Service Authorization Additional Line Information Page
You use the Service Authorization Additional Line Information page to add, view, or edit additional information on service line item. The Service Authorization Additional Line Information page contains fields in the following panels:
Amount/Unit Activity Fields
| Field | Description |
|---|---|
| This amount/unit activity information is display only. | |
| Approved Units | The approved number of units, visits, or sessions. |
| Used Units | The number of used units, visits, or sessions applied to the authorization. |
| Remaining Units | The number of remaining units, visits, or sessions. It is derived from subtracting the used units from the approved units. |
| Approved Amount | The approved amount for the approved units, visits, or sessions. |
| Used Amount | The amount of monies used so far against the approved amount. |
| Remaining Amount | The amount of monies still available to be used for the authorization. It is derived from subtracting the used amount from the approved amount. |
Durable Medical Equipment Fields
| Field | Description |
|---|---|
| Serial # | The serial number on the durable medical equipment. |
| Acquisition Cost | The acquisition cost for the durable medical equipment after discounts have been applied. |
| MSRP | The manufacturers' suggested retail price (MRSP) for the durable medical equipment. |
| Hourly Rental Charge | The hourly charge to rent the durable medical equipment. |
| Condition | The condition of the durable medical equipment (new or used). |
MMIS Reject Reasons Fields
| Field | Description |
|---|---|
|
The MMIS reject reasons information is display only. |
|
| LI | The line number of the authorizations that received a MMIS reject reason during processing. |
| MMIS Reject Reason |
The reject reason code assigned by NH MMIS during claims processing. |