ABMDLCK1 ; IHS/ASDST/DMJ - check visit for elig - CONT'D ;
;;2.6;IHS 3P BILLING SYSTEM;**11,21**;NOV 12, 2009;Build 379
;;Y2K/OK - IHS/ADC/JLG 12-18-97
;Original;TMD;
; Code has been added to use the billing limit from the parameters file
; if no back billing limit has been set for the insurer. ;JLG 4/8/98
;
; IHS/DSD/JLG - 6/29/1999 - NOIS HQW-0798-100082 Patch 3 #4
; Modified to capture reason for ineligibility, for programmers use
;
; IHS/DSD/MRS - 8/27/1999 - NOIS XAA-0899-200058 Patch 3 #13
; Modified to prevent generating out-patient claims for Medicare
; with Part A only
;
; IHS/ASDS/LSL - 06/26/2001 - V2.4 Patch 9 - NOIS HQW-0798-100082
; Modified to expand no eligibility found. Reasons 42-58 can be
; found in this routine. Changes are not documented inside routine.
; I will take responsibility for the entire routine for patch 9.
;
; IHS/SD/SDR - v2.5 p10 - IM19802 - Fixed check for error 56 (user would get error if any provider met criteria
; IHS/SD/SDR - v2.5 p10 - IM20771 - Added check for outpatient visit and patient has MCR Part A only
;
;IHS/SD/SDR - 2.6*21 - HEAT127079 - Made change to show error 58 for POV correctly
;
; *********************************************************************
;
CHK ;EP for setting elig hit
N V,X,X1,X2,ABMNON,INSM
; If node 2 in the insurer file is missing no entry in ABML
INS2 ;
S ABM("INS2")=$G(^AUTNINS(ABM("INS"),2))
I ABM("INS2")="" D Q
.S $P(ABML(99,ABM("INS")),U,6)=42
.S ABM("XIT")=1
;
; This is checking for insurer merged to another. It keeps looping
; until if finds an insurer that has not been merged to another. If it
; ever finds the "merged to" insurer is one that was previously found
; as "merged from" it quits and there is no entry in ABML.
;
Q:$D(INSM(ABM("INS")))
S INSM(ABM("INS"))=""
I $P(ABM("INS2"),U,7)]"" D G INS2
.S ABM("INS")=$P(ABM("INS2"),U,7)
Q:$D(ABMLX(ABM("INS")))
; Piece 7 is the status field. No entry in ABML if status unbillable
; 43 ; Insurer designated as unbillable
I $P($G(^AUTNINS(ABM("INS"),1)),U,7)=4 S $P(ABML(99,ABM("INS")),U,6)=43 Q
;
; Check both the default in the parameter file & in the insurer file
; for backbill limit. Use the one from the insurer file if it exists.
;
N ABMDBBL,ABMBBL
S ABMDBBL=$P(^ABMDPARM(DUZ(2),1,0),U,16)
S ABMBBL=$S($P(ABM("INS2"),U,4):$P(ABM("INS2"),U,4),1:ABMDBBL)
I ABMBBL>0 D I ABMVDT<X S ABMNON="B-BBL" G CHK2
.S X1=DT
.S X2=0-(ABMBBL*30.417)
.D C^%DTC
S:'$D(ABMVT) ABMVT=$$VTYP^ABMDVCK1(ABMVDFN,$G(SERVCAT),ABM("INS"),$G(ABMCLN))
