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Routine: BARADJR8

BARADJR8.m

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  1. BARADJR8 ; IHS/SD/POT - CREATE ENTRY IN A/R EDI STND CLAIM ADJ REASON ;
  1.  ;;1.8;IHS ACCOUNTS RECEIVABLE**24**;;OCT 26, 2005;Build 69
  1.  ; IHS/SD/POTT HEAT147789 - v1.8 p24 - updated SARs part1
  1.  ; IHS/SD/POTT HEAT146880 1 v1.8 p24
  1.  ; IHS/SD/POTT 3/26/2014 FIXED TYPE IN SAR code 247: Adj code should be 13 instead of 1.
  1.  ; code cloned from BARADJR7
  1.  ;
  1.  ; *********************************************************************
  1. EN ; EP
  1.  D RPMSREA                   ; Create RPMS Reasons
  1.  D STND                      ; Create new StanJdard Adj
  1.  D CLAIM                     ; Create new Claim Status Codes
  1.  D ^BARVKL0
  1.  Q
  1.  ; ********************************************************************
  1.  ;
  1. RPMSREA ;
  1.  ; Create new Adjustment Reasons in A/R TABLE ENTRY
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  D BMES^XPDUTL("Adding New Adjustment Reasons to A/R Table Entry file...")
  1.  F  D RPMSREA2 Q:BARVALUE="END"
  1.  Q
  1.  ; ********************************************************************
  1.  ;
  1. RPMSREA2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@1+BARCNT),BARD,2,4)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y
  1.  S DIC="^BARTBL("
  1.  S DIC(0)="LZE"
  1.  S DINUM=$P(BARVALUE,BARD)
  1.  S X=$P(BARVALUE,BARD,2)
  1.  S DIC("DR")="2////^S X=$P(BARVALUE,BARD,3)"
  1.  K DD,DO
  1.  D MES^XPDUTL($P(BARVALUE,BARD)_"  "_$P(BARVALUE,BARD,2))
  1.  D FILE^DICN
  1.  Q
  1.  ; ********************************************************************
  1. CHNGREA ; EP
  1.  ; Change category of these reasons to Non-Payment
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  F  D CHNGREA2 Q:BARVALUE="END"
  1.  Q
  1.  ; ********************************************************************
  1. CHNGREA2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@4+BARCNT),BARD,3)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DIE
  1.  S DIE="^BARTBL("
  1.  S DA=BARVALUE
  1.  S DR="2////^S X=4"
  1.  D ^DIE
  1.  Q
  1.  ; ********************************************************************
  1. STND ;
  1.  ; Create entries in A/R EDI STND CLAIM ADJ REASONS to accomodate
  1.  ; Standard codes added between 6/02 and 9/03.
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  D BMES^XPDUTL("Updating Standard Adjustment Reasons in A/R EDI STND CLAIM ADJ REASONS file...")
