For draft eligibility request:
For approved / rejected eligibility request:
For draft authorization request:
For approved / rejected authorization request:
No. | Control Name | Type | Description |
1 | Request Type | drop-down list | Type of prior request.Default value: - Authorization if the request is opened by clicking on Create New Prior Request button or by selecting E-Prior Requests > New Authorization from the menu;- Eligibility if the request is opened by selecting E-Prior Requests > New Eligibility from the menu.Possible values: Authorization, Eligibility. |
2 | Your 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 |
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4 | Visit Type | drop-down list | Patient visit type.Default value: 1 - No bed + No emergency room. 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 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 |
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7 | Type | drop-down list | Diagnosis type.Default value: empty. Possible values: Principal, Secondary, Admitting. A request may have:- the principal diagnosis only;- the principal diagnosis and from one to several secondary / admitting diagnoses. |
8 | ICD9 Diagnosis | text field | Diagnosis from ICD9 code set.Default value: empty. Format: code: description. 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 | grid | All diagnoses added to the request. The grid contains the following columns:- Type, shows value selected from Type drop-down list;- Code, shows value set in ICD9 Diagnosis field. |
10 | Add this diagnosis to your favourites | link label | The link label appears when ICD9 Diagnosis is set and this diagnosis is not in Favourites list yet. On clicking the link the diagnosis adds to Favourites list and link disappears. |
11 | Search for your favourite diagnosis | link label | On clicking the link label Your Favourite Diagnoses form opens where all diagnoses once added to favourites are listed. If user selects any of them and clicks on Select button, the form closes and the diagnosis appears in ICD9 Diagnosis field. |
12 | Add new diagnosis (Ctrl + N) | link label | On clicking the link label (or pressing Ctrl + N) an empty row adds to the Selected Diagnoses grid. |
13 | Remove this diagnosis (Ctrl + D) | link label | On clicking the link label (or pressing Ctrl + D) the highlighted row removes from the Selected Diagnoses grid. |
| Payer reply* |
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14 | Prior Authorization No | text field | Authorization number. This value is the same as Authorization No on Procedure Details tab.The field is not editable. |
15 | Authorization Start | text field | Authorization start date as per payer reply.The field is not editable. |
16 | Authorization End | text field | Authorization end date as per payer reply.The field is not editable. |
17 | Authorization Result | text field | Authorization result as per payer reply.The field is not editable. |
18 | Limit | text field | Limit value as per payer reply.The field is not editable. |
19 | Denial Code | text field | Denial code as per payer reply.The field is not editable. |
20 | Comments | text field | 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:
- Payer Reply on Request Details and Procedure Details tabs;
- Approved Totals on Procedure Details tab.