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Back  RFI # 1620: 278 Response 2000E HCR

Formal vs. Informal Help Informal Formal

Submitter

Elitsa Evans

Description

Health plan received a request for authorization that included 3 services: request for authorization of ambulance transportation to the doctor’s office, X-Ray and MRI services in 2000F. The health plan provided authorization including separate authorization numbers for the X-Ray and the MRI in HCR, 2000F but it didn't provide authorization for the ambulance transportation. Since the health plan is required to include HCR in 2000E loop, what value should be populated in HCR01 A1 or A2? What value should be populated in the HCR02 since the two services that have been authorized have different authorization numbers?

Submitter Assigned Keywords

HCR authorization 2000E loop

Response

There are two scenarios that could have happened based on how the ambulance portion was requested. If the ambulance services were requested at loop 2000E (Event Level using the CR1 with the UM03=56) and those services were not approved, then the expectation would be that an HCR01=A3 would be provided at 2000E in the response and in some cases an HCR02 may not be returned at this level.
The other scenario would be that all of the services were requested and returned at Loop 2000F. In this instance, Loop 2000E should have an HCR01=A2 (Certified partial) and the HCR02 can be a value at the UMO’s discretion and does not necessarily have to equal any of the values at 2000F. However, please note that the HCR01 and HCR02 at 2000F overrides any values that were at 2000E for those specific services only.
Submission 7/3/2012
Status Date 8/31/2012
Status F - Final
Primary References
Document 005010X217
Set ID278
Loop2000E
Segment IDHCR