;S V=$G(^ABMNINS(DUZ(2),ABM("INS"),1,+ABMVT,0)) ;abm*2.6*11 HEAT100200
;start new code abm*2.6*11 HEAT100200
I $G(ABMP("LDFN"))="" D
.I $G(ABMVDFN) S ABMP("LDFN")=$P($G(^AUPNVSIT(ABMVDFN,0)),U,6)
.I $G(ABMP("CDFN")) S ABMP("LDFN")=$P($G(^ABMDCLM(DUZ(2),ABMP("CDFN"),0)),U,3)
I $G(ABMP("LDFN"))'="" S V=$G(^ABMNINS(ABMP("LDFN"),ABM("INS"),1,+ABMVT,0))
I $G(ABMP("LDFN"))="" S V=$G(^ABMNINS(DUZ(2),ABM("INS"),1,+ABMVT,0))
;end new code HEAT100200
;
; V is the Visit type multiple of the insurer file, p 7 billable
; If not billable set ABMNON
;
I ABMVT,$P(V,U,7)="N" S ABMNON="UB-VT"
I ABMVT,$P(V,U,14)>ABMVDT D
.S ABMNON="BF-SD"
.I '$O(ABML(ABM("PRI")),-1) S ABM("BEFSD")=1
;
; billing start date later than visit date & this insurer is primary
G CHK2:'$G(ABMCLN) ;Jmp to CHK2 if no clinic
I $P(ABM("INS2"),U,5)="O",$P(^DIC(40.7,ABMCLN,0),U,2)'=56 S ABMNON="OD-ND"
;
; ABM("INS2") is node 2 of insurer file. Checking dental billing status
; In piece 5 O means only dental billable, U means dental unbillable
; Clinic stop 56 is dental, 39 is pharmacy
E I $P(^DIC(40.7,ABMCLN,0),U,2)=56,$P(ABM("INS2"),U,5)="U" S ABMNON="UB-D"
E I $P(^DIC(40.7,ABMCLN,0),U,2)=39,$P(ABM("INS2"),U,3)="U" S ABMNON="UB-P"
S ABM=0
F S ABM=$O(^AUTNINS(ABM("INS"),17,ABM)) Q:'ABM D Q:$D(ABMNON)
.I +^AUTNINS(ABM("INS"),17,ABM,0)=ABMCLN S ABMNON="UB-CL"
CHK2 ;
;
N T,P,SDT,EDT
S (SDT,EDT)=""
I ABM("TYP")?1(1"M",1"R"),$D(ABM("REC")) D
.;check if patient only has part A; mark as unbillable if outpatient
.S ABMCB="M"
.S:$$PARTB^ABMDSPLB(DFN,ABMVDT) ABMCB=1
.I $G(ABMCB)="M",($G(ABMP("VTYP"))'=111)&($G(ABMVT)'=111) S ABMNON="UB-PA"
.Q:ABM("REC")<ABMVDT&((ABMDISDT<$P(ABM("REC"),U,2))!'$P(ABM("REC"),U,2))
.S SDT=$S(ABMVDT<ABM("REC"):+ABM("REC"),1:"")
.S EDT=$S($P(ABM("REC"),U,2)<ABMDISDT:$P(ABM("REC"),U,2),1:"")
E I ABM("TYP")="D" D
.Q:ABM("NDFN")=""
.Q:ABM("NDFN")<ABMVDT&((ABMDISDT<$P(ABM("SUB"),U,2))!'$P(ABM("SUB"),U,2))
.S SDT=$S(ABMVDT<ABM("NDFN"):ABM("NDFN"),1:"")
.S EDT=$S($P(ABM("SUB"),U,2)<ABMDISDT:$P(ABM("SUB"),U,2),1:"")
S T=$S(ABM("TYP")'="P":ABM("TYP"),$$ACCREL^ABMDLCK(ABM("MDFN")):"A",1:"P")
I ABM("PRIMARY")=ABM("INS"),$P($G(ABML(1,+$O(ABML(1,"")))),U,3)'?1(1"W",1"A") S ABM("PRI")=1
E I ABM("PRIMARY")=ABM("INS"),T="A" S ABM("PRI")=1
N UBILL
I $D(ABMNON) D
.I ABMNON="UB-VT" S UBILL=44 Q ;Unbillable visit type
.I ABMNON="B-BBL" S UBILL=45 Q ;Before back billing limit
.I ABMNON="OD-ND" S UBILL=46 Q ;Non dental visit for dental ins.
