Authorization Claims Enrollment System (ACES) User Guide Version 2 12/12/2012 Sharp Health Plan www.sharphealthplan.com

Authorization Claims Enrollment System (ACES) User Guide Version 2 12/12/2012 Sharp Health Plan www.sharphealthplan.com

Table of Contents LOG IN... 1 LOG OUT... 1 PATIENT... 2 Search for Patient... 2 Demographics Screen... 3 View Demographics Screen... 3 Print Demographics Screen... 3 Insurance Screen... 4 View Insurance Screen... 4 View Enrollment Detail Screen... 4 View Plan Detail Screen... 5 View PCP History Screen... 5 Enroll New Member... 6 REFERRALS... 8 Create a Referral... 8 Return Mail Message... 9 How to complete your referral request form... 11 Notification of Decision... 15 Referral Inquiry Screen... 16 View Referral Inquiry Screen... 16 How to view a referral... 17 How to print your referral screen... 18 TRACKER... 19 View Tracker Screen... 19 Search using Referred By or To Tab... 20 Search using Master Vendor... 20 View Referral List... 21 How to view a referral... 22 How to Use Tracker Search... 23 CLAIMS... 24 View Claims Screen... 24 Search Claims By Patient... 24 Search Claims By Vendor... 25 Use Claim Search... 26 View Claims List... 27 View Claims Detail... 27 View Claim Lines... 29 How to print your claim screen... 29 REFERENCE... 30 CONTACT US... 32 REFERRAL TYPE DESCRIPTION GUIDE... 35

LOG IN LOG IN 1. Double click on ACES Icon on your desktop 2. Log in window will appear a. Enter your username b. Enter your password 3. Select Login 3 a b 4. After Selecting login the Patients Search Screen will appear LOG OUT 1. To log out Select Log out on right corner of your screen 1 1

PATIENT SEARCH FOR PATIENT PATIENT Patient Section is used to view a variety of patient information, including: Demographic information Insurance information New member enrollment Copay due for a service Search for Patient 1. See Recommended Patient Lookup Options (bottom of screen) for search criteria: Single Factor Multi Factor a. Single Factor Look Up: b. Enter any one of the following in the Member Number Field: i. Health Plan ID # (example for Sharp Health Plan 10570686V*03 located on ID card) ii. Entity Medical Record # iii. Sharp Healthcare # (example 105-706-869) iv. Social Security # (Sharp Health Plan does not use Social Security number) v. Claim # vi. Referral # vii. Select Search OR b c. Multi-Factor Look-Up: i. Enter Patient s Name (last name, first name), Date of birth and Gender ii. Select Search ii vii i 2. After you enter your criteria to search for a patient, the following patient information will appear 3. Select patients name 3 2

PATIENT Demographics Screen Demographics Screen The Demographics Screen displays patients registration data and employer information from IDX. View Demographics Screen 1. Selected your patient (see Search for Patient Instructions on page 2)the following Demographics screen will appear a. Patients name will be stored under Select Patient Column; system will store the last 3 patients you viewed. b. Patients information will appear in banner on the top of page b a Print Demographics Screen 1. Select Print on your demographics screen 2. A pop up window will appear with your print image a. Select Print in the upper right corner b. A print window will appear c. Select your printer and select Print a 1 c c 3

PATIENT Insurance Screen Insurance Screen Displays will appear the same stating Sharp Health Plan. Name Sharp Health Plan The Insurance screen displays a summary of the patient s insurer information. View Insurance Screen HMO SHP 1. Selected your patient (see Search for Patient Instructions on page2) 2. Selecting the Insurance tab 3. The following information will appear on Insurance Screen: a. Name: Displays the insurer b. HMO: Displays the HMO name c. Cert No.: Displays the policy s certificate number d. Employer: Displays the subscriber s employer e. Rel: Displays the patient s relationship to the subscriber f. Subscriber Name: Displays the subscriber s name: last name, first name g. Eff Dt: Displays the effective date of coverage h. Exp Dt: Displays the expiration date of coverage i. Add New Enrollment Button: This is used to create a New Enrollment 2 (a) (b) (c) (d) (e) (f) (g) (h) (i) View Enrollment Detail Screen 1. To view the Enrollment Detail Screen select insurance name 1 Displays will appear the same stating Sharp Health Plan. Insurance: Sharp Health Plan HMO HMO: Sharp Health Plan 2. Enrollment Detail Screen appears showing detailed insurance information 4

