Sub-Field: 9002080.01

lvn = ACHSORDN

DATE DOCUMENT ENTERED

lvn = ACHSBORD

lvn = ACHSTOS

lvn = ACHSCN

lvn = ACHSCAN

lvn = ACHSOBJC

lvn = ACHSPROV

1)= S ^ACHSF(DA(1),"VB",+X,DA,"1")=""

2)= K ^ACHSF(DA(1),"VB",+X,DA,"1")

lvn = ACHSTAO

ENTER $ AMOUNT OF ESTIMATED VENDOR CHARGES

ENTER $ AMOUNT OF IHS ADJUSTMENT

lvn = ACHSSTS

lvn = ACHSCOPT

TYPE A WHOLE NUMBER BETWEEN 0 AND 9

1)= S ^ACHSF(DA(1),"D","B",1000000+(X_$P(^ACHSF(DA(1),"D",DA,0),"^",1)),DA)=""

2)= K ^ACHSF(DA(1),"D","B",1000000+(X_$P(^ACHSF(DA(1),"D",DA,0),"^",1)),DA)

The code that actually sets the 4-digit FY into the Document record was in ACHS*3.1*1.

TYPE A WHOLE NUMBER BETWEEN 1 AND 999

TYPE A WHOLE NUMBER BETWEEN 1 AND 999

lvn = ACHSDEST

ENTER THE CHS CLERK ENTERING THIS DOCUMENT

lvn = ACHSDCR

lvn = ACHSDCR

lvn = ACHSPATF

ENTER PATIENTS CHART NUMBER

ENTER THE PATIENT

1)= S ^ACHSF(DA(1),"PB",+X,DA,"1")=""

2)= K ^ACHSF(DA(1),"PB",+X,DA,"1")

ENTER A NUMBER BETWEEN 1 AND 999

ENTER Y IF VENDOR IS TO BE PAID AT DRG RATE

1)= S ^ACHSF(DA(1),"TPR",$E(X,1,30),DA)=""

2)= K ^ACHSF(DA(1),"TPR",$E(X,1,30),DA)

1)= S ^ACHSF(DA(1),"ESIG",+X,DA)=""

2)= K ^ACHSF(DA(1),"ESIG",+X,DA)

ENTER COMMENTS REGARDING THIS BLANKET ORDER

ENTER PAYMENT AMOUNT

ENTER PAYMENT OBLIGATION ADJUSTMENT

AMOUNT OF PAYMENT OBLIGATION ADJUSTMENT

ENTER DATE OF PAYMENT

ENTER THE TYPE OF THE LAST PAYMENT

ENTER 3RD PARTY PAYMENT AMOUNT

ENTER INTERIM PAYMENT

ENTER NUMBER OF INTERIM PAYMENT

ENTER DATE OF LAST INTERIM PAYMENT

lvn = ACHSAPA

ENTER TOTAL ADJUSTMENT AMOUNT

ENTER NUMBER OF ADJUSTMENT

ENTER ADJUSTED 3RD PARTY PAYMENT AMOUNT

Please enter the number of days the patient is estimated to be hospitalized from block 17, ESTIMATED DAYS.

Enter a brief description of the treatment to be provided.  lvn = ACHSDES

The account number is issued by the Provider.

The Patient Account Number is taken from the Notification Report, and printed on the Master Delivery Order List (MDOL).

ENTER HOSPITAL ORDER NUMBER

ENTER CHECK NUMBER

1)= S ^ACHSF(DUZ(2),"TCHK",999999999-X,DA)=""

2)= K ^ACHSF(DUZ(2),"TCHK",999999999-X,DA)

3)= PREVENTS DUPLICATE CHECK NUMBERS!!

This x-ref is set and checked in the 638 check writting routines.

ENTER CHECK PRINT DATE

ENTER THE DATE THE CHECK CLEARED

Select the VISIT, in the Patient Care Component (PCC), that is associated with this document.

If medical data associated with the document is edited, any existing VISIT is deleted, first, by setting the value of this field to APCDVDLT and calling routine ^APCDVDLT, which also deletes any Purposes of visit in the

V POV file that point to the VISIT.

Select the V CHS, in the Patient Care Component (PCC), that is associated with this document.

If medical data associated with the document is edited, any existing V CHS is deactivated, by deleting the associated VISIT (see VISIT field).