.I ABMNON="BF-SD" S UBILL=47 Q ;Before billing start date
.I ABMNON="UB-D" S UBILL=48 Q ;Dental not billable
.I ABMNON="UB-P" S UBILL=49 Q ;Pharmacy not billable
.I ABMNON="UB-CL" S UBILL=50 Q ;Clinic not billable
.I ABMNON="UB-PA" S UBILL=28 Q ;outpatient with MCR part A only
I +$G(UBILL) D
.S $P(ABML(99,ABM("INS")),"^",6)=UBILL
.S ABM("XIT")=1
S ABML(ABM("PRI"),ABM("INS"))=$S(T="D":ABM("MDFN"),1:"")_U_$S(T="D":ABM("NDFN"),T="W"&($G(ABMWCIEN)):ABMWCIEN,1:ABM("MDFN"))_U_T_U_SDT_U_EDT_U_$G(UBILL)
I ABMVDFN D
.S ABM=""
.F S ABM=$O(^AUPNVPRV("AD",ABMVDFN,ABM)) Q:'ABM D Q:$$PRVX^ABMDLCK3(P)
..S P=+^AUPNVPRV(ABM,0)
.I '$G(ABM("PRV")) D Q:'ABM("ORDPRV")
..S:'$D(ABM("ORDPRV")) ABM("ORDPRV")=$$ORPHAN^ABMDVCK2(ABMVDFN)
..S:'ABM("ORDPRV") ABMNON="NO-VP",$P(ABML(99,ABM("INS")),U,6)=56
; 56 ; Missing provider not allowed
I $D(ABMNON) S ABM("XIT")=1 Q
Q:'ABM("COV")
S ABM("CV")=$O(ABML(ABM("PRI"),ABM("INS"),"COV",""))
S:ABM("CV")="" ABM("CV")=$O(ABML(99,ABM("INS"),"COV",""))
S ABML(ABM("PRI"),ABM("INS"),"COV",ABM("COV"))=$G(COV)
Q:'$G(ABMVDFN)!'$G(ABMCLN)
;
; The code below here is checking to see if this visit is not
; covered. If not priority is changed to 99.
;
Q:$G(ABM("EMPL REL"))=1 ;This is for workmans comp
S:'$D(ABMVT) ABMVT=$$VTYP^ABMDVCK1(ABMVDFN,$G(SERVCAT),ABM("INS"),$G(ABMCLN))
Q:ABMVT=111 ;If hospitalization
Q:'$D(^AUTTPIC(ABM("COV")))
Q:$G(COV)="A"
;
; This is checking to see if provider class is not covered
; Loops thru until it finds a provider not in the unbillable list
; or to the end of list.
; ABM("FLG") is set to 1 if provider not covered
; Provider not in coverage file means billable
; If BUB=B
; CPT code in one range is billable and done
; CPT code not in all ranges is billable
; If BUB=U
; all CPT codes in a range unbillable
; one CPT codes out of all ranges is billable
;
N BUB,INRANGE,OUTOFRNG
S ABM("PRV")=0
S ABM=""
F S ABM=$O(^AUPNVPRV("AD",ABMVDFN,ABM)) Q:'ABM D Q:'ABM("FLG")
.S P=$P(^AUPNVPRV(ABM,0),U)
.I $$PRVX^ABMDLCK3(P) D
..I $D(^AUTTPIC(ABM("COV"),15,ABM("PRV"))) D
...S BUB=$P(^AUTTPIC(ABM("COV"),15,ABM("PRV"),0),U,2)
...I BUB="" S ABM("FLG")=1,$P(ABML(99,ABM("INS")),U,6)=55 Q
...S ABM("FLG")=$$PROVSPEC^ABMDLCK3(ABM("COV"),ABM("PRV"),BUB)
...I ABM("FLG")=1 S $P(ABML(99,ABM("INS")),U,6)=51 Q
..E D
...I $P($G(ABML(99,ABM("INS"))),U,6)=51!($P($G(ABML(99,ABM("INS"))),U,6)=56) K ABML(99,ABM("INS"))
...S ABM("FLG")=0 ; Set to zero if not in list
.E S ABM("FLG")=1,$P(ABML(99,ABM("INS")),U,6)=56 ;Set if default non covered provider
; If there are not entries in the V prov file same as flagging all
; providers unbillable
I $G(ABM("FLG"),1),'$$ORPHAN^ABMDVCK2(ABMVDFN) D Q
.S ABM("XIT")=1
I $D(^AUTTPIC(ABM("COV"),11,ABMCLN,0)) D Q
.S ABM("XIT")=1
.S $P(ABML(99,ABM("INS")),U,6)=57
S ABM("POV")=0,ABM("FLG")=0
;
; This code is checking to see if the coverage type represented by
; the ien ABM("COV") covers the POV for this visit. If it is not
; covered ABM("FLG") is set and UNCHK is run.
