73 lines
2.9 KiB
Mathematica
73 lines
2.9 KiB
Mathematica
RCRCVCP ;ALB/CMS THIRD PARTY REFERRAL CHECK LIST ; 9/02/97
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V ;;4.5;Accounts Receivable;**63**;Mar 20, 1995
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;;Per VHA Directive 10-93-142, this routine should not be modified.
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Q
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CHK(EXP) ;
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;Send 1 for expanded view of check list
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NEW II,LN,LT,RCY,X S (VALMCNT,X)=""
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S LT="RCLST"
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F II=1:1 D Q:$P(LN,";",3)="EOF"
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.S LN=$T(@LT+II)
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.I $P(LN,";",3)="EOF" Q
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.I 'EXP,+$P(LN,";",4) Q
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.S VALMCNT=+$G(VALMCNT)+1
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.S RCY=$P(LN,";",5),X=$$SETFLD^VALM1(RCY,X,"LINE")
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.S ^TMP("RCRCVC",$J,VALMCNT,0)=X
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.Q
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I VALMCNT=0 W !,"NOTHING TO REPORT"
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CHKQ Q
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;
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RCLST ;Referral Check List
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;;1;0;o MEDICAL NECESSITY/EMERGENCY DENIAL
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;;1;1;The insurance company determines that the medical treatment was not a
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;;1;2;medical necessity within the policy guidelines of a legitimate emergency
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;;1;3;as required by most Health Maintenance Organizations (HMO).
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;;1;4;
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;;2;0;o PRE-AUTHORIZATION/PRE-ADMISSION CERTIFICATION DENIAL
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;;2;1;The care was not pre-authorized or pre-certified, as required by the
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;;2;2;insurance company, and no payment or a reduced payment was made in
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;;2;3;accordance with the insurance policy.
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;;2;4;
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;;3;0;o INSURANCE DEDUCTIBLES
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;;3;1;The claim was approved or partially approved, but the payment was applied
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;;3;2;to the deductible.
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;;3;3;
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;;4;0;o MAXIMUM BENEFITS USED
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;;4;1;The insurance company has a dollar or visit ceiling and the maximum was
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;;4;2;met or exceeded the limits of the policy. This includes
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;;4;3;"lifetime ceilings". An example is a limited number of outpatient
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;;4;4;visits for mental health allowed each calendar year."
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;;4;5;
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;;5;0;o REASONABLE AND CUSTOMARY RATES
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;;5;1;The insurance company has paid based upon usual and customary rates
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;;5;2;in the community for the care provided.
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;;5;3;
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;;6;0;o LENGTH OF STAY
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;;6;1;The insurance company pays based upon an appropriate determination
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;;6;2;of length of stay and the veteran has an extended stay beyond the terms
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;;6;3;of the insurance policy.
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;;6;4;
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;;7;0;o LEVEL OF CARE
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;;7;1;Acute vs. Non-Acute Care/Nursing Home vs. Skilled Nursing Home Care
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;;7;2;
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;;7;3;The carrier's payment (or lack thereof) is based upon an appropriate
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;;7;4;determination that the level of care exceeded that which was medically
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;;7;5;necessary. Most insurance companies will not pay for nursing home
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;;7;6;care unless it is skilled nursing care.
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;;7;7;
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;;8;0;o SPECIAL CONSENT FORM
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;;8;1;A SPECIAL CONSENT FORM MUST BE FAXED TO REGIONAL COUNSEL WITHIN
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;;8;2;24 HOURS OF REFERRAL if treatment falls under the 38 USC 7332.
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;;8;3;
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;;9;0;o NO EVIDENCE OF FOLLOW-UP
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;;9;1;Regional Counsel personnel is unable to determine what communication
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;;9;2;has taken place between VAMC and the insurance company.
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;;9;3;
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;;10;0;o CORRESPONDENCE NOT RECEIVED
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;;10;1;Evidence of collection action by VAMC, i.e., report of contact or
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;;10;2;written correspondence between VAMC and insurance company has not
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;;10;3;been received.
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;;EOF
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Q
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;RCRCVCP
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