prior request is sent, all data controls become read-only on the form. When the reply is received, additional sections appear:

...

the payer.