United Healthcare (UHC) Review Notification, Subscriber and Dependent v1.2

Transcription

1 United Healthcare (UHC) Review Notification, Subscriber and Dependent v

2 This publication is the proprietary property of Emdeon and is furnished solely for use pursuant to a license agreement giving the user the right to use the Emdeon product(s) referenced in this document. All uses of this document are subject to the terms of such license agreement. This document may not be used except as permitted by such license agreement or changed, copied, photocopied, reproduced, translated, or reduced to any electronic medium or machine readable form without the prior consent of Emdeon. Copyright is held by Emdeon Business Services, LLC. Emdeon is not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or consequential damages.

3 Table of Contents Table of Contents Overview About the Transaction Customer Support Emdeon Customer Support Requests Request Data Input Prompts Account # Admission Date Admission Type Admit Msg Amount Date of Birth Dep DOB Dep First Name Dep Gender Dep Group # Dep Last Name Diagnosis Code Diagnosis Code Diagnosis Code Discharge Date Est DOB First Name Gender Group # Last Mnst Period Last Name PE Addl ID PE Addl ID PE Addl ID PE Admin Ref # PE Contact PE Contact PE Contact PE Last/Org PE Last/Org PE Last/Org PE Level of Svc PE Place of Svc PE Prov Addr PE Prov Addr PE Prov Addr PE Prov City PE Prov City PE Prov City PE Entity Type PE Entity Type PE Prov First PE Prov First PE Prov First PE Prov ID PE Prov ID PE Prov ID Emdeon Business Services LLC. All rights reserved. Page i

4 Table of Contents PE Prov State PE Prov State PE Prov State PE Prov ZIP PE Prov ZIP PE Prov ZIP PE Prov Tel PE Prov Tel PE Prov Tel PE Service Type Proc Code Relationship Req Addl ID Req Last/Org Req Prov ID Service Type Sub DOB Sub First Name Sub Last Name Subscriber ID Svc Admin Ref # Svc Contact Svc Date Begin Svc Date End Svc Last/Org Svc Prov Addl ID Svc Prov Addr Svc Prov City Svc Prov Entity Svc Prov First Svc Prov ID Svc Prov State Svc Prov Tel Svc Prov Zip Svc Unit Count Svc Unit Qual Responses About Your Responses Status Closed Retry Error Input Information Notification Status Payer Information Requesting Provider Information Subscriber Subscriber Additional ID Dependent Dependent Additional ID Patient Event Service Level Error Messages Index Emdeon Business Services LLC. All rights reserved. Page ii

5 Overview Overview About the Transaction The United Healthcare (UHC) subscriber and dependent Health Care Services Review Notification informs UHC that a plan member has been admitted to a facility (e.g., acute care hospital, skilled nursing facility, or an acute rehabilitation facility), which allows UHC the opportunity to coordinate programs related to the setting of care, discharge planning, and referral to after-care programs. Timely admission notification allows UHC staff, physicians and hospital staff to engage in dialogue designed to ensure that the patient s care path is consistent with evidence-based therapies and management and to coordinate care related to the facility stay. It is extremely important that UHC be made aware of an admission as soon as possible. This enables UHC to engage the appropriate resources for a positive effect on clinical outcomes while the patient is in the hospital and to coordinate care after discharge. Note: If you are using Emdeon MAX shell versions prior to 2.3 or Server versions prior to 4.11, you must run this transaction using dialup. Customer Support Emdeon Customer Support customer.service@emdeon.com 2014 Emdeon Business Services LLC. All rights reserved. Page 1

6 Requests Requests Request Data The following list shows the information for which you are prompted in a typical Health Care Services Review Notification. See the Input Prompts on page 3 for specific requirements. Requesting Provider Information Provider last name/organization name Provider ID Patient Event (PE) Information PE place of service PE level of service PE Administrative reference number Admission type Admission date Discharge date Admitting message Principal diagnosis code Secondary diagnosis codes Patient Event (PE) Provider Information (Information for up to three PE providers may be entered.) Provider last name/organization name Provider first name Provider ID or admitting facility ID Provider entity type Provider address Provider s contact person Provider telephone number, fax number or address Service Type Service Provider Information Provider last name/organization name Provider first name Provider ID Provider entity type Provider address Provider s contact person Provider telephone number, fax number or address Service-Related Information Primary procedure code 2014 Emdeon Business Services LLC. All rights reserved. Page 2

