No. | Control Name | Type | Description |
| Activity Details |
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1 | Type | drop-down list | Procedure type.Default value: 3 - CPT code. Possible values:3 - CPT code;4 - HCPCS code;5 - Trade Drug code;6 - Dental code;8 - Service code;9 - APR / DRG code.The latest saved Type will be preselected by default in new requests and e-claims. |
2 | Procedure | drop-down list | Procedure (or activity) from the list of the specified type.Default value: empty.Format: code: description.User can type it manually (e.g. a greenrain code of a trade drug) and press Enter key or they can select it from the list which opens by pressing […] button. |
3 | Ordering Clinician | text field | Doctor who ordered a procedure or prescribed a drug. Default value: empty.Format: clinician license: clinician name.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 Clinician will be preselected by default in new requests and e-claims.! Ordering Clinician is mandatory if Visit Start Date >= 1-Jun-2014.! Ordering Clinician must be empty if Visit Start Date < 1-Jun-2014. |
4 | Performing Clinician | text field | Doctor who performed a procedure or dispensed a drug.Default value: empty.Format: clinician license: clinician name.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 Clinician will be preselected by default in new requests and e-claims.! Performing Clinician is optional if Visit Start Date >= 1-Jun-2014.! Performing Clinician is mandatory if Visit Start Date < 1-Jun-2014. |
5 | Start Date | date picker | Activity Start Date.Default value: today.Possible values: between Start Date and End Date of visit period. If user changes visit period and activity Start Date becomes outside its boundaries, it adjusts to new value of visit Start Date / End Date. |
6 | Quantity | text field | How many items of selected procedure clinician prescribes. Default value: empty.Possible values: 0.0001-999.9999. |
7 | Pre-Auth. No | text field | Authorization number.Default value: empty. |
8 | Comments | text field | Comments on the activity left by provider.Default value: empty. |
9 | Add PDF attachment / View PDF attachment | link label | On clicking Add PDF attachment link 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. |
10 | Update observations | link label | On clicking the link Observations form opens where user can set observations of LOINC or text type (learn more). |
| Price Per One Unit |
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11 | Discount | text field | Price discount in percent.Default value: empty.Possible values: 0-100%. |
12 | Copay | text field | Patient copay in percent.Default value: empty.Possible values: 0-100%.If user enters / modifies Copay, Unit Patient Share recalculates: Unit Patient Share = Unit Gross Price x Copay / 100.If user modifies Unit Patient Share, Copay value clears. |
13 | Deductible | text field | The amount patient have to pay out-of-pocket for expenses before the payer will cover the remaining costs.Default value: empty. |
14 | Gross Price | text field | Gross price for one unit of the procedure. Default value: empty.If user sets Type = 5 - Trade Drug Code and selects any trade drug in Procedure, Unit Gross Price fills with Price value for this drug but still can be changed to another value. |
15 | Patient Share | text field | Patient share for one unit of the procedure.Default value: empty. Unit Patient Share = Unit Gross Price x Copay / 100. |
16 | Net Price | text field | Net price for one unit of the procedure.Default value: empty. Unit Net Price = Unit Gross Price - Unit Patient Share.If user modifies Net Price, Gross Price adjusts.If user modifies Gross Price or Patient Share, Net Price adjusts. |
17 | Selected Procedures | grid | All procedures for a claim, one procedure per line. The grid contains the following columns:- Code, shows selected value in Procedure;- Quantity, shows set value in Quantity;- Gross, calculates as Quantity x Unit Gross Price x (100 - Discount) / 100;- Net, calculates as Quantity x Unit Net Price x (100 - Discount) / 100;- Clinician, shows Ordering Clinician. |
18 | Add new procedure (Ctrl + N) | link label | On clicking the link label (or pressing Ctrl + N) an empty row adds to the Selected Procedures grid. |
19 | Remove this procedure (Ctrl + D) | link label | On clicking the link label (or pressing Ctrl + D) the highlighted row removes from the Selected Procedures grid. |
| Totals |
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20 | Total Gross | text field | Total gross price for all procedures (activities) in the claim.Default value: empty. |
21 | Total Patient Share | text field | Total patient share for all procedures (activities) in the claim.Default value: empty. |
22 | Total Net | text field | Total net price for all procedures (activities) in the claim.Default value: empty. |