;
S ABM=""
F S ABM=$O(^AUPNVPOV("AD",ABMVDFN,ABM)) Q:'ABM D Q:'ABM("FLG")
.S ABM("POV")=$P(^AUPNVPOV(ABM,0),U)
.; Code to handle messed up .01 field in V POV file
.I 'ABM("POV") S:ABM("FLG")=0 ABM("FLG")=-1 Q
.I $D(^AUTTPIC(ABM("COV"),13,ABM("POV"))) S ABM("FLG")=1 Q
.E S ABM("FLG")=0 ;Set to 0 if not in list
Q:ABM("FLG")<1
I ABM("FLG") D
.S ABM("XIT")=11
.S $P(ABML(99,ABM("INS")),U,6)=58
I $G(ABM("XIT")) D UNCHK^ABMDLCK2 ;abm*2.6*21 IHS/SD/SDR HEAT127079
Q
; ABM("XIT") serves as a flag that the priority needs to be 99
ABMDLCK1 ; IHS/ASDST/DMJ - check visit for elig - CONT'D ;
+1 ;;2.6;IHS 3P BILLING SYSTEM;**11,21**;NOV 12, 2009;Build 379
+2 ;;Y2K/OK - IHS/ADC/JLG 12-18-97
+3 ;Original;TMD;
+4 ; Code has been added to use the billing limit from the parameters file
+5 ; if no back billing limit has been set for the insurer. ;JLG 4/8/98
+6 ;
+7 ; IHS/DSD/JLG - 6/29/1999 - NOIS HQW-0798-100082 Patch 3 #4
+8 ; Modified to capture reason for ineligibility, for programmers use
+9 ;
+10 ; IHS/DSD/MRS - 8/27/1999 - NOIS XAA-0899-200058 Patch 3 #13
+11 ; Modified to prevent generating out-patient claims for Medicare
+12 ; with Part A only
+13 ;
+14 ; IHS/ASDS/LSL - 06/26/2001 - V2.4 Patch 9 - NOIS HQW-0798-100082
+15 ; Modified to expand no eligibility found. Reasons 42-58 can be
+16 ; found in this routine. Changes are not documented inside routine.
+17 ; I will take responsibility for the entire routine for patch 9.
+18 ;
+19 ; IHS/SD/SDR - v2.5 p10 - IM19802 - Fixed check for error 56 (user would get error if any provider met criteria
+20 ; IHS/SD/SDR - v2.5 p10 - IM20771 - Added check for outpatient visit and patient has MCR Part A only
+21 ;
+22 ;IHS/SD/SDR - 2.6*21 - HEAT127079 - Made change to show error 58 for POV correctly
+23 ;
+24 ; *********************************************************************
+25 ;
CHK ;EP for setting elig hit
+1 NEW V,X,X1,X2,ABMNON,INSM
+2 ; If node 2 in the insurer file is missing no entry in ABML
INS2 ;
+1 SET ABM("INS2")=$GET(^AUTNINS(ABM("INS"),2))
+2 IF ABM("INS2")=""
Begin DoDot:1
+3 SET $PIECE(ABML(99,ABM("INS")),U,6)=42
+4 SET ABM("XIT")=1
End DoDot:1
QUIT
+5 ;
+6 ; This is checking for insurer merged to another. It keeps looping
+7 ; until if finds an insurer that has not been merged to another. If it
+8 ; ever finds the "merged to" insurer is one that was previously found
+9 ; as "merged from" it quits and there is no entry in ABML.