PATIENT Insurance Screen View Plan Detail Screen 1. Select Plan Detail within the Enrollment Detail screen 1 2. Plan Detail screen appears showing patients benefit information (example: Copay information) 3. Select drop down menu to view additional benefit copay information for other services. 4. To return to the main Insurance Screen select Back 4 3 Displays will appear the same stating Sharp Health Plan. Insurance: Sharp Health Plan HMO HMO: Sharp Health Plan View PCP History Screen 1. From the Main Insurance Screen select PCP History to view patient primary care physicians history. 1 2. Primary Care Physician (PCP) history screen shows your patients PCP history 3. To return to the main Insurance Screen select Back twice 3 5

PATIENT ENROLL NEW MEMBER Enroll New Member 1. Enter the following Multi-Factor information for your patient a. Enter patients last name, first name b. Enter patients date of birth c. Select patients gender d. Select Search d c a b OR 2. Enter any of the following Single-Factor information for your patient a. Health Plan ID# (example for Sharp Health Plan 10570686V*03 located on ID card) b. E + Entity Medical Record # (Sharp Health Plan does not use this feature) c. M + Sharp Healthcare # (example 105-706-869) d. S + Social Security # (Sharp Health Plan does not use Social Security number) e. C + Claim # f. R + Referral # 3. Message No results found will appear 4. Select Enroll New Member 3 4 5. Mini-Registration/Enrollment Screen will appear a. Select the drop down menu b. Select the Sharp Entity that your patient belongs to b a **REMEMBER TO SELECT** SHARP HEALTH PLAN 6

PATIENT ENROLL NEW MEMBER 6. A blank Mini-Registration/Enrollment Form will appear a. Complete form with your patients Demographics and Enrollment information b. Select Save to send your information to our Eligibility Department who will verify patients eligibility. a a b 7. You will then be taken to the Select Patient Screen a. Enter your patient information b. Select Search to begin entering a referral for your patient Note: Keep in mind your referral will pend until our Eligibility department verifies your patient information, if information cannot be verified your referral will be deleted and you will receive a message flagged in RED from systems in your Outlook inbox. b a 7

REFERRALS- CREATE A REFERRAL REFERRALS Referrals section provides full referral inquiry and management abilities. You can use Referrals to: View a summary of all of a patient s referrals Drill down to details about a single referral Enter referrals for a patient Create a Referral 1. Select your patient (See Search for Patient instructions) 2. Select Referrals from left column 2 4 3. Referral Inquiry screen will appear 4. Select Referral Add tab 5. The Referral Add screen will appear a. Select the Sharp Entity drop down menu b. Select the Sharp Entity that your patient belongs to i. Note for Sharp Health Plan Members: The Sharp Entity is always Sharp Health Plan. Patient s FCS will be Sharp Health Plan HMO. a b The Sharp Entity needs to say: SHARP HEALTH PLAN 6. The FSC field will automatically populate with your Sharp Health Plan information after you select the Sharp Entity 7. Select Generate SHARP HEALTH PLAN SHARP HEALTH PLAN HMO 6 8. The Enrollment Snapshot screen will appear, you will need to verify your patient information a. If no changes to your patients information select No Change b. If there are changes, make your changes and select Save Changes 7 8

REFERRALS- CREATE A REFERRAL Note: If there is a change to the patient s Health Plan information be aware that when our Eligibility department cannot verify the information your referral will be deleted. Check your Outlook inbox for a messaged flagged in RED from Systems **REMEMBER needs to say: SHARP HEALTH PLAN a b Return Mail Message c. If address information shows return mail i. Update patients information with current address information ii. Select Save Changes a WATCH DEMO VIDEO iii. If you select No Changes you will receive the following message letting you know that address is not valid with US Postal Service. 1. Select Click here to enter a valid address? to update your patients address information and Save Changes to continue with your referral request. 2. If you select Continue with referral? message will appear one more time. 1 WATCH DEMO VIDEO 9

REFERRALS- CREATE A REFERRAL 9. After you verify or update your patient s information the Referral Add screen will appear. 10