  1.  F  D STND2 Q:BARVALUE="END"
  1.  Q
  1.  ; ********************************************************************
  1. STND2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@2+BARCNT),BARD,2,6)
  1.  Q:BARVALUE="END"
  1. STND3 ;
  1.  ;look for existing entry
  1.  K DIC,DA,X,Y
  1.  S DIC="^BARADJ("
  1.  S DIC(0)="M"
  1.  S X=$P(BARVALUE,BARD)
  1.  D ^DIC
  1.  I +Y>0 D  Q  ;if existing entry found - edit it
  1.  .D MES^XPDUTL($P(BARVALUE,BARD)_$S($L($P(BARVALUE,BARD))=2:"   ",$L($P(BARVALUE,BARD))=1:"    ",1:"  ")_$E($P(BARVALUE,BARD,2),1,65))
  1.  .K DIC,DIE
  1.  .S DIE="^BARADJ("
  1.  .S DA=+Y
  1.  .S DR=".02///^S X=$P(BARVALUE,BARD,2)"              ; Short Desc
  1.  .S DR=DR_";.03////^S X=$P(BARVALUE,BARD,3)"   ; RPMS Cat
  1.  .S DR=DR_";.04////^S X=$P(BARVALUE,BARD,4)"   ; RPMS Type
  1.  .S DR=DR_";101///^S X=$P(BARVALUE,BARD,5)"    ; Long Desc 
  1.  .D ^DIE
  1.  ;create new entry if none found
  1.  K DIC,DA,X,Y
  1.  S DIC="^BARADJ("
  1.  S DIC(0)="LZE"
  1.  S X=$P(BARVALUE,BARD)                                     ; Stnd Code
  1.  S DIC("DR")=".02///^S X=$P(BARVALUE,BARD,2)"              ; Short Desc
  1.  S DIC("DR")=DIC("DR")_";.03////^S X=$P(BARVALUE,BARD,3)"   ; RPMS Cat
  1.  S DIC("DR")=DIC("DR")_";.04////^S X=$P(BARVALUE,BARD,4)"   ; RPMS Type
  1.  S DIC("DR")=DIC("DR")_";101///^S X=$P(BARVALUE,BARD,5)"    ; Long Desc
  1.  K DD,DO
  1.  D MES^XPDUTL($P(BARVALUE,BARD)_$S($L($P(BARVALUE,BARD))=2:"   ",$L($P(BARVALUE,BARD))=1:"    ",1:"  ")_$E($P(BARVALUE,BARD,2),1,65))
  1.  D FILE^DICN
  1.  Q
  1.  ; ********************************************************************
  1. CLAIM ;
  1.  ; Populate A/R EDI CLAIM STATUS CODES to accomodate new codes added
  1.  ; between 6/02 and 9/03. Inactivate necessary codes.
  1.  S BARCNT=0
  1.  F  D CLAIM2 Q:BARVALUE="END"
  1.  S BARCNT=0
  1.  F BARVALUE=8,10,11,13,14,28,69,70 D CLAIM3
  1.  Q
  1.  ; ********************************************************************
  1. CLAIM2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@3+BARCNT),BARD,2,4)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y
  1.  S DIC="^BARECSC("
  1.  S DIC(0)="LZE"
  1.  S X=$P(BARVALUE,BARD)                        ;Status Cd
  1.  S DIC("DR")="11///^S X=$P(BARVALUE,BARD,2)"  ;Description
  1.  K DD,DO
  1.  D FILE^DICN
  1.  Q
  1.  ; ********************************************************************
  1. CLAIM3 ;
  1.  K DIC,DA,X,Y
  1.  S DIC="^BARECSC("
  1.  S DIC(0)="XZQ"
  1.  S X=BARVALUE
  1.  K DD,DO
  1.  D ^DIC
  1.  Q:+Y<1
  1.  K DA,DIE,DR
  1.  S DA=+Y
  1.  S DIE=DIC
  1.  S DR=".02///Y"
  1.  D ^DIE
  1.  Q
  1.  ; ********************************************************************
  1. MODIFY ; EP
  1.  ; Change PENDING to NON PAYMENT
  1.  S BARD=";;"
  1.  S BARCNT=0
  1.  F  D MODIFY2 Q:BARVALUE="END"
  1.  Q
  1.  ; *********************************************************************
  1. MODIFY2 ;
  1.  S BARCNT=BARCNT+1
  1.  S BARVALUE=$P($T(@4+BARCNT),BARD,2)
  1.  Q:BARVALUE="END"
  1.  K DIC,DA,X,Y,DR
  1.  S DIC="^BARADJ("
  1.  S DIC(0)="Z"
  1.  S X=$P(BARVALUE,BARD)  ;Stnd Code
  1.  K DD,DO
  1.  D ^DIC
  1.  Q:'+Y
  1.  ;
  1.  S DIE=DIC
  1.  S DA=+Y
  1.  S DR=".03////^S X=4"
  1.  D ^DIE
  1.  Q
  1.  ;
  1.  ; *********************************************************************
  1.  ; IEN;;NAME;;TABLE TYPE