7 Requests Service type Service quantity Service administrative reference number Service begin date Service end date Patient Information Subscriber last name Subscriber first name Subscriber ID Subscriber date of birth Subscriber gender (subscriber transactions only) Last menstrual period Estimated date of birth Dependent last name (dependent transactions only) Dependent first name (dependent transactions only) Dependent group number (dependent transactions only) Dependent date of birth (dependent transactions only) Dependent gender (dependent transactions only) Relationship (dependent transactions only) Input Prompts Prompts are listed in alphabetical order. Account # The patient s account number. For your internal use only (not sent to the payer). Admission Date The proposed or actual date of admission, in MMDDCCYY format. Admission Type The type of admission. Choose a value from the drop-down list. Admit Msg Requirement: Required if Diagnosis Code 1 is not entered. The admit time (AT) followed by a free-form text message (ICD) about the admission or the patient s diagnosis (admitting reason, chief complaint, etc.). You can enter up to 28 characters. Enter the admit time in HHMMSS format (hour, minutes and seconds), enter a semi-colon (;), then enter ICD= followed by the text message. Use this format for the admit time and message: 2014 Emdeon Business Services LLC. All rights reserved. Page 3

8 Requests AT=HHMMSS;ICD=ZZZZ For example: AT=081500;ICD=mult fractures Note: Do not use facility-specific acronyms, terminology or abbreviations. Use English descriptions or common industry terminology. Amount The amount of the claim. For your internal use only (not sent to the payer). Date of Birth Used in: Subscriber transactions The subscriber s date of birth, in MMDDCCYY format. Dep DOB Used in: Dependent transactions. The dependent s date of birth, in MMDDCCYY format. Dep First Name Used in: Dependent transactions. The dependent s first name. Dep Gender Used in: Dependent transactions. The dependent s gender. Choose a value from the drop-down list. Dep Group # Used in: Dependent transactions. The dependent s plan group number. Dep Last Name Used in: Dependent transactions. The dependent s last name. Diagnosis Code 1 Requirement: Required if the Admit Msg was not entered. The primary ICD-9-CM or ICD-10-CM patient diagnosis code Emdeon Business Services LLC. All rights reserved. Page 4

9 Requests Diagnosis Code 2 A second ICD-9-CM or ICD-10-CM patient diagnosis code. Diagnosis Code 3 A third ICD-9-CM or ICD-10-CM patient diagnosis code. Discharge Date The date the patient was discharged, in MMDDYY or MMDDCCYY format. Est DOB Requirement: Situational. The estimated date of birth, in MMDDYY or MMDDCCYY format, if the patient s review involves a pregnancy. If you do not enter a date, the date defaults to the current date. First Name Used in: Subscriber transactions. The subscriber s first name. Gender Used in: Subscriber transactions. The subscriber s gender. Choose a value from the drop-down list. Group # Used in: Subscriber transactions. The subscriber s plan group number. Last Mnst Period Requirement: Situational. The date of the patient s last menstrual period, in MMDDYY or MMDDCCYY format. Last Name Used in: Subscriber transactions. The subscriber s last name. PE Addl ID 2014 Emdeon Business Services LLC. All rights reserved. Page 5

10 An additional provider ID for the admitting facility or Patient Event (PE) provider. United Healthcare Review Notification Requests PE Addl ID 2 An additional ID for the second Patient Event (PE) provider. PE Addl ID 3 An additional provider ID for the third Patient Event (PE) provider. PE Admin Ref # An administrative reference number for the Patient Event (PE) provider. PE Contact A contact person s name for the admitting facility. If you do not have a contact person s name, enter Not Available in this field. PE Contact 2 A contact person s name for the second Patient Event (PE) provider. PE Contact 3 A contact person s name for the third Patient Event (PE) provider. PE Last/Org The admitting facility s name. PE Last/Org 2 The last name of a second Patient Event (PE) provider, if a person, or organization name. PE Last/Org 3 The last name of a third Patient Event (PE) provider, if a person, or organization name. PE Level of Svc The level of urgency of the service rendered. Choose a value from the drop-down list Emdeon Business Services LLC. All rights reserved. Page 6

