This file may contain entries of all type of billable events that need to be tracked by MCCR. The information in this file is used for MCCR and or UR purposes. It is information about the event itself not otherwise stored or pertinent for MCCR purposes. Per VHA Directive 10-93-142, this file definition should not be modified.
.01entry id(+)0;1NUMERICBThis is a unique number assigned to this entry. The first 3 characters of the number are the station number.
.02patient0;2POINTER2CEnter the patient that this Claims Tracking entry is for. This is the patient whose admission, outpatient visit, prescription refill, prosthetic device or other encounter for medical care or services is being tracked.
.03visit0;3POINTER9000010AVSITThis is the visit for the patient that is being tracked in this entry. This field is a place holder for when visit tracking is implemented. It will point to the visit that is being tracked.
.04outpatient encounter0;4POINTER409.68ASCEThis is the outpatient encounter that is being tracked. If this is entered and the provider and/or diagnosis for the encounter are entered then the inforamation will be extracted from the encounter file.
.05admission0;5POINTER405ADThis is the admission that is being tracked. When an entry is added for inpatient care for any date the software will find the current admission for that date and use the current admission from the patient movement file.
.06episode date0;6DATE-TIMEDThis is the date of the episode of care or services that is being tracked. For admissions, it is the admission date. For outpatient visits it is the visit date. For prescription refills it is the refill date. For prosthetic items it is the date that the prosthetic item was issued. The data in this field is entered by the Claims tracking event tracker routines.
.07admission type0;7SET OF CODES1:SCHEDULED
Enter whether this admission was a scheduled admission, a direct admission from the outpatient area, or whether this was an urgent or emergent admission. The type of admission will impact whether pre-certification reviews should be done and the impact on reimbursements.
.08prescription0;8POINTER52If the entry that is being tracked is a prescription refill then this field should point to the entry in the prescription file.
.09prosthetic item0;9POINTER660APROIf this tracking entry is for a prothetic item, this is the pointer to the prosthetic item file.
.1refill date0;10NUMERICThis is a free text pointer to the REFILL multiple (subfile #52.1) in the PRESCRIPTION file (#52). The top-level pointer for the prescription entry in the PRESCRIPTION file (#52) can be found in the PRESCRIPTION field (#.08) of the CLAIMS TRACKING file (#356). The refill date is found at the first '^' piece of the REFILL multiple of the PRESCRIPTION file. Original Fills will be added as of July 2001. The Refill Date for these will be '0'.
.11initial bill number0;11POINTER399EThis is the bill number in the BILL/CLAIMS file for the initial bill number for this entry. It is the bill to the third party for this claim.
.12other type of bill0;12SET OF CODES1:TORT FEASOR
ACIf this claims tracking entry can be billed as other than an insurance claim or a patient bill enter the type of claim. If a patient has ever had a claim type other than insurance then special warnings may be given in the billing and claims tracking package.
.14second opinion required0;14BOOLEAN1:YES
If this patient insurance policy requires a second opinion enter 'YES'. If a second opinion is not required then enter 'NO'.
.15second opinion obtained0;15BOOLEAN1:YES
If a second opinion was required by this patients' insurance policy, enter 'YES' if it was obtained or 'NO' if it was not obtained. If a second opinion was obtained but did not meet the insurance companies criteria for any reason, enter 'NO'. This field will be used to help determine the estimated reimbursement from the insurance carrier. If a second opinion was not obtained certain denials and penalties may be assessed.
.17earliest auto bill date0;17DATE-TIMEABDThis is the earliest date that this visit can be automatically billed. The automatic billing software will use this date when searching for events to bill. All events with an Earliest Auto Bill Date on or before the run date of the automatic biller will be considered for inclusion on a bill. This field may be set in one of two ways. If AUTOMATE BILLING is on for the Event Type then this field will be automatically set when apparently billable events are added to the claims tracking module. This field can also be directly set by a user, AUTOMATE BILLING does not need to be on for the Event Type. When the automated biller runs it will attempt to add the event to a bill. This date should be deleted if the event turns out not to be suitable for a reimbursable insurance bill. This field will automatically be deleted if the event is added to a bill or a reason not-billable is entered.
.18event type0;18POINTER356.6EVNTThis is the type of event that is being tracked. This field is automatically stored when an entry is created. Scheduled admissions are tracked to allow for precertification reviews. When an admission occurs within 7 days of a scheduled admission the scheduled admission will be updated to an inpatient care event type automatically. Choose an event type of Scheduled Admission only for future scheduled admissions and choose an event type of admission for past admissions. If you are using the scheduled admissions portion of the MAS package then scheduled admissions will automatically be added to claims tracking 7 days before the scheduled admission and automatically converted to an event type of admission after the patient has been admitted. For admissions you will be able to specify the type of admission in another field.
.19reason not billable0;19POINTER356.8ARThis is the primary reason this episode of care should not be billed to an insurance company. If a reason not billable is entered, then this episode will no longer appear on reports as billable and will not be used by the automated biller as a billable event.
.2inactive0;20SET OF CODES0:INACTIVE
An entry is automatically inactived if the parent event that is being tracked is either deleted or edited so that it no longer is a valid tracking entry. Inactivating an entry has the same affect as deleting an entry except that the activity is left as a history.
.21estimated ins. payment (pri)0;21NUMERICThis is the estimated amount that the primary insurance carrier is expected to pay on this claim.
.22estimated ins. payment (sec)0;22NUMERICThis the the estimated amount that the secondary insurance carrier is expected to pay on this claim.
.23estimated ins. payment (ter)0;23NUMERICThis is the estimated amount that the tertiary insurance carrier is expected to pay on this claim.
