For draft authorization request:
For approved / rejected authorization request:
No. | Control Name | Type | Description |
| Activity Details |
|
|
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. |
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. |
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 | Comments | text field | Comments on the activity left by provider.Default value: empty. |
8 | 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. |
9 | Update observations | link label | On clicking the link Observations form opens where user can set observations of LOINC or text type. |
| Requested Price Per One Unit |
|
|
10 | Discount | text field | Price discount in percent.Default value: empty.Possible values: 0-100%. |
11 | 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. |
12 | Unit 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. |
13 | Unit Patient Share | text field | Patient share for one unit of the procedure.Default value: empty. Unit Patient Share = Unit Gross Price x Copay / 100. |
14 | Unit 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. |
| Payer Reply* |
|
|
15 | Payment Amount | text field | Amount approved by payer for activity.The value is auto filled from payer reply and is not editable. |
16 | Patient Share | text field | Patient share for activity as per payer reply.The value is auto filled from payer reply and is not editable. |
17 | List Price | text field | Activity list price as per payer reply.The value is auto filled from payer reply and is not editable. |
18 | Denial Code | text field | 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. |
19 | Authorization no | text field | Authorization number. This value is the same as Prior Authorization No on Request Details tab.The field is not editable. |
20 | Selected Procedures | grid | All procedures in the request, one procedure per line. The grid contains the following columns:- Code, shows selected value in Procedure;- Quantity, shows set value in Quantity;- Net, calculates as Quantity x Unit Net Price x (100 - Discount) / 100;- Payment Amount, shows Payment Amount from Payer Reply section;- Denial Code, shows Denial Code from Payer Reply section. |
21 | 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. |
22 | 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. |
| Requested Totals |
|
|
23 | Gross Price | text field | Total gross price for all procedures (activities) in the request.Default value: empty. |
24 | Patient Share | text field | Total patient share for all procedures (activities) in the request.Default value: empty. |
25 | Net Price | text field | Total net price for all procedures (activities) in the request.Default value: empty. |
| Approved Totals* |
|
|
26 | Gross Price | text field | Total gross price for all procedures (activities) in the payer reply.It is not editable. |
27 | Patient Share | text field | Total patient share for all procedures (activities) in the payer reply.It is not editable. |
28 | Net Price | text field | Total net price for all procedures (activities) in the payer reply.It 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.