Enter the Referral from the MCIS system that is the authorization basis for this purchase order.

This is handled programmatically.

ENTER THE AUTHORIZED BEGINNING DATE

ENTER THE AUTHORIZED ENDING DATE

This field is calculated whenever referral data fields are entered or edited from CHS Kernel options.  It can be directly edited using FM.

ENTER ESTIMATED REFERRAL COST

Provider that referred the patient to CONTRACT HEALTH

or health of the individual, necessitate the use of the most accessible health care available and capable of furnishing such services.  Diagnosis and treatment of injuries or medical conditions that, if left untreated,

would result in uncertain but potentially grave outcomes.

II - PREVENTIVE CARE:  Primary health care that is aimed at the prevention of long term disability.  This includes services proven effective in avoiding the occurrence of a disease (primary prevention) and services

proven effective in mitigating the consequences of an illness or condition (secondary prevention).  Level II services are available at most IHS facilities.

III - PRIMARY AND SECONDARY CARE:  Inpatient and outpatient care services that involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity and mortality.  This involves

treatment for conditions that may be delayed without progressive loss of function or risk of life, limb or senses.  It includes services that may not be available at many IHS facilities and/or may require specialty

consultation.  Level III referrals should be approved by the local CHS committee or clinical director before the services are rendered.

IV - CHRONIC TERTIARY AND EXTENDED CARE:  Inpatient and outpatient care services

(1) that require sophisticated specialists or equipment and tertiary care facilities,

(2) that are not essential for initial/emergent diagnosis or therapy, or

(3) that are high cost, are elective, and have less impact on mortality than morbidity.

These services are not readily available from direct care IHS facilities.  Careful case management by the service unit CHS committee is a requirement, as is monitoring by the Area Chief Medical Officer, or his/her

designee.  Depending on cost, the referral may require concurrence by the Chief Medical Officer.

lvn = ACHSRMPC

CAUSE OF INJURY FROM THE REFERRAL FORM

IS THIS REFERRAL ALCOHOL RELATED?

ENTER ESTIMATED DATE OF SERVICE

1)= S ^ACHSF(DA(1),"ES",X,DA)=""

2)= K ^ACHSF(DA(1),"ES",X,DA)

SPECIFIC REFERRAL, TYPE E:  Emergency examination and treatment not to exceed obligation amount.  Services limited to Levels I-III of the IHS Schedule of Oral Health Services.

SPECIFIC REFERRAL, TYPE B:  Examination and treatment limited to Levels I-III of the IHS Schedule of Oral Healthy Services.  Treatment plans exceeding $200 must be returned for predetermination.

SPECIFIC REFERRAL, TYPE S:  Specialty services limited to specifically listed services, not to exceed obligated amount.  ADA code(s) should be listed.

SPECIFIC REFERRAL, TYPE L:  Authorization for dental laboratory services for a removeable or fixed appliance.

ENTER THE REFERRAL DIAGNOSIS

ENTER THE NARRATIVE

ENTER THE REFERRAL PX

ENTER THE NARRATIVE FOR THIS REFERRAL PX

ENTER THE DIAGNOSIS RELATED GROUP FROM TREATMENT INFORMATION

ENTER THE DATE THE PATIENT WAS ADMITTED TO THE FACILITY

ENTER THE DATE THIS PATIENT WAS DISCHARGED FROM THE FACILITY

9.2 = S Y(9002080.01,93,1)=$S($D(^ACHSF(D0,"D",D1,8)):^(8),1:"") S X=$P(Y(9002080.01,93,1),U,3),X1=X,X2=$P(Y(9002080.01,93,1),U,2),X="" D:X2 ^%DTC:X1 S X=X=0

9.3 = X ^DD(9002080.01,93,9.2) S Y(9002080.01,93,2)=X S X=1,Y(9002080.01,93,3)=X S X=1,Y(9002080.01,93,4)=X S X=$P(Y(9002080.01,93,1),U,3),X1=X,X2=$P(Y(9002080.01,93,1),U,2),X="" D:X2 ^%DTC:X1 S X=X

COMPUTED FIELD

ENTER TYPE OF DISCHARGE THE PATIENT RECEIVED (INPATIENT ONLY)

ENTER DIAGNOSIS

ENTER THE PROCEDURE

ENTER THE CPT, ADA OR REV INFORMATION

lvn = ACHSTRAN