REFERRALS- HOW TO COMPLETE REFERRAL REQUEST FORM How to complete your referral request form 1. After you verify or update your patient s information the Referral Add screen will appear. (a) (x) (c) (b) (d) (e) (f) (g) (h) (i) (j) (k) (n) (l) (o) (m) (p) (q) (r) (s) (t) (u) (v) (w) 2. Complete your referral request form with the following information a. Priority Field: Select any of the following as your Priority for your request: i. Routine: Turn Around Time for Routine Commercial is 5 business days of the receipt of the request when all necessary information is received at time of initial request. ii. Urgent: Turn Around Time for Urgent is 24 hours for Commercial upon receipt of the request when all necessary information is received at time of initial request. ROUTINE URGENT 1. The following message will appear when you select Urgent read carefully and select OK b. Date field: Will be grayed out 1 11

REFERRALS- HOW TO COMPLETE REFERRAL REQUEST FORM c. Patient Request Field: Indicate No or Yes if your request is from the patient. i. The following message will appear when you select Yes read carefully and select OK d. Description Field: Type a brief description of services to be rendered and press tab (Do not use abbreviations) (example of appropriate documentation: Neurology Consultation) Note Reminder: What ever you type in the description line/field will be pulled into our patient letters. e. Refer By: Type referring provider s name and press tab. To search, enter the first two characters of the provider s last name. i. As you begin to type your providers last name the system will begin to automatically search. ii. Select provider and press tab 1. Search Window may appear when you move your cursor to another field a. Select your provider and press tab iii. Non-Contracted Providers: Enter Non-Contracted SHP Provider in this field 1. Complete Other/Non-contracted Prov/Facility Section below (j - p), these are now mandatory fields. f. Refer To: Type refer to provider s name and press tab. To search, enter the first two characters of the provider s last name. 12

REFERRALS- HOW TO COMPLETE REFERRAL REQUEST FORM g. Specialty: This field will automatically show the specialty of your Refer-To provider h. Surgeon/Specialist: Type surgeon s name and press tab. To search, enter the first two characters of the provider s last name. i. Assisting Surgeon: Type the last name of your assisting surgeon and press tab. j. Other/Non-contracted Prov/Facility: Type the full name of the non-contracted SHP provider or facility and press tab. a. Note: When entering Non/Contracted Provider information the first 4 lines in your comments fields will be grayed out. k. Address 1: Type in the # and street name and press tab. l. Address 2: Type in the Suite #, Bldg#, etc, if applicable and press tab. m. City/State/Zip: Type in the City, State and Zip and press tab. n. NPI# (National Provider Identifier): Type in the NPI# and press tab. o. Phone: Type in the phone # including area code and press tab. p. Fax: Type in the Fax# including area code and press tab. 13

REFERRALS- HOW TO COMPLETE REFERRAL REQUEST FORM q. Ref Type: Enter in referral type mnemonic or click blue icon for a list and make your selection. Press tab to move to the next field (also see under References for Referral Type Description Guide for additional help). q q r. Diagnosis Fields: Type the Diagnosis and press tab. To search, enter the first two characters of the diagnosis code and make your selection. Note: You may enter up to 4 diagnosis codes r r s. Procedure Codes: Type the Procedure CPT code, select code and press tab. To search, enter the first two characters of the CPT code and make your selection. s s Note: You may enter up to 20 CPT codes by selecting Add More Procedures t. Units: This field will default with 1 unit. Type in the number of Units for Procedure if it s more than 1 and press tab. u. EDC (Estimated Delivery Date): Enter in patients estimated delivery date. Note: Mandatory Field when diagnosis or CPT codes are related to Total OB Care or Abortion. u 14

