| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | review date(+) | 0;1 | DATE-TIME | B | This is the date of the contact for this entry. It is frequently necessary to call insurance companies for insurance verification, pre-certification reviews, continued stay review, appeals, etc. This is the date that you called the insurance company. | |
| .02 | tracking id | 0;2 | POINTER | 356 | C | This is the Claims Tracking entry that was the primary episode of care that caused this contact. Generally contacts are associated with an episode of care but occasionally they are not. |
| .03 | related review | 0;3 | POINTER | 356.1 | AD | This is the review in the Claims Tracking Reviews file that this insurance contact is associated with. This field will be system generated wheneve there is a utilization review entry created for a case that is also an insurance case. |
| .04 | type of contact(+) | 0;4 | POINTER | 356.11 | AC | This is the type of contact with a patient or insurance company that you are making. If this is a contact with a patient then select patient. If this is a contact with an insurance company then indicate if this is for pre-certification, urgent/emergent admission, continued stay, discharge, outpatient treatment, or an appeal. You may also select other if this is a contact that you wish to record but does not meet one of these categories. To add an appeal it must be associated with a denial. |
| .05 | patient | 0;5 | POINTER | 2 | D | Enter the patient that was contacted. |
| .06 | person contacted | 0;6 | FREE TEXT | This is the name of the person you contacted. This is a free text name that can be entered. It is recommended that you use the format of Firstname MI Lastname, just as they would say it to you. | ||
| .07 | contact phone # | 0;7 | FREE TEXT | This is the phone number of the person you contacted. If you contacted an insurance company and this number is not in the insurance company file, then you may want to enter it into that file as well. The number entered here will only be seen when looking at this contact. | ||
| .08 | insurance company contacted | 0;8 | POINTER | 36 | This is the insurance company that is being contacted. This is generally triggered by the HEALTH INSURANCE POLICY field. | |
| .09 | *call reference number | 0;9 | FREE TEXT | If the company you called gave you a reference number for the call then enter that reference number here. Many companies will issue reference numbers so that they can track their calls and allow reference back to them by others. This field has been replaced by 2.01 and marked for deletion by IB*2*458. | ||
| .1 | appeal status | 0;10 | SET OF CODES | 1:OPEN 2:PENDING 3:CLOSED 4:REFERED TO DISTRICT COUNSEL | If this Insurance Action is an appeal, this is the status of the appeal. Appeals that are OPEN will continue to be on the list of pending work based on the next review date. | |
| .11 | action | 0;11 | POINTER | 356.7 | ACT | Enter the action that the insurance company took on this call. Each contact can only have one action. If you need to enter more than one action, enter another contact. If you change the action, previously entered information will be deleted. If this contact was with an insurance company as part of an admission or continued stay review then you should enter the action that the insurance company took on thecall. Based upon the answer to this question along with the type of contact, you will be prompted for varying information. |
| .12 | care authorized from(+) | 0;12 | DATE-TIME | If the insurance company pre-approved the admission for this patient, this is the beginning date that they approved care from. | ||
| .13 | care authorized to(+) | 0;13 | DATE-TIME | If the insurance company pre-approved the admission for this patient, this is the ending date of the care approved. Typically insurance companies will approve only a certain number of days of care for reimbursement. This is the ending date of the number of days that they approved for reimbursement. | ||
| .14 | diagnosis authorized | 0;14 | POINTER | 80 | If the insurance company approved the care for this patient for reimbursement this is the diagnosis that they approved. Typically when an insurance company approves care for reimbursement they approve it for a specific diagnosis. This is the diagnosis that they approved. | |
| .15 | dates of denial from(+) | 0;15 | DATE-TIME | If the insurance company disapproved or denied pre-approving the care for this patient, this is the beginning date of care that they denied. For some patients there may be both a number of approved and denied days. | ||
| .16 | dates of denial to(+) | 0;16 | DATE-TIME | If the insurance company disapproved or denied pre-approving the care for this patient, this is the ending date of care that they denied. For some patients there may be both a number of approved and denied days. | ||
| .17 | method of contact | 0;17 | SET OF CODES | 1:PHONE 2:MAIL 3:OVERNIGHT MAIL 4:PERSONAL 5:VOICE MAIL 6:OTHER | This is the method that you used to contact the person contacted in this entry. Most contacts will be by phone but many others will be by mail. | |
| .18 | parent review | 0;18 | POINTER | 356.2 | AP | This is the first contact in a series of contacts. This field will generally be system generated. When adding an appeal to a denied claim, this will be the denial contact that is being appealed. |
| .19 | review status | 0;19 | SET OF CODES | 0:INACTIVE 1:ENTERED 2:PENDING 10:COMPLETE | AE | Enter whether or not this entry is active or not. Inactivating an entry has the same effect as deleting the entry. |
| .2 | case pending | 0;20 | SET OF CODES | 1:UR/CLINICAL INFORMATION 2:PENDING MEDICAL REVIEW 3:OTHER | If the action by the insurance company on this contact is pending, then this is what the case is pending for. Generally cases are pending further UR/Clinical information from the site or Medical Review at the insurance company. | |
| .21 | no coverage | 0;21 | SET OF CODES | 1:PATIENT NOT ELIGIBLE 2:SERVICE NOT PROGRAM BENEFIT 3:COVERAGE CANCELED BEFORE TREATMENT 4:OTHER | If the action by the insurance company on this contact was that the patient was not covered by this carrier for this care then this is the reason that they claim no coverge. | |