  1.  ; *********************************************************************
  1. 1 ;; A/R Table Entry file - Adds (S DIC="^BARTBL(")
  1.  ;;300;;Doc rcvd inconsist w/exp cntnt;;4
  1.  ;;301;;Doc rcvd not contain req cntnt;;4
  1.  ;;302;;Doc reqd to adjudicate clm/svc;;4
  1.  ;;303;;Sequestration-red in fed pymt;;15
  1.  ;;304;;Submit svcs to pt's med plan;;4
  1.  ;;305;;Clm pending due to litigation;;21
  1.  ;;306;;Not payable per mngd care cont;;4
  1.  ;;307;;Clm pndng during prem grace pd;;21
  1.  ;;308;;Clm not cvrd - pt incarcerated;;4
  1.  ;;400;;Cancelled/Expired Appropriation;;22
  1.  ;;401;;ST-mandated rqrmt for property;;22
  1.  ;;402;;Not work related inj/illness;;4
  1.  ;;403;;WC case settled, pt resp;;4
  1.  ;;404;;WC case adjudicated as non-WC;;4
  1.  ;;405;;Based on payer reas & cust fee;;4
  1.  ;;406;;Based on entitlement to bnfts;;4
  1.  ;;407;;Resub w/correct proc code;;22
  1.  ;;408;;Clm is under investigation;;22
  1.  ;;409;;No CPT/HCPCS to describe svc;;4
  1.  ;;410;;Zero pmt due to litigation;;4
  1.  ;;411;;Clm pending due to litigation;;21
  1.  ;;412;;WC fee schedule adjustment;;4
  1.  ;;413;;Pmt reduced due to WC policies;;4
  1.  ;;414;;Pmt incl w/pmt for other svc;;4
  1.  ;;415;;WC Med Trtmt Guideline adjstmt;;4
  1.  ;;416;;Med prov not auth'd for WC;;4
  1.  ;;417;;Referral not auth'd by attndng;;15
  1.  ;;418;;Proc not listed/comp svc allwd;;4
  1.  ;;419;;No pymt due,proc fee is zero;;4
  1.  ;;420;;Svc not pd under oupt fee schd;;4
  1.  ;;421;;TPL Payment denied-MPC/PIP;;4
  1.  ;;422;;TPL Payment adjusted-MPC/PIP;;4
  1.  ;;423;;TPL Fee Sch Adjust-MPC/PIP;;4
  1.  ;;762;;Property & Casualty Require;;4
  1.  ;;823;;Pmt incl w/pmt for other svc;;4
  1.  ;;824;;WC Med Trtmt Guideline adjstmt;;4
  1.  ;;825;;Med prov not auth'd for WC;;4
  1.  ;;826;;Referral not auth'd by attndng;;15
  1.  ;;827;;Proc not listed/comp svc allwd;;22
  1.  ;;828;;No pymt due,proc fee is zero;;22
  1.  ;;829;;Svc not pd under oupt fee schd;;4
  1.  ;;841;;Payment denied;;4
  1.  ;;842;;Payment adjusted;;4
  1.  ;;843;;Fee schedule adjustment;;22
  1.  ;;980;;Dx inconsist w pt's birth wt;;4
  1.  ;;981;;Low Income Subsidy copay amt;;14
  1.  ;;982;;Svcs not provided by netwk/pcp;;4
  1.  ;;983;;Svcs not auth'd by network/pcp;;4
  1.  ;;984;;Pmt reduced to zero due to lit;;21
  1.  ;;985;;Prov performance prog withhold;;15
  1.  ;;986;;Non-payable code for req'd rep;;4
  1.  ;;987;;Ded-Prof svc rendered in Inst;;1
  1.  ;;988;;Coins-Prof svc rendrd in Inst;;14
  1.  ;;989;;Clm identified as readmission;;4
  1.  ;;END
  1.  ; ********************************************************************
  1.  ; STND CODE ;; SHORT DESC ;; RPMS CAT ;; RPMS TYP ;; LONG DESC
  1.  ; ********************************************************************
  1. 2 ;;DIC="^BARADJ("
  1.  ;;133;;The disposition of this claim/service is pending further review;;21;;733;;The disposition of the claim/service is pending further review. (Use only with Group Code OA)
  1.  ;;240;;Dx inconsistent with pt's birth weight.;;4;;980;;The diagnosis is inconsistent with the patient's birth weight. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
  1.  ;;241;;Low Income Subsidy (LIS) co-pay amount;;14;;981;;Low Income Subsidy (LIS) Co-payment Amount
  1.  ;;242;;Svcs not provided by network/primary care providers;;4;;982;;Services not provided by network/primary care providers.