REFERRALS- HOW TO COMPLETE REFERRAL REQUEST FORM v. LMP (Last Menstrual Period): Type in patients last menstrual period date for this OB referral or Select date from calendar Note: Mandatory Field when diagnosis or CPT codes are related to Total OB Care or Abortion. w. Referral Comments: Type in your comments and press tab to move to the next line. Note: You have up to 9 lines unless you have non-contracted provider information and you will be permitted to enter up to 80 characters per line. x. Save: Select Save to submit your referral y. This is the Final Message that appears once referral is completed z. You may check the status of your referral in the Referral Inquiry Screen (See View Referral Inquiry Screen for Instructions on page 16) i. Your referral will appear in the Pending Referral section until it s processed by IDX, then it will appear in the Non-pending Referrals section Note: Do Not Print Referral when it still showing as being Processed i Notification of Decision You will receive the following email in your Outlook Inbox notifying you of the final decision. Please keep an eye out for these emails from Sharp_Utilization_Management@SHDMP.SHARP.COM This will say - Sharp Health Plan 15

REFERRALS- VIEW REFERRAL INQUIRY SCREEN Referral Inquiry Screen Referrals inquiry screen displays all of a selected patient s referrals View Referral Inquiry Screen 1. Select your patient (See Search for Patient instructions on page 2) 2. Select Referrals from left side column or 3. View the Referral Inquiry Screen after you complete a new referral request. 2 3 4. The Referral Inquiry Screen will then appear with the following information: a. 1 st box: Displays all referrals pending process by the system, once its processed it will appear on the 2 ND box below. b. 2 nd box: Displays all referrals being currently being processed or completed by SHP Utilization Management (UM) staff. c. Sort Column information: Select arrows to ascend/descend items in column. d. Referral No: Displays the referral s unique referral number. e. Referred To: Displays the organization of the provider to whom the patient was referred. Also called the referral target. f. Status: Displays the status of your referral (example: approved/closed/processing). Note: This field must indicate Approved for referral to be a valid approval. g. In IDX: If it indicates Yes it means your referral has been processed by SHP. If it indicates No it means your referral has not been processed by SHP yet. h. From Date: Displays the date on which the referral becomes valid. Services approved for this referral can take place any time between the From Date and To Date. i. To Date: Displays the last date on which the referral is valid. Services approved for this referral can take place any time between the From Date and To Date. j. Referral Type: Displays the referral type mnemonic (see References Section for Referral Type Definitions Guide). k. HMO: Displays the patient s HMO. l. PCP: Displays the Patients Primary Care Physicians name. m. Diagnosis: Displays first diagnosis (DX1) listed on referral request. a (d) (e) (f) (g) (h) (i) (j) (k) (l) b c 16

REFERRALS- REFERRAL INQUIRY VIEW REFERRALS CREATED BY YOUR PROVIDER How to view a referral 1. Open up Referral Inquiry Screen (see View Referral Inquiry Screen instructions on page 16) Note: You can search list using (Ctrl + F) a. Type in your search request b. Select Find Next a b 2. Select referral # 2 3. Referral Screen will appear displaying your referral information THIS WILL SAY: SHP 17

REFERRALS- REFERRAL INQUIRY - PRINT REFERRAL SCREEN How to print your referral screen 1. Select your referral from the Referral Inquiry Screen 1 2. After selecting your referral the following Referral Inquiry Screen will appear 3. Select Print on your Referral screen 4. A pop up window will appear with your print image a. Select Print in the upper right corner b. A print window will appear c. Select your printer and select Print 3 2 a c c 18

TRACKER VIEW TRACKER SCREEN TRACKER Referral Tracker enables you to: Track referrals by the referring clinician or referral target (Refer To Provider) View or editing referrals by the referring clinician or referral target (Refer To Provider) Search by the referring provider or organization Search by the referral target (Refer To) provider or organization View Tracker Screen 1. Select Tracker from left side column after you log in (see Log In instructions on page 1) 1 2. The Referral Tracker Screen will then appear with the following information: a. Referred By Tab: Enables you to search referrals referred by a specified provider b. Referred To Tab: Enables you to list referrals referred to a specified organization or provider. i. Referred By/To Search Window: Enables you to search by entering the name of your referring clinician, referred to specified organization or provider ii. Change HMO: Enables you to search referrals for a different HMO iii. Tracker Search: Enables you to search for referrals by several criteria iv. Master Vendor: Enables you to search for referrals by practice name (example: Grossmont Medical Group) Note: Do not use Master Vendor here for any Large Practices with more then 3 providers in their group, you may use Tracker Search for these Groups. 2 2 ii iii i iv 19