+10 ;
+11 IF $DATA(INSM(ABM("INS")))
QUIT
+12 SET INSM(ABM("INS"))=""
+13 IF $PIECE(ABM("INS2"),U,7)]""
Begin DoDot:1
+14 SET ABM("INS")=$PIECE(ABM("INS2"),U,7)
End DoDot:1
GOTO INS2
+15 IF $DATA(ABMLX(ABM("INS")))
QUIT
+16 ; Piece 7 is the status field. No entry in ABML if status unbillable
+17 ; 43 ; Insurer designated as unbillable
+18 IF $PIECE($GET(^AUTNINS(ABM("INS"),1)),U,7)=4
SET $PIECE(ABML(99,ABM("INS")),U,6)=43
QUIT
+19 ;
+20 ; Check both the default in the parameter file & in the insurer file
+21 ; for backbill limit. Use the one from the insurer file if it exists.
+22 ;
+23 NEW ABMDBBL,ABMBBL
+24 SET ABMDBBL=$PIECE(^ABMDPARM(DUZ(2),1,0),U,16)
+25 SET ABMBBL=$SELECT($PIECE(ABM("INS2"),U,4):$PIECE(ABM("INS2"),U,4),1:ABMDBBL)
+26 IF ABMBBL>0
Begin DoDot:1
+27 SET X1=DT
+28 SET X2=0-(ABMBBL*30.417)
+29 DO C^%DTC
End DoDot:1
IF ABMVDT<X
SET ABMNON="B-BBL"
GOTO CHK2
+30 IF '$DATA(ABMVT)
SET ABMVT=$$VTYP^ABMDVCK1(ABMVDFN,$GET(SERVCAT),ABM("INS"),$GET(ABMCLN))
+31 ;S V=$G(^ABMNINS(DUZ(2),ABM("INS"),1,+ABMVT,0)) ;abm*2.6*11 HEAT100200
+32 ;start new code abm*2.6*11 HEAT100200
+33 IF $GET(ABMP("LDFN"))=""
Begin DoDot:1
+34 IF $GET(ABMVDFN)
SET ABMP("LDFN")=$PIECE($GET(^AUPNVSIT(ABMVDFN,0)),U,6)
+35 IF $GET(ABMP("CDFN"))
SET ABMP("LDFN")=$PIECE($GET(^ABMDCLM(DUZ(2),ABMP("CDFN"),0)),U,3)
End DoDot:1
+36 IF $GET(ABMP("LDFN"))'=""
SET V=$GET(^ABMNINS(ABMP("LDFN"),ABM("INS"),1,+ABMVT,0))
+37 IF $GET(ABMP("LDFN"))=""
SET V=$GET(^ABMNINS(DUZ(2),ABM("INS"),1,+ABMVT,0))
+38 ;end new code HEAT100200
+39 ;
+40 ; V is the Visit type multiple of the insurer file, p 7 billable
+41 ; If not billable set ABMNON
+42 ;
+43 IF ABMVT
IF $PIECE(V,U,7)="N"
SET ABMNON="UB-VT"
+44 IF ABMVT
IF $PIECE(V,U,14)>ABMVDT
Begin DoDot:1
+45 SET ABMNON="BF-SD"
+46 IF '$ORDER(ABML(ABM("PRI")),-1)
SET ABM("BEFSD")=1
End DoDot:1
+47 ;
+48 ; billing start date later than visit date & this insurer is primary
+49 ;Jmp to CHK2 if no clinic
IF '$GET(ABMCLN)
GOTO CHK2
+50 IF $PIECE(ABM("INS2"),U,5)="O"
