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
Fig.1 New eligibility request
Fig.2 Approved / rejected eligibility request
Fig.3 New authorization request
Fig.4 Approved / rejected authorization request
Control Name | Type | Default Value / State | Mandatory | Description |
Request Type | drop-down list | preselected (Authorization) / enabled | Yes | Type of a prior request. Default value: |
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Possible values: Authorization, Eligibility. |
2
Request ID | text 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
Yes | ||||
Date ordered | date picker | Yes | ||
Encounter start | date picker | checked (today) / enabled | Yes | 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) / enabled | Yes | Patient visit type. Possible values:
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5
date picker
The latest saved |
Encounter type will be preselected by default in new requests and |
claims. |
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
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Type
Diagnosis type | drop-down list | empty / enabled | Yes | Diagnosis type. |
Possible values:
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A request may have: |
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8
ICD9 Diagnosis
ICD10 diagnosis | text field + [...] selection button | empty / enabled | Yes | Diagnosis from |
ICD10 code set. |
Format: code: description. |
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. |
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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:
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Add this diagnosis to your favourites |
link | hidden | - | The link |
appears when |
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. |
Search for your favourite diagnosis |
link | enabled | - | On clicking the link |
Your Favourite Diagnoses form opens where all diagnoses once added to |
favorites are listed. If the user selects any of them and |
clicks Select button, the form closes and the diagnosis appears in |
ICD10 diagnosis field. |
12
Add new diagnosis (Ctrl + N) |
link | enabled | - | On clicking the link |
(or pressing Ctrl + N) an empty row adds to the Selected |
diagnoses grid. |
13
Remove this diagnosis (Ctrl + D) |
link | enabled | - | On clicking the link |
(or pressing Ctrl + D) the highlighted row removes from the Selected |
diagnoses grid. |
14
Authorization no | text field | disabled | - | Authorization number. This value is the same as Authorization |
no on Procedure Details tab. |
15
Authorization |
start | text field | disabled | - | Authorization start date as per the payer reply. |
16
Authorization |
end | text field | disabled | - | Authorization end date as per the payer reply |
17
Authorization |
result | text field | disabled | - | Authorization result as per the payer reply. |
18
Limit | text field | disabled | - | Limit value as per the payer reply. |
Denial |
code | text field | disabled | - | Denial code as per the payer reply. |
20
Comments | text field | disabled | - | Comment left by |
* When prior request is sent, all data controls become read-only on the form. When the reply is received, additional sections appear:
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the payer. |