Home   Package List   Routine Alphabetical List   Global Alphabetical List   FileMan Files List   FileMan Sub-Files List   Package Component Lists   Package-Namespace Mapping  
Routine: RCRCVCP

RCRCVCP.m

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