11 PE Place of Svc The place of service for the patient event. Choose a value from the drop-down list. PE Prov Addr 1 The street address or PO Box portion of the admitting facility. PE Prov Addr 2 United Healthcare Review Notification Requests The street address or PO Box portion of the second Patient Event (PE) provider s address. PE Prov Addr 3 The street address or PO Box portion of the third Patient Event (PE) provider s address. PE Prov City The city portion of the admitting facility s address. PE Prov City 2 The city portion of the second Patient Event (PE) provider s address. PE Prov City 3 The city portion of the third Patient Event (PE) provider s address. PE Entity Type 2 The second type of entity admitting or attending the patient. Choose a value from the drop-down list. PE Entity Type 3 Used in: Subscriber transactions. The third type of entity admitting or attending the patient. Choose a value from the drop-down list. PE Prov First The admitting facility s name Emdeon Business Services LLC. All rights reserved. Page 7

12 Requests PE Prov First 2 The first name of the second Patient Event (PE) provider. PE Prov First 3 The first name of the third Patient Event (PE) provider. PE Prov ID The facility ID of the admitting facility. The admitting facility ID must match the provider ID of the requesting provider. PE Prov ID 2 The provider ID of the second Patient Event (PE) provider. You must enter either the admitting or attending provider ID. PE Prov ID 3 The provider ID of the third Patient Event (PE) provider. Enter either the admitting or attending provider ID. PE Prov State The state portion of the admitting facility s address. PE Prov State 2 The state portion of the second Patient Event (PE) provider s address. PE Prov State 3 The state portion of the third Patient Event (PE) provider s address. PE Prov ZIP The admitting facility s ZIP code, in or format. Do not enter a dash. PE Prov ZIP 2 The second Patient Event (PE) provider s ZIP code, in or format. Do not enter a dash Emdeon Business Services LLC. All rights reserved. Page 8

13 PE Prov ZIP 3 United Healthcare Review Notification Requests The third Patient Event (PE) provider s ZIP code, in or format. Do not enter a dash. PE Prov Tel The admitting facility s telephone number, FAX number or address. PE Prov Tel 2 The second Patient Event (PE) provider s telephone number, FAX number or address. PE Prov Tel 3 The third Patient Event (PE) provider s telephone number, FAX number or address. PE Service Type The type of service relating to the patient event. Choose a value from the drop-down list. Proc Code The primary procedure code relating to the service(s) requested. Relationship Used in: Dependent transactions. The relationship of the patient to the subscriber. Req Addl ID An additional provider ID for the requesting provider. Req Last/Org The requesting provider s last name, if a person, or organization name. Req Prov ID The provider ID of the requesting provider. The requesting provider s provider ID must match the admitting facility ID entered in the first PE Prov ID field Emdeon Business Services LLC. All rights reserved. Page 9

14 Service Type The type of service relating to the condition. Choose a value from the drop-down list. Sub DOB Used in: Dependent transactions. The subscriber s date of birth, in MMDDCCYY format. Sub First Name Used in: Dependent transactions. The subscriber s first name. Sub Last Name Used in: Dependent transactions. The subscriber s last name. Subscriber ID The UHC subscriber ID of the plan subscriber. Svc Admin Ref # An administrative reference number for the service provider. Svc Contact A contact name for the service provider. Svc Date Begin The proposed or actual beginning date of service, in MMDDYY or MMDDCCYY format. Svc Date End The proposed or actual ending date of service, in MMDDYY or MMDDCCYY format. Svc Last/Org Requirement: Required if the servicing provider is not the Patient Event provider. The service provider s last name, if a person, or organization name. United Healthcare Review Notification Requests 2014 Emdeon Business Services LLC. All rights reserved. Page 10

15 Requests Svc Prov Addl ID An additional provider ID for the service provider. Svc Prov Addr 1 The street or PO Box portion of the service provider s address. Svc Prov City The city portion of the service provider s address. Svc Prov Entity The type of service provider ID used in this transaction. Choose a value from the drop-down list. Svc Prov First Requirement: Required if the servicing provider is not the Patient Event provider. The service provider s first name. Svc Prov ID The service provider s ID. Svc Prov State The service provider s state. Svc Prov Tel The service provider s telephone number, fax number, or address. Svc Prov Zip The service provider s ZIP code, in or format (no dash). Svc Unit Count The quantity of the services to be rendered Emdeon Business Services LLC. All rights reserved. Page 11

16 Requests Svc Unit Qual Requirement: Required if you entered a service quantity; otherwise, optional. The type of units entered in the Svc Qty field. Choose a value from the drop-down list Emdeon Business Services LLC. All rights reserved. Page 12

