019.1



Form Name: BAR Dictionary 19 Financial Status Classifications FormRevision Date: November 19, 2013Requested By: Departmental Support Review:Require System Change Approval:Date to System Change Committee:Requestor Phone #: Today's Date: Date Reviewed:Date Needed: ADD _____EDIT _____DEACTIVATE _____Send to Anesthesia for entry in Anesthesia module.* is a required field1 *FSC NAME: Number:______ HMO?:______ PPO?:______ Can this FSC be copied from another FSC? NO:_____ Yes:_____ If Yes, FSC #:______3 *STATEMENT: Is this Self Pay/.Cycle Stmt?: No___ Yes___ Is this an Employer Stmt only? N___ Y___4 *CLAIMS: Yes____ No____ Create New Run:_____ Add to existing run: Yes___ No___ Run #:____5 MNE6 Certificate number required? No ____ Yes____7 * Registration FSC: No____ Yes____11 If non-registration FSC but claim producing, what one FSC should it be linked to?:13 Grouping Category: Appeal form:23 Keep Cert# Index for Lookups? No____ Yes____26 *Reporting Category 1:27 *Reporting Category 2:28 *Reporting Category 3:29 Sort Value if relationship is Self:30 Relationship is Not Self:31 If a registration FSC, use Effective Date?: No____ Yes____36 Fee Schedule Hierarchy:37 Account Status43 Employer FSC?: No____ Yes___49 Carrier Address 1:50 Carrier City, State:51 Carrier Zip:52 FSC Assignment:53 Carrier Address 2:54 Remittance Address 1: Washington University55 Remittance Address 2: P.O. Box 6035256 Remittance City, State: St. Louis, MO57 Remittance Zip: 63160-035258 Carrier Phone:61 Carrier FAX: 62 Case FSC:63 Destination code:64 Referral Mailed:65 Referral Not Required:66 Referral Needed if Secondary:67 MH Carrier Name:68 MH Carrier Addr1:69 MH Carrier Addr2:70 MH Carrier City, State:71 MH Carrier Zip Code:72 Destination Code Sub-ID:73 *TES Category I:74 TES Category II: :77 Medicode Payor Type: 78 Medicode Proc Field: 79 Medicode Global Period Type: 80 Medicode Global Period Default:81 UHC FSC: 82 Capitation Referral Exception: 83 Claims Status Available? 84 Enter C if Capitation :85 Print Zero aim:86 HMO Use Anes Modifier 87 HMO use Anes Mod when 2nd to Mcare88 EKG Roll - Up 89 OPEN REF-HMO number for tracking Open Referrals:94 When Transferring to this FSC, request a claim?106 EDI Trading Partner? 107 OPENREF-Enter 1 to do Referral Limit Checking for Each Procedure: 109 OPENREF - Corresponding OPEN HMO registration FSC: 124 GHP FSC:125 PH NO Referral: 126 PH NO Precert/Auth 127 PH NO Eligibility: 128 PH NO Benefits: 129 PH NO Mental Health: 130 Valid Security Category: 131 OR Exempt from PS TES Edit: 149 Apply FSC Restriction to Insurance Company D120 entry Y 174 Eligibility Payor Category: 224 PA, NP billable?232 aMPI Mapped FSC Y 233 Subscriber is always Self If the insurance name and address is a Dictionary 120 pull, this needs to be answered on the Dictionary 120 entry. Please request that field be updated on the Dictionary 120 pull.ETM Specific Fields169 Payer’s Website URL:199 ETM Appeal Pending: 182 ETM Role:200 ETM FUP Pending: 190 ETM InsFup# days unpaid Elec Claims:203 AN ETM View Group By:191 ETM InsFup# days unpaid Paper Claims:223 ETM Special Billing Group By: 192 ETM InsFup # days for Invoice Followup:227 SU ETM View Group By:193 ETM Stage Custom Location 4118:194 OS ETM VIEW GROUP BY:Related Dictionary Set Up questions that must be answered:Can this FSC be added to an established Payment code (2) Dictionary entry? No Yes If yes, PCShould this FSC be added to an existing Discount Type (104) Dictionary entry? No Yes If yes, Disc#What Procedures Codes (1) Dictionary entries are not Normally Covered by this FSC? Does the FSC Default Table Need Updating for this FSC? No Yes Group 3 Group 4 Group 6 Group 7 Group 8 Group 9 Group 10 Group 11 Group 12 Group 13 Group 14If so, for which FSC? Does this FSC be added to any Rejection Type (7) Dictionary entries: NoYes If yes, Rej Type # Has the FSC been added to the exchange? GE case #AVM Special Billing Specific InformationThis section is applicable only to Special Billing Visit plans used in AVM. These are plans where the corresponding FSC is non-registration. In most instances, these will not be plans/FSCs handled by the PBS Special Billing Unit.SB-a Name of Special Billing Type: IS Only: Number: Mnemonic: SB-b Should the patient’s registration insurance also be pulled into the visit? Y / NSB-c If Y, should it be before or after the special billing plan? Before / AfterSB-d Last plan to use in visit list (optional):Section BClaim FormsDoes this FSC require special coding on the Claim Forms? No Yes (Provider numbers etc.)If yes, what?Section C FSC Follow Up QuestionsCan the Follow Up Questions be copied from another FSC? No Yes If yes, #For aMPI mapped FSC standardized follow-up questions, see FSCFupQuestbyPayortype excel sheet. Pick the appropriate template for FSC being created. Templates are based on FSC type and 120 pull. These questions must appear on aMPI mapped FSC. For all non-aMPI Mapped FSC, please see below.If questions can’t be copied, please mark Column 1 for each question you want to appear as a follow-up question for this FSC with a “R” for fields that required an answer, or “X”, if answer is optional 1. If you would like a different description please write it in Column 3. Write format text or help messages in the column 4.Mark "R" ormark "X"Field NameOverride field name/description to:Length, Special formats, and/or Help message text:1 Certificate Number2 Group Number3 Plan4 Relationship to Subscriber5 Subscriber Name (if different12 Military Branch15 Status/Ret or Dependent67 Subscriber's Employer24 Ins. Co Dictionary Entry25 Ins. Co. Name Override26 Ins Co. Address Line 127 Ins Co. Address Line 228 Ins. Co. City,State29 Ins. Co. Zip Code17 State abrv.36 Ins. Co. Telephone14 Ins. Co. Fax Telephone40 Ins. Co. Dictionary Contact Person10 Effective Date11 Expiration DateOther?Section DTesting Sign OffThis section is to show completion of testing sign in the test system prior to FSC being available in the live system.aMPI mapping testing through Initiate must be completed if aMPI/Multi-Registration Related question is completed with a “Y”. FSC Default testing must be completed for all new FSC/Plans.aMPI Testing:BPIN Company CodeBPIN Plan CodeDate TestedSign OffFSC Default Testing: FSC DefaultDate TestedSign OffPaycode Testing: PaycodeDate TestedSign OffRejection Code Testing:Rejection Code TypeDate TestedSign OffFOR INFORMATION SYSTEMS USE ONLY: ENTERED BY:Notification Sent:DATE ENTERED: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download