IF $PIECE(^DIC(40.7,ABMCLN,0),U,2)'=56
SET ABMNON="OD-ND"
+51 ;
+52 ; ABM("INS2") is node 2 of insurer file. Checking dental billing status
+53 ; In piece 5 O means only dental billable, U means dental unbillable
+54 ; Clinic stop 56 is dental, 39 is pharmacy
+55 IF '$TEST
IF $PIECE(^DIC(40.7,ABMCLN,0),U,2)=56
IF $PIECE(ABM("INS2"),U,5)="U"
SET ABMNON="UB-D"
+56 IF '$TEST
IF $PIECE(^DIC(40.7,ABMCLN,0),U,2)=39
IF $PIECE(ABM("INS2"),U,3)="U"
SET ABMNON="UB-P"
+57 SET ABM=0
+58 FOR
SET ABM=$ORDER(^AUTNINS(ABM("INS"),17,ABM))
IF 'ABM
QUIT
Begin DoDot:1
+59 IF +^AUTNINS(ABM("INS"),17,ABM,0)=ABMCLN
SET ABMNON="UB-CL"
End DoDot:1
IF $DATA(ABMNON)
QUIT
CHK2 ;
+1 ;
+2 NEW T,P,SDT,EDT
+3 SET (SDT,EDT)=""
+4 IF ABM("TYP")?1(1"M",1"R")
IF $DATA(ABM("REC"))
Begin DoDot:1
+5 ;check if patient only has part A; mark as unbillable if outpatient
+6 SET ABMCB="M"
+7 IF $$PARTB^ABMDSPLB(DFN,ABMVDT)
SET ABMCB=1
+8 IF $GET(ABMCB)="M"
IF ($GET(ABMP("VTYP"))'=111)&($GET(ABMVT)'=111)
SET ABMNON="UB-PA"
+9 IF ABM("REC")<ABMVDT&((ABMDISDT<$PIECE(ABM("REC"),U,2))!'$PIECE(ABM("REC"),U,2))
QUIT
+10 SET SDT=$SELECT(ABMVDT<ABM("REC"):+ABM("REC"),1:"")
+11 SET EDT=$SELECT($PIECE(ABM("REC"),U,2)<ABMDISDT:$PIECE(ABM("REC"),U,2),1:"")
End DoDot:1
+12 IF '$TEST
IF ABM("TYP")="D"
Begin DoDot:1
+13 IF ABM("NDFN")=""
QUIT
+14 IF ABM("NDFN")<ABMVDT&((ABMDISDT<$PIECE(ABM("SUB"),U,2))!'$PIECE(ABM("SUB"),U,2))
QUIT
+15 SET SDT=$SELECT(ABMVDT<ABM("NDFN"):ABM("NDFN"),1:"")
+16 SET EDT=$SELECT($PIECE(ABM("SUB"),U,2)<ABMDISDT:$PIECE(ABM("SUB"),U,2),1:"")
End DoDot:1
+17 SET T=$SELECT(ABM("TYP")'="P":ABM("TYP"),$$ACCREL^ABMDLCK(ABM("MDFN")):"A",1:"P")
+18 IF ABM("PRIMARY")=ABM("INS")
IF $PIECE($GET(ABML(1,+$ORDER(ABML(1,"")))),U,3)'?1(1"W",1"A")
SET ABM("PRI")=1
+19 IF '$TEST
IF ABM("PRIMARY")=ABM("INS")
IF T="A"
SET ABM("PRI")=1
+20 NEW UBILL
+21 IF $DATA(ABMNON)
Begin DoDot:1
+22 ;Unbillable visit type
IF ABMNON="UB-VT"
SET UBILL=44
QUIT
+23 ;Before back billing limit
IF ABMNON="B-BBL"
SET UBILL=45
QUIT
+24 ;Non dental visit for dental ins.
