source: WorldVistAEHR/trunk/r/ACCOUNTS_RECEIVABLE-PRCA-PRY-RC/RCRCVCP.m@ 1259

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1RCRCVCP ;ALB/CMS THIRD PARTY REFERRAL CHECK LIST ; 9/02/97
2V ;;4.5;Accounts Receivable;**63**;Mar 20, 1995
3 ;;Per VHA Directive 10-93-142, this routine should not be modified.
4 Q
5CHK(EXP) ;
6 ;Send 1 for expanded view of check list
7 NEW II,LN,LT,RCY,X S (VALMCNT,X)=""
8 S LT="RCLST"
9 F II=1:1 D Q:$P(LN,";",3)="EOF"
10 .S LN=$T(@LT+II)
11 .I $P(LN,";",3)="EOF" Q
12 .I 'EXP,+$P(LN,";",4) Q
13 .S VALMCNT=+$G(VALMCNT)+1
14 .S RCY=$P(LN,";",5),X=$$SETFLD^VALM1(RCY,X,"LINE")
15 .S ^TMP("RCRCVC",$J,VALMCNT,0)=X
16 .Q
17 I VALMCNT=0 W !,"NOTHING TO REPORT"
18CHKQ Q
19 ;
20RCLST ;Referral Check List
21 ;;1;0;o MEDICAL NECESSITY/EMERGENCY DENIAL
22 ;;1;1;The insurance company determines that the medical treatment was not a
23 ;;1;2;medical necessity within the policy guidelines of a legitimate emergency
24 ;;1;3;as required by most Health Maintenance Organizations (HMO).
25 ;;1;4;
26 ;;2;0;o PRE-AUTHORIZATION/PRE-ADMISSION CERTIFICATION DENIAL
27 ;;2;1;The care was not pre-authorized or pre-certified, as required by the
28 ;;2;2;insurance company, and no payment or a reduced payment was made in
29 ;;2;3;accordance with the insurance policy.
30 ;;2;4;
31 ;;3;0;o INSURANCE DEDUCTIBLES
32 ;;3;1;The claim was approved or partially approved, but the payment was applied
33 ;;3;2;to the deductible.
34 ;;3;3;
35 ;;4;0;o MAXIMUM BENEFITS USED
36 ;;4;1;The insurance company has a dollar or visit ceiling and the maximum was
37 ;;4;2;met or exceeded the limits of the policy. This includes
38 ;;4;3;"lifetime ceilings". An example is a limited number of outpatient
39 ;;4;4;visits for mental health allowed each calendar year."
40 ;;4;5;
41 ;;5;0;o REASONABLE AND CUSTOMARY RATES
42 ;;5;1;The insurance company has paid based upon usual and customary rates
43 ;;5;2;in the community for the care provided.
44 ;;5;3;
45 ;;6;0;o LENGTH OF STAY
46 ;;6;1;The insurance company pays based upon an appropriate determination
47 ;;6;2;of length of stay and the veteran has an extended stay beyond the terms
48 ;;6;3;of the insurance policy.
49 ;;6;4;
50 ;;7;0;o LEVEL OF CARE
51 ;;7;1;Acute vs. Non-Acute Care/Nursing Home vs. Skilled Nursing Home Care
52 ;;7;2;
53 ;;7;3;The carrier's payment (or lack thereof) is based upon an appropriate
54 ;;7;4;determination that the level of care exceeded that which was medically
55 ;;7;5;necessary. Most insurance companies will not pay for nursing home
56 ;;7;6;care unless it is skilled nursing care.
57 ;;7;7;
58 ;;8;0;o SPECIAL CONSENT FORM
59 ;;8;1;A SPECIAL CONSENT FORM MUST BE FAXED TO REGIONAL COUNSEL WITHIN
60 ;;8;2;24 HOURS OF REFERRAL if treatment falls under the 38 USC 7332.
61 ;;8;3;
62 ;;9;0;o NO EVIDENCE OF FOLLOW-UP
63 ;;9;1;Regional Counsel personnel is unable to determine what communication
64 ;;9;2;has taken place between VAMC and the insurance company.
65 ;;9;3;
66 ;;10;0;o CORRESPONDENCE NOT RECEIVED
67 ;;10;1;Evidence of collection action by VAMC, i.e., report of contact or
68 ;;10;2;written correspondence between VAMC and insurance company has not
69 ;;10;3;been received.
70 ;;EOF
71 Q
72 ;RCRCVCP
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