TRACKER SEARCH USING REFERRED BY OR TO TAB Search using Referred By or To Tab 1. Open Tracker Screen (see View Tracker Screen for instructions on page 19) 2. Select the Referred By or the Referred To Tab to begin your search 3. Click Change HMO 4. Select the HMO group you wish to search referrals for Note: If you are currently in a patient within your HMO, you do not need to select Change HMO. 2 2 3 4 FOR SHP THIS SHOULD ALWAYS BE - Sharp Health Plan 5. Enter the first two characters of the referring provider s last name 6. Select your physicians name from search options 7. Select Search 4 6 5 Search using Master Vendor Search using Master Vendor enables you to search all referrals for the physicians under a practice name (example: Grossmont Surgical Associates) Note: Do not select Master Vendor for your search here for any Large Practices with more then 3 providers in their group, you may use Tracker Search for these Groups 1. Select the box for next to This is a master vendor 1 2. Enter the first two characters of the practice name 3. Select your practice group name 4. Select Search 2 3 4 20

TRACKER VIEW REFERRAL LIST View Referral List 1. After selecting your provider in Tracker a referral list will appear with the following information: a. Total Rows Returned: Displays the total number of referrals. b. Sort Column information: Select arrows to ascend/descend items in column c. Referral No: Displays the referral s unique referral number. d. Patient: Displays the name of your patient e. HMO: Displays the patient s HMO f. Referral Type: Displays the type of service authorized by the referral (see References Section for Referral Type Definitions Guide) g. Referred By: Displays the name of the requesting provider h. Referred To: Displays the organization or the provider to whom the patient was referred. i. From Date: Displays the start date on which the referral is valid. a (c) (d) (e) (f) (g) (h) (i) b 2. To view more columns scroll to the bottom of your page or select END on your keyboard 3. Move scroll (at the bottom of your grid) to the right side. 3 4. Scroll back to the top of your page or select HOME on your keyboard to view the rest of your columns. 4 2 5. The columns will display the following information: a. To Date: Displays the last date on which the referral is valid. b. Auth: Displays the number of treatments authorized. c. Rem: Displays the number of treatments remaining. d. Status: Displays the status of your referral (example: approved/closed/processing). Note: This field must indicate Approved for referral to be a valid approval. e. Diagnosis: Displays first diagnosis (DX1) listed on referral request. f. Description: Displays the description of the referral. (a) (b) (c) (d) (e) (f) 21

TRACKER HOW TO VIEW A REFERRAL How to view a referral 1. After selecting your provider in Tracker search a referral list will appear. Note: You can search list using (Ctrl + F) a. Type in your search request b. Select Find Next a b 2. Select referral # 2 3. Referral Screen will appear displaying your referral information 22

TRACKER HOW TO USE TRACKER SEARCH How to Use Tracker Search 1. After you select Tracker from left side column 2. Select the Referred By or the Referred To Tab to begin your search 3. Select Tracker Search 2 4. The Referral Search Screen will then appear with the following search criteria for you to fill out: a. Date Ordered: Enables you to specify the date on which the referral was ordered. The format is mm/dd/yyyy. Click to the right of the box to select a date. b. Valid From: Enables you to specify the first date on which the referral is valid. c. Valid To: Enables you to specify the last date on which the referral is valid. d. Referral Type: Enables you to specify the type of service authorized by the referral. Type the first few letters of the referral type and select from the list of matching entries. (see References Section for Referral Type Definitions Guide) e. Status: Enables you to specify the referral status. Type the first few letters of the status, press TAB, and select from the list of matching entries. f. Referred By: Enter and select the name of the referred by provider g. Referred To: Enter and select the name of the organization or provider patient is being referred to h. This is a master vendor: Select this boxes if you are entering in a practice name i. Diagnosis: Enter and select your diagnosis code (a) (b) (c) (f) (g) (i) (d) (e) (h) 5. Once you have entered your search information select Search 2 6. Referral list will then appear for you to select your referral to view. (see details about Referral list under View Referral List on page 21) 23