IF ABMNON="OD-ND"
SET UBILL=46
QUIT
+25 ;Before billing start date
IF ABMNON="BF-SD"
SET UBILL=47
QUIT
+26 ;Dental not billable
IF ABMNON="UB-D"
SET UBILL=48
QUIT
+27 ;Pharmacy not billable
IF ABMNON="UB-P"
SET UBILL=49
QUIT
+28 ;Clinic not billable
IF ABMNON="UB-CL"
SET UBILL=50
QUIT
+29 ;outpatient with MCR part A only
IF ABMNON="UB-PA"
SET UBILL=28
QUIT
End DoDot:1
+30 IF +$GET(UBILL)
Begin DoDot:1
+31 SET $PIECE(ABML(99,ABM("INS")),"^",6)=UBILL
+32 SET ABM("XIT")=1
End DoDot:1
+33 SET ABML(ABM("PRI"),ABM("INS"))=$SELECT(T="D":ABM("MDFN"),1:"")_U_$SELECT(T="D":ABM("NDFN"),T="W"&($GET(ABMWCIEN)):ABMWCIEN,1:ABM("MDFN"))_U_T_U_SDT_U_EDT_U_$GET(UBILL)
+34 IF ABMVDFN
Begin DoDot:1
+35 SET ABM=""
+36 FOR
SET ABM=$ORDER(^AUPNVPRV("AD",ABMVDFN,ABM))
IF 'ABM
QUIT
Begin DoDot:2
+37 SET P=+^AUPNVPRV(ABM,0)
End DoDot:2
IF $$PRVX^ABMDLCK3(P)
QUIT
+38 IF '$GET(ABM("PRV"))
Begin DoDot:2
+39 IF '$DATA(ABM("ORDPRV"))
SET ABM("ORDPRV")=$$ORPHAN^ABMDVCK2(ABMVDFN)
+40 IF 'ABM("ORDPRV")
SET ABMNON="NO-VP"
SET $PIECE(ABML(99,ABM("INS")),U,6)=56
End DoDot:2
IF 'ABM("ORDPRV")
QUIT
End DoDot:1
+41 ; 56 ; Missing provider not allowed
+42 IF $DATA(ABMNON)
SET ABM("XIT")=1
QUIT
+43 IF 'ABM("COV")
QUIT
+44 SET ABM("CV")=$ORDER(ABML(ABM("PRI"),ABM("INS"),"COV",""))
+45 IF ABM("CV")=""
SET ABM("CV")=$ORDER(ABML(99,ABM("INS"),"COV",""))
+46 SET ABML(ABM("PRI"),ABM("INS"),"COV",ABM("COV"))=$GET(COV)
+47 IF '$GET(ABMVDFN)!'$GET(ABMCLN)
QUIT
+48 ;
+49 ; The code below here is checking to see if this visit is not
+50 ; covered. If not priority is changed to 99.
+51 ;
+52 ;This is for workmans comp
IF $GET(ABM("EMPL REL"))=1
QUIT
+53 IF '$DATA(ABMVT)
SET ABMVT=$$VTYP^ABMDVCK1(ABMVDFN,$GET(SERVCAT),ABM("INS"),$GET(ABMCLN))
+54 ;If hospitalization
IF ABMVT=111
QUIT
+55 IF '$DATA(^AUTTPIC(ABM("COV")))
QUIT
+56 IF $GET(COV)="A"
QUIT
+57 ;
+58 ; This is checking to see if provider class is not covered
+59 ; Loops thru until it finds a provider not in the unbillable list
+60 ; or to the end of list.