  1.  ;;243;;Svcs not authorized by network/primary care providers;;4;;983;;Services not authorized by network/primary care providers.
  1.  ;;244;;Pymt red to zero due to lit. Addt'l info will be sent following concl of lit.;;21;;984;;Payment reduced to zero due to litigation. Additional information will be sent following the conclusion of litigation. To be used for Property & Casualty only.
  1.  ;;245;;Prov performance program withhold.;;15;;985;;Provider performance program withhold.
  1.  ;;246;;This non-payable code is for req'd reporting only.;;4;;986;;This non-payable code is for required reporting only.
  1.  ;;247;;Ded for Prof svc rendered in Institutional setting and billed on Inst clm.;;13;;987;;Deductible for Professional service rendered in an Institutional setting and billed on an Institutional claim.
  1.  ;;248;;Coins for Prof svc rendered in Institutional setting and billed on Inst clm.;;14;;988;;Coinsurance for Professional service rendered in an Institutional setting and billed on an Institutional claim.
  1.  ;;249;;Clm identified as a readmission.;;4;;989;;This claim has been identified as a readmission. (Use only with Group Code CO).
  1.  ;;250;;Documentation recv'd is inconsistent w/expected content.;;4;;300;;The attachment/other documentation content received is inconsistent with the expected content.
  1.  ;;251;;Documentation recv'd did not contain content required to process clm/svc.;;4;;301;;The attachment/other documentation content received did not contain the content required to process this claim or service.
  1.  ;;252;;Doc required to adjudicate clm/svc. At least one Remark Code must be provided.;;4;;302;;An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided.
  1.  ;;253;;Sequestration - reduction in federal pymt.;;15;;303;;Sequestration - reduction in federal payment
  1.  ;;254;;Clm rcvd by dental plan but bnfts not avail. Submit to pt's medical plan.;;4;;304;;Claim received by the dental plan, but benefits not available under this plan. Submit these services to the patient's medical plan for further consideration.
  1.  ;;255;;Clm pending due to litigation.;;21;;305;;The disposition of the related Property & Casualty claim (injury or illness) is pending due to litigation. (Use only with Group Code OA)
  1.  ;;256;;Svc not payable per managed care contract.;;4;;306;;Service not payable per managed care contract.
  1.  ;;257;;Clm pending during the prem grace period, per Health Ins Exchange requirements.;;21;;307;;The disposition of the claim/service is pending during the premium payment grace period, per Health Insurance Exchange requirements. (Use only with Group Code OA)
  1.  ;;258;;Clm/svc not cvrd when pt in cust/incarcerated. Fed,state,local auth may cover.;;4;;308;;Claim/service not covered when patient is in custody/incarcerated. Applicable federal, state or local authority may cover the claim/service.
  1.  ;;END
  1.  ;
  1.  ; ********************************************************************
  1.  ; CLAIM STATUS CODE ;; DESCRIPTION
  1.  ; ********************************************************************
  1. 3 ;; - A/R EDI Claim Status Codes file - Adds DIC="^BARECSC("
  1.  ;;END
  1.  ;
  1.  ; ********************************************************************
  1.  ; STANDARD CODE ;; RPMS REASON
  1.  ; ********************************************************************
  1. 4 ;;A/R Table Entry file - Edits DIE="^BARTBL("
  1.  ;;END;;END