CLAIMS VIEW CLAIMS SCREEN CLAIMS Claims Inquiry enables administrative staff and clinicians to view claim information and search for claims by vendor or by patient. You can view a list of claims, and then drill down to view details of a single claim, all the way down to the claim line level. View Claims Screen 1. Select your patient (see Search for Patient instructions on page 2) 2. Select Claims from left column 2 Remember this should say: Sharp Health Plan 3. Claims List screen will appear Search Claims By Patient 1. Open Claims Screen (see View Claims Screen instructions on page 24) 2. Select By Patient Tab 2 3. Click Change HMO 4. Select the HMO group you wish to search claims for 4 5. Claims List will then appear, listing all claims for that patient. (see details about Claims list under View Claims List on page 27) 24

CLAIMS SEARCH CLAIMS BY VENDOR Search Claims By Vendor 1. Open Claims Screen (see View Claims Screen instructions on page 25) 2. Select By Vendor Tab 2 3. The Vendor Lookup screen will then appear 4. Enter vendor name 5. Select your vendor 6. Select Search 4 6 5 7. Claims List will then appear, listing all claims for that vendor. (see details about Claims list under View Claims List on page 27) 25

CLAIMS USE CLAIM SEARCH Use Claim Search Claims Search enables you to search for a claim by several search criteria. 1. Open Claims Screen (see View Claims Screen instructions on page 24) 2. You can access Claim Search through the By Patient or By Vendor Tab 3. Select Claims Search 3 4. The Claims Search Screen will then appear with the following information: a. Vendor: Displays the vendor for whose claim you are searching. Type the first few letters of the vendor and select from the list of matching entries. b. Service From: Enables you to specify a starting service date by which to search for the claim. The system will find only claims with service dates that fall between the Service From and Service To dates. To select a date from the calendar, click the calendar button. c. Service To: Enables you to specify an ending service date by which to search for the claim. The system will find only claims with service dates that fall between the Service From and Service To dates. To select a date from the calendar, click the calendar button. d. Status: Enables you to specify a claim status for the search. The system will find only claims with the specified status. Type the first few letters of the status and select from the list of matching entries. e. Diagnosis: Enables you to specify a diagnosis for the search. The system will find only claims with the specified diagnosis. Type the first few letters of the diagnosis and select from the list of matching entries. (b) (c) (a) (d) (e) 5. Once you have entered your search information Select Search 5 6. Claims List will then appear, listing all claims for that patient or vendor. (see details about Claims list under View Claims List on page 27) 26

CLAIMS VIEW CLAIMS LIST View Claims List 1. After you enter your search information a claims list will appear with the following information: a. Total Rows Returned: Displays the total number of referrals. b. Claim No: Displays the claim number. Click a claim number to view details about that claim. c. Patient or Vendor: Displays the patient name if you are viewing claims by vendor, or the vendor name if you are viewing claims by patient. d. Received Date: Displays the date on which the claim was received. e. Service Date: Displays the service date for the services billed on the claim. f. Billed Amount: Displays the total amount billed on the claim. g. Approved Amount: Displays the total approved amount for the services billed on the claim. h. Status: Displays the status of the claim. Claim statuses are set up by your organization. i. Status Date: Displays the final decision date for your claim. a (b) (c) (c) (d) (e) (f) (g) (h) (i) View Claims Detail The Claims Detail display lists details of a selected claim 1. Open Claims Screen (see View Claims Screen instructions on page 24) 2. Enter your search information through By Patient or By Vendor Tabs (see Search Claims by Patient or Vendor instructions on page 24-25) 3. Claims list will then appear Note: You can search list using (Ctrl + F) a. Type in your search request b. Select Find Next Remember this should say: Sharp Health Plan a b 4. Select claim # 3 27

CLAIMS VIEW CLAIM DETAIL Remember this should say: Sharp Health Plan 5. Claim Header Screen will then appear displaying the following information: a. Sharp Entity: Displays the Sharp Entity of your claim b. Claim: Displays the claim number c. Referral: Displays the referral number for this claim d. Service Date: Displays the earliest service date for the services billed on the claim e. Vendor: Displays the vendor for the claim f. Billed Amount: Displays the total amount billed for all procedures on the claim g. Approved Amount: Displays the total approved amount for all procedures on the claim h. Status: Displays the claim status i. Diagnosis: Displays up to three diagnoses for this claim j. Claim Lines: This section displays the details about each claim line. Select to view claim line detail. (see View Claim Lines on page 29) k. #: Displays the claim line number l. From: Displays the beginning service date m. To: Displays the ending service date n. Proc Code: Displays the procedure number o. Proc Description: Displays the procedure name p. Modifier: Displays the procedure code modifier q. Days: Displays the number of days of service provided r. Units: Displays the number of units of service provided s. Billed: Displays the amount billed for this procedure t. Statistical: Tells if this claim was submitted for statistical use only (not for payment). Y indicates that the claim was submitted for statistical purposes only. (b) (d) (f) (h) (a) (c) (e) (g) (i) (j) (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) 28