| .22 | follow-up with appeal | 0;22 | BOOLEAN | 1:YES 0:NO | If the action by the insurance company on this contact was a denial, then enter whether you wish to follow up with an appeal. If you answer 'YES' then this will be included on your Pending Work. | |
| .23 | type of appeal | 0;23 | SET OF CODES | 1:CLINICAL 2:ADMINISTRATIVE | If you are appealing the decision of an insurance company enter whether this is a clinical or administrative appeal. | |
| .24 | next review date | 0;24 | DATE-TIME | APEND | This is the date that this should show up on your Pending Work list. If you have entered an admission review with a next review date in three days, you will, in three days, have either a continued stay review or a discharge review to do depending on the patient's status. If this is a denial contact an the next review date is in three days, in three days you will show and appeal that needs to be done. Etc. If no entry is in this field then you will not be reminded of pending work. | |
| .25 | number of days pending appeal | 0;25 | NUMERIC | If the insurance company denied reimbursement for days of care, either in part or in total, and you are appealing that denial, then enter the number of days being appealed. | ||
| .26 | outpatient treatment | 0;26 | FREE TEXT | If this contact is to determine if a particular outpatient treatment will be authorized for reimbursement, this is the outpatient treatment that is authorized. Enter the free-text description of the outpatient treatment. | ||
| .27 | treatment authorized | 0;27 | BOOLEAN | 1:YES 0:NO | Entry 'YES' if this was authorized or 'NO' if it was not authorized. If this contact is to determine if a particular outpatient treatment is authorized for reimbursement, then this is whether or not the treatment was authorized. | |
| .28 | *authorization number | 0;28 | FREE TEXT | Enter the treatment authorization number that the insurance company gave you during this contact. The data in this field if it exists will be considered the Treatment Authorization code for this care and will automatically used by the billing module. This field has been replaced by 2.02 and marked for deletion by IB*2*458. | ||
| .29 | final outcome of appeal | 0;29 | SET OF CODES | 1:APPROVED 2:DENIED 3:PARTIAL APPROVAL | Enter the final outcome of this appeal. Did the insurance company approve, partially approve or deny this appeal? If the appeal was approved or partially approved you may enter the dates that it was approved for. | |
| 1.01 | date entered | 1;1 | DATE-TIME | This is the date this contact was entered into the computer. It is generated when the contact is entered and is not editable by the user. | ||
| 1.02 | entered by | 1;2 | POINTER | 200 | This is the user who was signed on to the computer system when this contact was created. If this contact was created automatically by the computer from an admission or discharge, then this might be a user from IRM, MAS, or other service. | |
| 1.03 | date last edited | 1;3 | DATE-TIME | This is the date that this contact was last edited by a user using the input options. After every editing sequence the files are checked for changes. If any are noted then this field is updated. | ||
| 1.04 | last edited by | 1;4 | POINTER | 200 | This is the user that last edited this contact using the input screens. | |
| 1.05 | health insurance policy(+) | 1;5 | FREE TEXT | Select the policy for this patient that you are contacting the insurance company for. | ||
| 1.07 | deny entire admission | 1;7 | BOOLEAN | 0:NO 1:YES | If the insurance company denies the entire admission for reimbursement then enter YES. You will then not asked to enter the Care Denied From and Care Denied To questions for this admission. If you want to enter the dates care was denied from and to, then answer NO. If this question is answered YES, then the days denied for this episode will be the admission to discharge date and any report will use the portion of the episode that falls within the date range of the report. | |
| 1.08 | authorize entire admission | 1;8 | BOOLEAN | 0:NO 1:YES | If the insurance company authorizes the entire admission for reimbursement then enter YES. You will then not asked to enter the Care Authorized From and Care Authorized To questions for this admission. If you want to enter the dates care was authorized from and to, then answer NO. If this question is answered YES, then the days authorized for this episode will be the admission to discharge date and any report will use the portion of the episode that falls within the date range of the report. | |
| 2.01 | call reference number | 2;1 | FREE TEXT | If the company you called gave you a reference number for the call then enter that reference number here. Many companies will issue reference numbers so that they can track their calls and allow reference back to them by others. | ||
| 2.02 | authorization number | 2;2 | FREE TEXT | Enter the treatment authorization number that the insurance company gave you during this contact. The data in this field, if it exists, will be considered the Treatment Authorization code for this care and will automatically be used by the billing module. | ||
| 11 | comments | 11;0 | WORD-PROCESSING | This field is used to store long textual information about the contact. This may be used to document specific information that is not captured in other fields or to pass along pertinent information to other users. | ||
| 12 | reasons for denial | 12;0 | MULTIPLE | 356.212 | If this contact was a denial, this is the reason(s) for denial. More than one reason may be selected from the available choices. | |
| 13 | penalty | 13;0 | MULTIPLE | 356.213 | If the action taken by an insurance company was to assess a penalty, then this is the reason for the penalty. | |
| 14 | approve on appeal from | 14;0 | MULTIPLE | 356.214 | Enter the dates that were approved for payment after an appeal. If the appeal was partially or fully approved enter the dates that this appeal was approved from. |