RCRCVCP ;ALB/CMS THIRD PARTY REFERRAL CHECK LIST ; 9/02/97
V ;;4.5;Accounts Receivable;**63**;Mar 20, 1995
;;Per VHA Directive 10-93-142, this routine should not be modified.
Q
CHK(EXP) ;
;Send 1 for expanded view of check list
NEW II,LN,LT,RCY,X S (VALMCNT,X)=""
S LT="RCLST"
F II=1:1 D Q:$P(LN,";",3)="EOF"
.S LN=$T(@LT+II)
.I $P(LN,";",3)="EOF" Q
.I 'EXP,+$P(LN,";",4) Q
.S VALMCNT=+$G(VALMCNT)+1
.S RCY=$P(LN,";",5),X=$$SETFLD^VALM1(RCY,X,"LINE")
.S ^TMP("RCRCVC",$J,VALMCNT,0)=X
.Q
I VALMCNT=0 W !,"NOTHING TO REPORT"
CHKQ Q
;
RCLST ;Referral Check List
;;1;0;o MEDICAL NECESSITY/EMERGENCY DENIAL
;;1;1;The insurance company determines that the medical treatment was not a
;;1;2;medical necessity within the policy guidelines of a legitimate emergency
;;1;3;as required by most Health Maintenance Organizations (HMO).
;;1;4;
;;2;0;o PRE-AUTHORIZATION/PRE-ADMISSION CERTIFICATION DENIAL
;;2;1;The care was not pre-authorized or pre-certified, as required by the
;;2;2;insurance company, and no payment or a reduced payment was made in
;;2;3;accordance with the insurance policy.
;;2;4;
;;3;0;o INSURANCE DEDUCTIBLES
;;3;1;The claim was approved or partially approved, but the payment was applied
;;3;2;to the deductible.
;;3;3;
;;4;0;o MAXIMUM BENEFITS USED
;;4;1;The insurance company has a dollar or visit ceiling and the maximum was
;;4;2;met or exceeded the limits of the policy. This includes
;;4;3;"lifetime ceilings". An example is a limited number of outpatient
;;4;4;visits for mental health allowed each calendar year."
;;4;5;
;;5;0;o REASONABLE AND CUSTOMARY RATES
;;5;1;The insurance company has paid based upon usual and customary rates
;;5;2;in the community for the care provided.
;;5;3;
;;6;0;o LENGTH OF STAY
;;6;1;The insurance company pays based upon an appropriate determination
;;6;2;of length of stay and the veteran has an extended stay beyond the terms
;;6;3;of the insurance policy.
;;6;4;
;;7;0;o LEVEL OF CARE
;;7;1;Acute vs. Non-Acute Care/Nursing Home vs. Skilled Nursing Home Care
;;7;2;
;;7;3;The carrier's payment (or lack thereof) is based upon an appropriate
;;7;4;determination that the level of care exceeded that which was medically
;;7;5;necessary. Most insurance companies will not pay for nursing home
;;7;6;care unless it is skilled nursing care.
;;7;7;
;;8;0;o SPECIAL CONSENT FORM
;;8;1;A SPECIAL CONSENT FORM MUST BE FAXED TO REGIONAL COUNSEL WITHIN
;;8;2;24 HOURS OF REFERRAL if treatment falls under the 38 USC 7332.
;;8;3;
;;9;0;o NO EVIDENCE OF FOLLOW-UP
;;9;1;Regional Counsel personnel is unable to determine what communication
;;9;2;has taken place between VAMC and the insurance company.
;;9;3;
;;10;0;o CORRESPONDENCE NOT RECEIVED
;;10;1;Evidence of collection action by VAMC, i.e., report of contact or
;;10;2;written correspondence between VAMC and insurance company has not
;;10;3;been received.
;;EOF
Q
;RCRCVCP
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HRCRCVCP 3040 printed Dec 13, 2024@01:47:54 Page 2
RCRCVCP ;ALB/CMS THIRD PARTY REFERRAL CHECK LIST ; 9/02/97
V ;;4.5;Accounts Receivable;**63**;Mar 20, 1995
+1 ;;Per VHA Directive 10-93-142, this routine should not be modified.