+61 ; ABM("FLG") is set to 1 if provider not covered
+62 ; Provider not in coverage file means billable
+63 ; If BUB=B
+64 ; CPT code in one range is billable and done
+65 ; CPT code not in all ranges is billable
+66 ; If BUB=U
+67 ; all CPT codes in a range unbillable
+68 ; one CPT codes out of all ranges is billable
+69 ;
+70 NEW BUB,INRANGE,OUTOFRNG
+71 SET ABM("PRV")=0
+72 SET ABM=""
+73 FOR
SET ABM=$ORDER(^AUPNVPRV("AD",ABMVDFN,ABM))
IF 'ABM
QUIT
Begin DoDot:1
+74 SET P=$PIECE(^AUPNVPRV(ABM,0),U)
+75 IF $$PRVX^ABMDLCK3(P)
Begin DoDot:2
+76 IF $DATA(^AUTTPIC(ABM("COV"),15,ABM("PRV")))
Begin DoDot:3
+77 SET BUB=$PIECE(^AUTTPIC(ABM("COV"),15,ABM("PRV"),0),U,2)
+78 IF BUB=""
SET ABM("FLG")=1
SET $PIECE(ABML(99,ABM("INS")),U,6)=55
QUIT
+79 SET ABM("FLG")=$$PROVSPEC^ABMDLCK3(ABM("COV"),ABM("PRV"),BUB)
+80 IF ABM("FLG")=1
SET $PIECE(ABML(99,ABM("INS")),U,6)=51
QUIT
End DoDot:3
+81 IF '$TEST
Begin DoDot:3
+82 IF $PIECE($GET(ABML(99,ABM("INS"))),U,6)=51!($PIECE($GET(ABML(99,ABM("INS"))),U,6)=56)
KILL ABML(99,ABM("INS"))
+83 ; Set to zero if not in list
SET ABM("FLG")=0
End DoDot:3
End DoDot:2
+84 ;Set if default non covered provider
IF '$TEST
SET ABM("FLG")=1
SET $PIECE(ABML(99,ABM("INS")),U,6)=56
End DoDot:1
IF 'ABM("FLG")
QUIT
+85 ; If there are not entries in the V prov file same as flagging all
+86 ; providers unbillable
+87 IF $GET(ABM("FLG"),1)
IF '$$ORPHAN^ABMDVCK2(ABMVDFN)
Begin DoDot:1
+88 SET ABM("XIT")=1
End DoDot:1
QUIT
+89 IF $DATA(^AUTTPIC(ABM("COV"),11,ABMCLN,0))
Begin DoDot:1
+90 SET ABM("XIT")=1
+91 SET $PIECE(ABML(99,ABM("INS")),U,6)=57
End DoDot:1
QUIT
+92 SET ABM("POV")=0
SET ABM("FLG")=0
+93 ;
+94 ; This code is checking to see if the coverage type represented by
+95 ; the ien ABM("COV") covers the POV for this visit. If it is not
+96 ; covered ABM("FLG") is set and UNCHK is run.
+97 ;
+98 SET ABM=""
+99 FOR
SET ABM=$ORDER(^AUPNVPOV("AD",ABMVDFN,ABM))
IF 'ABM
QUIT
Begin DoDot:1
+100 SET ABM("POV")=$PIECE(^AUPNVPOV(ABM,0),U)
+101 ; Code to handle messed up .01 field in V POV file
+102 IF 'ABM("POV")
IF ABM("FLG")=0
SET ABM("FLG")=-1
QUIT
+103 IF $DATA(^AUTTPIC(ABM("COV"),13,ABM("POV")))
SET ABM("FLG")=1
QUIT
+104 ;Set to 0 if not in list
IF '$TEST
SET ABM("FLG")=0
End DoDot:1
IF 'ABM("FLG")
QUIT
+105 IF ABM("FLG")<1
QUIT
+106 IF ABM("FLG")
Begin DoDot:1
+107 SET ABM("XIT")=11
+108 SET $PIECE(ABML(99,ABM("INS")),U,6)=58
End DoDot:1
+109 ;abm*2.6*21 IHS/SD/SDR HEAT127079
IF $GET(ABM("XIT"))
DO UNCHK^ABMDLCK2
+110 QUIT
+111 ; ABM("XIT") serves as a flag that the priority needs to be 99
