Submit Authorization Request (Patient Event Details Tab) Page
You use the Other Service Authorization Info tab of the Submit Authorization Request page to enter additional information when submitting a service authorization. Other services include chiropractic, non-emergency transportation, and so on. Other services information is optional.
The Patient Event tab of the Submit Authorization Request page contains the following panels:
- Supplemental Health Care Service Review Information
- Related Causes
- Admission Review, Institutional Claim
- Health Care Services Delivery
- Ambulance/Non-Emergency Transportation
- Chiropractic Certification
- Home Oxygen Therapy
- Home Health Care
- DME Patient Conditions
- Functional Limitations
- Activity Permitted
- Mental Status
You can open or close certain panels. Click
(the plus sign) beside a panel to open the panel. Click
(the minus sign) to close the panel.
Supplemental Health Care Service Review Fields
| Field | Description |
|---|---|
| Current Health |
The current state of the patient's health. Examples: Acute; Chronic; Mild Disease; Normal, Healthy; Good; Excellent |
| Prognosis Code |
The expected results after treatment. Examples: Poor, Guarded, Fair, Terminal |
| Delay Reason |
The reason for delay Examples: Proof of Eligibility Unknown, Litigation, Administration Delay |
| Release of Information |
The consent on the ability to release information Examples: On file with payor; Provider has limited/restricted; Yes, Provider has signed agreement. |
| Date of Onset |
The date the supplemental health care services began. |
Related Causes Fields
| Field | Description |
|---|---|
| Is this Authorization Accident or Employment related? | Select yes or no. If yes is selected, then additional fields are displayed for entry. |
| Related Cause 1 - 3 | Up to three causes can be entered regarding the authorization for an accident or employment related incident. |
| Auto Accident State | The state in which the vehicle accident occurred. |
| Auto Accident Country | The country in which the vehicle accident occurred. |
| Accident Date | The date the accident occurred. |
| Is this Authorization pregnancy related? | Select yes or no. If yes is selected, then additional fields are displayed for entry. |
| Last Menstrual Period | The date of the woman's last menstrual cycle. |
| Estimated Date of Birth | The estimated date the child is to be delivered or born. |
Admission Review, Institutional Claim Fields
| Field | Description |
|---|---|
| Admission Begin Date | The date the patient or resident was admitted. |
| Admission End Date | The date the patient's or resident's admission ended. |
| Discharge Date | The date the patient or resident was discharged. |
| Admission Type Code |
The basic reason for admission. Examples: Emergency, Urgent, Elective, Newborn, Trauma, Information Not Available |
| Admission Source Code |
The source of the admission. Examples: Clinc Referral/Prematur Deliv, Transfer from HHA, Emergency Room |
| Patient Status Code |
The current status code of the patient. Examples: Still a patient, Disch Trans to SNF, Left Against Medical Advice, Expired |
| Nursing Home Residential Status Code |
The nursing home status of the resident. Examples: Still a Resident; Newly admitted, Temporarily Absence - Hospital |
Health Care Service Delivery Fields
| Field | Description |
|---|---|
| Service Quantity | The numeric value of the service quantity type being delivered. |
| Service Quantity Type (per every) |
The type of service quantity being delivered. Examples: Days, Units, Hours, Month, Visits |
| Service Frequency Count |
The numeric frequency value of the service being delivery. Examples: 2, 4 |
| Frequency Period (for) |
Indicates how often (at what frequency) the service is being delivery Examples: Days, Months, Weeks |
| Service Duration Count |
Indicates the numeric value of the duration count Examples: 6, 10 |
| Duration of Services |
The length of time the services are to be used. Examples: Yes, Episode, Visit, Month, Week, Hours, Days |
| Calendar Pattern (in the) |
Code specifying the calendar pattern being used for health care delivery service. Examples: Monday thru Thursday, As Directed |
| Time of Day |
The time of day the health care delivery service is being performed. Examples: 1st Shift (normal hours), 2nd Shift, 3rd Shift, A.M., As Directed, Any Shift, None |
Ambulance/Non-Emergency Transportation Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Ambulance Certification |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the physical condition of the patient who used the ambulance or non-emergency transportation. Examples: Patient moved by stretcher, Pat bed confirmed after the ambulance |
| Transport Code |
Code for the type of transport used for the patient. Examples: Initial Trip, Return Trip, Transfer Trip, Round Trip |
| Transport Reason Code |
The reason the ambulance transport was dispatched. Examples: Pat trnsp nearest facility for care; Patient trans Residential Facility. |
| Round Trip Purpose Description | Description of why the round trip transportation was needed. |
| Stretcher Purpose Description | Description of why a stretcher was needed for the patient. |
| Transport Distance | Distance in miles that the ambulance transported the patient. |
| Patient Weight | Weight of the patient in pounds (Ibs). |
|
Pick-up Location, Final Schedule Destination Address, First Stop, Second Stop, Third Stop Enter the last name or organization and address for all stops made during the transportation of the patient or patients. |