.24tracked as insurance claim?0;24BOOLEAN1:YES
AIEnter 'YES' if the patient is insured for this event. Enter 'No' if the patient is not insured for this event. If this event is not tracked as an insurance claim, the field REASON NOT BILLABLE will automatically have entered "NOT INSURED" if it is not otherwise entered.
.25tracked as random sample?0;25BOOLEAN1:YES
Enter if this is to be tracked as a Random Sample for UR purposes. The Claims tracking module is designed to flag one admission per week each from the 3 major bedsections, Medicine, Surgery, and Psychiatry, as a random sample that is to have utilization review follow-up. If there is not sufficient activity in your facility for the automated tracker to set up the minimum random sample, then you may manually add entires to be tracked for UR purposes.
.26tracked as special condition0;26SET OF CODES1:TURP
If you are tracking special conditions for follow up by UR then indicate that this is a special condition UR case and UR will be required and the information about this case will appear on special condition reports. The choices are: TURP -- Transurethral Prostatectomy COPD -- Chronic Obstructive Pulmonary Disease CVD -- Cerebrovascular Disease
.27tracked as a local addition?0;27BOOLEAN1:YES
If this is being track as a local addition for UR purposes then enter 'YES'.
.28estimated mt charges0;28NUMERICEnter the estimated amount of Means Test copayment charges that are to be paid by the patient for this case.
.29estimated total charges0;29NUMERICEnter the estimated total charges from this case. This is the estimated total amount due the government. The total estimated charges minus the estimated payments from all sources will be the amount not anticipated to be reimbursed from this case. Comparing estimated receipt versus the actual amount received will help determine if all payers have sufficiently re-imbursed the government.
.3admitting reason (icd)0;30POINTER356.9This is the ICD diagnosis code for the admitting diagnosis.
.31special consent roi0;31SET OF CODES1:NOT REQUIRED
Enter whether or not a special consent release of information form for this patient for this episode of care is required, obtained, or not necessary. If ROI is required but not obtained, certain clinical information may not be released to Insurance carriers. This will affect contacts with insurance companies and bill preparation. Generally a special consent is required if the patient has or was treated for Drug and Alcohol, HIV, and sickle cell anemia.
.32scheduled admission0;32POINTER41.1ASCHIf this claims tracking entry is for a scheduled admission, this is the scheduled admission. This field points to the entry in the Scheduled Admissions file that is being tracked. When this scheduled admission is acutally admitted, it will be converted to an inpatient admission tracking record automatically.
1.01date entered1;1DATE-TIMEEnter the date that this entry was created. This will usually be the date that the automated tracker created this entry on.
1.02entered by1;2POINTER200Enter the name of the user who first created this entry. This is most important if this entry was not created by the automated tracker.
1.03date last edited1;3DATE-TIMEEnter the date that this claim was last edited.
1.04last edited by1;4POINTER200Enter the user who last edited this claim tracking entry.
1.05hospital reviews assigned to1;5POINTER200Enter the UR person that this case is assigned to if it is assigned to an individual for hospital Reviews. Cases may be assigned for an individual to follow for the length of their admission. If viewing pending work by who it is assigned to then this field is used to sort the pending work.
1.06ins. reviews assigned to1;6POINTER200Enter the Insurance UR person that this case is assigned to if it is assigned to an individual for Insurance UR. Cases may be assigned for an individual to follow for the length of their admission. If viewing pending work by who it is assigned to then this field is used to sort the pending work.
1.07follow-up type1;7SET OF CODES1:NONE
Enter type of follow that the insurance company requires for this visit. This information will be used by the reports to determine if the case requires pre-cert or not, or pre-cert and continued stay.
1.08additional comment1;8FREE TEXTEnter any brief comment about this episode that may explain why a case is not billable.
1.09acute care discharge date1;9DATE-TIMEADISThis date is filled by ACUTE CARE DISCHARGE DATE of the HOSPITAL REVIEW File (#356.1) when a discharge is entered. Used by UTILIZATION MANAGEMENT ROLLUP in association with the ADIS cross-reference.
1.1ecme number1;10FREE TEXTAEThis is the ECME NUMBER associated with the e-Pharmacy Claim. This field may only be set for e-pharmacy prescriptions and refills.
1.11ecme reject1;11SET OF CODES0:NO
This field is a flag to mark ECME claims rejected by the Payer. The field is only meaningful if the field 1.1 "ECME NUMBER" is defined.
2.01non billable coder2;1POINTER200This field is populated automatically with the logged on user if REASON NOT BILLABLE is non-blank and ADDITIONAL COMMENTS was edited.
2.02last reviewed by2;2POINTER200This field is populated automatically with the logged on user reviewing this episode of care.
2.03billable coder2;3POINTER200This field is populated automatically with the logged on user if REASON NOT BILLABLE is blank and BILLABLE FINDINGS TYPEs were changed or added.
2.04code valid billable date2;4DATE-TIMEThis date/time is automatically populated if BILLABLE FINDING TYPEs are added or edited and the episode is billable.
2.05code valid non billable date2;5DATE-TIMEThis date/time field is updated automatically if REASON NOT BILLABLE is blank and ADDITIONAL COMMENTS is edited.
3billable findings type3;0MULTIPLE356.03

Referenced by 4 types

  1. HOSPITAL REVIEW (356.1) -- tracking id
  2. INSURANCE REVIEW (356.2) -- tracking id
  3. CLAIMS TRACKING/BILL (356.399) -- claim tracking id
  4. IB AUTOMATED BILLING COMMENTS (362.1) -- claims tracking id