17 Responses Responses About Your Responses All of the items described in the following response explanation may not appear in every response. The database will return only the information that is applicable to your query. If the database does not return a particular piece or section of information in a specific response, the headings for that information will not print. Items will shift position to fill the vacancy. Your username appears in the upper left corner of the response. See your product User s Guide for information about creating usernames. Additional Reference Documents More information about your response can be found in the following documents: PC-Standard-Health-Care-Service Review-Dictionary.pdf gives a more detailed description of data fields returned in the standard Emdeon response. Dictionary-of-Transaction-Error-Messages.pdf a complete dictionary of error messages. Common Response Abbreviations.pdf common abbreviations used in the standard Emdeon response, along with their full description. These documents are available on your installation CD, and on the Web at: Note: The above documents are in Portable Document Format (.pdf). You must have the Adobe Acrobat Reader to view this document. If you do not have the Reader, you can download it for free at Status Closed Emdeon received a valid response. Read your response for clarification. Retry Emdeon did not receive a valid response. Read the message in the response for clarification. Error A communications-related error or error of greater severity occurred. Read the message in the response for clarification. Input Information The Input Information section shows the information you entered in your inquiry. Notification Status This section returns information about the status of the notification such as: An Action Code and a description assigned by the payer to identify the reason for the health care service review outcome: A1 - Certified in Total 2014 Emdeon Business Services LLC. All rights reserved. Page 13

18 Responses A2 - Certified Partial A3 - Not Certified A4 - Pended A6 Modified* C - Cancelled CT - Contact Payer NA - No Action Required *Note: Action Code A6 Modified indicates that the notification was successfully entered into the system. The ID number assigned by the requesting provider to the health care service review outcome. Whether or not a second surgical opinion is required. An administrative reference number for the notification and associated services. A previous authorization number. Payer Information This section returns information about the payer such as: The notification transaction reference number. The date the transaction was generated by the payer. The payer s primary identification number. The payer s name. The name of the payer s contact person. The telephone number for the payer s contact person. If the service authorization was rejected, this information describes the error condition associated with the rejection. A follow-up action message for the preceding reject reason. Requesting Provider Information This section returns information about the requesting provider such as: If the trading partner information was rejected, this information describes the error condition associated with the rejection. A follow-up action message for the preceding reject reason. The provider ID of the requesting provider. The requesting provider s name. The name of the requesting provider s contact person. The telephone number for the requesting provider s contact person. A description of the requesting provider s or facility s role. The taxonomy code and description designating the requesting provider s or facility s specialty. If the requesting provider was rejected, this information describes the error condition associated with the rejection. A follow-up message to the preceding reject reason Emdeon Business Services LLC. All rights reserved. Page 14

19 Subscriber This section returns information about the subscriber such as: United Healthcare Review Notification Responses An error message associated with the subscriber s diagnosis or the service date information. A follow-up action message for the preceding reject reason. Up to three trace numbers assigned to identify the transaction. Up to three originators of the trace numbers. The type of identification and an additional reference number for the subscriber. The subscriber s subscriber ID. The subscriber s name and date of birth. The subscriber s gender. If the subscriber was rejected, this information describes the error condition associated with the rejection. A follow-up action message for the preceding reject reason. Subscriber Additional ID This section returns information about additional information on the subscriber such as: The type of identification and an additional reference number for the subscriber. A free-form message about the additional reference number. Dependent This section returns information about the dependent such as: An error message associated with the dependent s diagnosis or the service date information. A follow-up action message for the preceding reject reason. Up to three trace numbers assigned to identify the transaction. Up to three originators of the trace numbers. The type of identification and an additional reference number for the dependent. The dependent s primary ID number. The dependent s name and date of birth. The dependent s gender. The dependent s relationship to the subscriber. If the dependent was rejected, this information describes the error condition associated with the rejection. A follow-up action message for the preceding reject reason. Dependent Additional ID This section returns information about additional information on the dependent such as: The type of identification and an additional reference number for the dependent. A free-form message about the additional reference number. Patient Event The Patient Event section contains details about the requested services such as: 2014 Emdeon Business Services LLC. All rights reserved. Page 15