|
| Last Name or Organization | The last name of the patient or organization being transported. |
| Address (Line 1 and 2) | The address of the pick-up location, final destination, or stops. |
| City | The city of the pick-up location, final destination, or stops. |
| State | The state of the pick-up location, final destination, or stops. |
| Zip | The zip code and extension of the pick-up location, final destination, or stops. |
Chiropractic Certification Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Chiropractic Certification |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the physical condition of the patient that is being treated. Examples: Patient confined to bed or chair, Without equip/surgery required |
| X-ray Availability Indicator | Indicate whether there was x-ray availability. |
| Treatment Series Number | Treatment number within a series of treatments. |
| Treatment Series Count | Number of treatments within a series of treatments. |
| Subluxation Level Code |
Select the exact spinal location of subluxation. Examples: Cervical 1 , Lumbar 1, Thoracic 7, Ilium, Coccyx, Sacrum, Occiput |
| Patient Condition Code | Select the ode Indicating the patient's condition. |
| Complication Indicator | Indicates whether the patient's condition is complicated. Select Yes or No. |
| Patient Condition Description 1 & 2 | A short description of the patient's condition. |
Home Oxygen Therapy Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Oxygen Therapy Certification |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select condition from list. Examples: Treat for terminal illness, Pat transported in emergency situation |
| Equipment Type Code 1 & 2 | Code for the type of equipment used for home oxygen therapy. |
| Equipment Reason Description | Reason for the type of equipment used for home oxygen therapy. |
|
Oxygen Flow Rate (liters per minute) |
Rate of flow needed for therapy. Indicate in liters per minute. |
| Oxygen Used (times per day) | Times per day that oxygen is used. |
| Oxygen Used (hours per period) | Hours per period that oxygen is used. |
| Respiratory Therapist Order Text | Order notes from the respiratory therapist for home oxygen. |
| Arterial Blood Gas Quantity | Percentage of arterial blood gas quantity. |
| Oxygen Saturation Quantity | Percentage of oxygen saturation quantity. |
| Oxygen Test Condition Code | Code for the oxygen test condition. |
| Oxygen Test Finding Code | Code for the findings of the oxygen test. Select all that apply. |
| Portable Oxygen Flow Rate | Flow rate of the portable oxygen tank. Indicate in liters per minute. |
| Oxygen Delivery System Code | Select code for the oxygen system delivered for use by the patient. |
| Oxygen Equipment Type Code | Select code for the type of equipment used for home oxygen therapy. |
Home Health Care Fields
| Field | Description |
|---|---|
| Prognosis Code |
The condition of the patient. Examples: Good, Fair, Guarded |
| Start Date | The date that home health care started. |
| Certification Period From | The date the certification period is to start. |
| Certification Period To | The date the certification period is to end. |
| Medicare Coverage? |
The status of the patient's Medicare coverage. Examples: No Medicare Coverage, Not Applicable, Yes Medicare Coverage |
| Certification Type Code |
The type of certification. Examples: Initial, Renewal, Revised |
| Surgery Date | The date of the surgery. |
| What type of Procedure Codes is authorized? | Identifies the list used for the procedure codes. Select either HCPCS or ICD Surgical Code. |
| Procedure Code |
The procedure or service provided. HCPCS (Healthcare Common procedure Coding System) or CDT (Current Dental Terminology) codes are typically used. |
| Physician Order Date | The date the physician or surgeon wrote the orders. |
| Last Visit Date | The date of the patient's last visit. |
| Patient Contact Date | The date the patient was contacted. |
| Last Admission Begin Date | The starting date of the patient's last admission. |
| Last Admission End Date | The ending date of the patient's last admission. |
| Patient Location |
The location where the home health care is being provided. Examples: Hospice, Nursing Home, Private Home |
DME Patient Conditions Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Durable Medical Equipment Certification |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the condition of the DME being used by the patient. Examples: Patient is ambulatory, Patient owns equipment |
Functional Limitations Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Functional Limitation |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the physical ability of the patient. Examples: Patient is confined to bed or chair; Patient has poor diabetic control |
Activities Permitted Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Activities Permitted |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the activity level of the patient. Examples: Paralysis, Patient is Ambulatory |
Mental Status Fields
| Field | Description |
|---|---|
| Condition Category |
The type of category for this patient event. Default: Mental Status |
| Do all condition codes apply? | Select Yes or No to indicate whether all condition codes enter apply to this category. |
| Condition 1 - 5 |
Select the mental status of the patient. Examples: Severe, Hostile, Agitated, Depressed |