+2 QUIT
CHK(EXP) ;
+1 ;Send 1 for expanded view of check list
+2 NEW II,LN,LT,RCY,X
SET (VALMCNT,X)=""
+3 SET LT="RCLST"
+4 FOR II=1:1
Begin DoDot:1
+5 SET LN=$TEXT(@LT+II)
+6 IF $PIECE(LN,";",3)="EOF"
QUIT
+7 IF 'EXP
IF +$PIECE(LN,";",4)
QUIT
+8 SET VALMCNT=+$GET(VALMCNT)+1
+9 SET RCY=$PIECE(LN,";",5)
SET X=$$SETFLD^VALM1(RCY,X,"LINE")
+10 SET ^TMP("RCRCVC",$JOB,VALMCNT,0)=X
+11 QUIT
End DoDot:1
if $PIECE(LN,";",3)="EOF"
QUIT
+12 IF VALMCNT=0
WRITE !,"NOTHING TO REPORT"
CHKQ QUIT
+1 ;
RCLST ;Referral Check List
+1 ;;1;0;o MEDICAL NECESSITY/EMERGENCY DENIAL
+2 ;;1;1;The insurance company determines that the medical treatment was not a
+3 ;;1;2;medical necessity within the policy guidelines of a legitimate emergency
+4 ;;1;3;as required by most Health Maintenance Organizations (HMO).
+5 ;;1;4;
+6 ;;2;0;o PRE-AUTHORIZATION/PRE-ADMISSION CERTIFICATION DENIAL
+7 ;;2;1;The care was not pre-authorized or pre-certified, as required by the
+8 ;;2;2;insurance company, and no payment or a reduced payment was made in
+9 ;;2;3;accordance with the insurance policy.
+10 ;;2;4;
+11 ;;3;0;o INSURANCE DEDUCTIBLES
+12 ;;3;1;The claim was approved or partially approved, but the payment was applied
+13 ;;3;2;to the deductible.
+14 ;;3;3;
+15 ;;4;0;o MAXIMUM BENEFITS USED
+16 ;;4;1;The insurance company has a dollar or visit ceiling and the maximum was
+17 ;;4;2;met or exceeded the limits of the policy. This includes
+18 ;;4;3;"lifetime ceilings". An example is a limited number of outpatient
+19 ;;4;4;visits for mental health allowed each calendar year."
+20 ;;4;5;
+21 ;;5;0;o REASONABLE AND CUSTOMARY RATES
+22 ;;5;1;The insurance company has paid based upon usual and customary rates
+23 ;;5;2;in the community for the care provided.
+24 ;;5;3;
+25 ;;6;0;o LENGTH OF STAY
+26 ;;6;1;The insurance company pays based upon an appropriate determination
+27 ;;6;2;of length of stay and the veteran has an extended stay beyond the terms
+28 ;;6;3;of the insurance policy.
+29 ;;6;4;
+30 ;;7;0;o LEVEL OF CARE
+31 ;;7;1;Acute vs. Non-Acute Care/Nursing Home vs. Skilled Nursing Home Care
+32 ;;7;2;
+33 ;;7;3;The carrier's payment (or lack thereof) is based upon an appropriate
+34 ;;7;4;determination that the level of care exceeded that which was medically
+35 ;;7;5;necessary. Most insurance companies will not pay for nursing home
+36 ;;7;6;care unless it is skilled nursing care.
+37 ;;7;7;
+38 ;;8;0;o SPECIAL CONSENT FORM
+39 ;;8;1;A SPECIAL CONSENT FORM MUST BE FAXED TO REGIONAL COUNSEL WITHIN
+40 ;;8;2;24 HOURS OF REFERRAL if treatment falls under the 38 USC 7332.
+41 ;;8;3;
+42 ;;9;0;o NO EVIDENCE OF FOLLOW-UP
+43 ;;9;1;Regional Counsel personnel is unable to determine what communication
+44 ;;9;2;has taken place between VAMC and the insurance company.
+45 ;;9;3;
+46 ;;10;0;o CORRESPONDENCE NOT RECEIVED
+47 ;;10;1;Evidence of collection action by VAMC, i.e., report of contact or
+48 ;;10;2;written correspondence between VAMC and insurance company has not
+49 ;;10;3;been received.
+50 ;;EOF
+51 QUIT
+52 ;RCRCVCP