20 An error message associated with the patient s diagnosis or the service date information. A follow-up action message for the preceding reject reason. Up to three trace numbers assigned to identify the transaction. Up to three originators of the trace numbers. A category code and a description of requested patient event. The type of certification for the patient event. The service type code and a description of the requested services. The date of the patient event. The proposed or actual admission and discharge dates. The issue and expiration dates for the patient event certification. United Healthcare Review Notification Responses Up to 12 diagnosis codes associated with the certification number, and their associated descriptions. The provider ID of the admitting facility or Patient Event provider. The admitting facility or Patient Event provider s name. An additional identification number for the Patient Event provider. The Patient Event provider s specialty. If the Patient Event provider was rejected, this information describes the error condition associated with the rejection. Service Level The Service Level section contains details about the level of services such as: An error message associated with the level of service or the service date information. A follow-up action message for the preceding reject reason. Up to three trace numbers assigned to identify the transaction. Up to three originators of the trace numbers. A category code and a description of requested level of service. The type of certification for the level of service. The service type code and a description of the level of service. The date of the service. The issue and expiration dates for the service certification. The effective date of the service certification. Up to two procedure codes for the professional services. Up to two quantities for the services rendered. The provider ID of the servicing provider. The servicing provider s name. An additional identification number for the servicing provider. The taxonomy code and description designating the servicing provider s specialty. If the servicing provider was rejected, this information describes the error condition associated with the rejection. A follow-up message to the preceding reject reason Emdeon Business Services LLC. All rights reserved. Page 16

21 Error Messages United Healthcare Review Notification Responses Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text. Messages are self-explanatory. For a comprehensive description of all error messages, see the document Dictionary of Transaction Error Messages. This document is available on your installation CD, and on the Web at: Emdeon Business Services LLC. All rights reserved. Page 17

22 Index Index A About the Transaction, 1 About Your Responses, 13 Account #, 3 Admission Date, 3 Admission Type, 3 Admit Msg, 3 Amount, 4 C Closed, 13 Customer Support, 1 D Date of Birth, 4 Dep DOB, 4 Dep First Name, 4 Dep Gender, 4 Dep Group #, 4 Dep Last Name, 4 Dependent, 15 Dependent Additional ID, 15 Diagnosis Code 1, 4 Diagnosis Code 2, 5 Diagnosis Code 3, 5 Discharge Date, 5 E Emdeon Customer Support, 1 Error, 13 Error Messages, 17 Est DOB, 5 F First Name, 5 G Gender, 5 Group #, 5 I Input Information, 13 Input Prompts, 3 L Last Mnst Period, 5 Last Name, 5 N Notification Status, 13 P Patient Event, 15 Payer Information, 14 PE Addl ID, 5 PE Addl ID 2, 6 PE Addl ID 3, 6 PE Admin Ref #, 6 PE Contact, 6 PE Contact 2, 6 PE Contact 3, 6 PE Entity Type 2, 7 PE Entity Type 3, 7 PE Last/Org, 6 PE Last/Org 2, 6 PE Last/Org 3, 6 PE Level of Svc, 6 PE Place of Svc, 7 PE Prov Addr 1, 7 PE Prov Addr 2, 7 PE Prov Addr 3, 7 PE Prov City, 7 PE Prov City 2, 7 PE Prov City 3, 7 PE Prov First, 7 PE Prov First 2, 8 PE Prov First 3, 8 PE Prov ID, 8 PE Prov ID 2, 8 PE Prov ID 3, 8 PE Prov State, 8 PE Prov State 2, 8 PE Prov State 3, 8 PE Prov Tel, 9 PE Prov Tel 2, 9 PE Prov Tel 3, 9 PE Prov ZIP, 8 PE Prov ZIP 2, 8 PE Prov ZIP 3, 9 PE Service Type, 9 Proc Code, 9 R Relationship, 9 Req Addl ID, 9 Req Last/Org, 9 Req Prov ID, 9 Request Data, 2 Requesting Provider Information, 14 Retry, 13 S Service Level, 16 Service Type, 10 Status, 13 Sub DOB, 10 Sub First Name, 10 Sub Last Name, 10 Subscriber, 15 Subscriber Additional ID, 15 Subscriber ID, 10 Svc Admin Ref #, 10 Svc Contact, 10 Svc Date Begin, 10 Svc Date End, 10 Svc Last/Org, 10 Svc Prov Addl ID, 11 Svc Prov Addr 1, 11 Svc Prov City, Emdeon Business Services LLC. All rights reserved. Page 18

23 Index Svc Prov Entity, 11 Svc Prov First, 11 Svc Prov ID, 11 Svc Prov State, 11 Svc Prov Tel, 11 Svc Prov Zip, 11 Svc Unit Count, 11 Svc Unit Qual, Emdeon Business Services LLC. All rights reserved. Page 19

24 Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers, and patients in the U.S. healthcare system. For more information, visit Emdeon Business Services LLC. All rights reserved Lebanon Pike, Suite 1000 Nashville, TN EMDEON.6 ( )