CLAIMS VIEW CLAIM LINES View Claim Lines 1. Select to view claim line details which will show the following information: a. Disposition Code: Displays comments explaining how claim was paid or why it was denied or additional information on claims. b. Fund: Displays who s financial risk paid it c. Days: Displays the number of days of service provided d. Units: Displays the number of units of service provided e. Dollars: Displays the amount a service was approved for f. Encounters: Tells if the procedure for this line is defined as an encounter g. Treatments: Tells if the procedure for this line is defined as a treatment (a) (b) (c) (d) (e) (f) (g) How to print your claim screen 1. Select your claim from the Claim List Screen 1 2. After selecting your claim the following Claim Header Screen will appear 3. Select Print on your Claim Header Screen 4. A pop up window will appear with your print image a. Select Print in the upper right corner b. A print window will appear Remember this should say: Sharp Health Plan c. Select your printer and select Print 3 2 a c c 29

REFERENCE REFERENCE References provides contact information and resources for our providers to use when working in ACES 1. Select References from the left side column 2. Single click on link under the Sharp Health Plan Tab will take you to Sharp Health Plan Web Page 1 2 30

REFERENCE 31

CONTACT US CONTACT US Contact Us provides a way for providers to communicate with Sharp Health Plan staff in regards to any questions or concerns related to referral issues only. 1. Select Contact Us from the left side column 2. Call Sharp Health Plan with your concerns. There is no email service available. 1 2 32

CONTACT US 33

CONTACT US This page is blank for your notes. 34

REFERRAL TYPE DESCRIPTION GUIDE REFERRAL TYPE DESCRIPTION GUIDE Use this to help you decide your referral type. REFERRAL TYPE Abbreviation DESCRIPTION Consult Only CONS When requesting 1 visit only for consultation Outpat Medical Diagnostic No MD DXNO Services performed by technician at hospital or ancillary facility. (Ct, MRI, Ultrasound, etc.) Medical Diagnostic w/md DXDOC Medical or diagnostic procedure performed by a physician at hospital. Must have phys. name to enter on this referral type. (Needle localization, vascular procedures, invasive radiology, etc.) Dialysis SMPDI Dialysis treatment on an outpatient basis Durable Medical Goods & Equip DME Supply or hardware, (i.e., crutches, wheelchairs, Ostomy supplies, etc.) Emergency ER Emergency room visit or urgent care visit Room/Urgent Care Home Health-Nursing HHNUR RN visits member at home, PT, OT, MSW, HHA (i.e., urinary catheter placement) Home Health-Infusion HHIV IV antibiotics, IV fluids, IV line care (picc line). Pharmacy supplies included on this referral. Hospice HOSPC Terminally ill patients Inpatient INPAT When member is in hospital over a 24 hour period and/or is classified as inpatient by the admitting physician. Mental Health MH Request for mental health services on outpatient basis are reviewed and authorized by PCSD Outpatient Surgery OPSUR MD performs surgery or procedure at a facility other than office. Physician Referral PHY PCP or Specialist performing services in offices. Including consultation and follow up visits. Prosthetics and Orthotics PROS Request for prosthetics or orthotics (braces, AFO s, wrist splints) Pharmacy/Injectables PHAR Self-Injectable (SQ= subcutaneous/ IM=Intramuscular). Nursing instructions included on this referral Skilled Nursing Facility SNF Member requires skilled nursing care. Custodial SNF CUST Member resides at nursing home does not require skilled care. Therapy THER Outpatient Physical (PT), Occupational (OT), Speech (ST), Cardiac, Pulmonary or Pain Rehab. Chiropractic, Acupuncture Transportation TRNSP Ambulance or wheel chair van services for non-emergent transportation. 35