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Change Request Form
ADD MODIFY INACTIVATE
/ RCT | IT ASSIGNED / Change Request No.Description
Operational (RCM)
Technical (IT)
A. CUSTOMER’S INFORMATION
1. Date of Request / 2.Originating Facility / 3. Requested by (name) / 4.Requestor’s E-mail/Phone/Ext. / 5.Form Completed by
6. Department / 7.Department Manager (Required for Approval)
B. FACILITY / DEPARTMENT / APPLICATION IMPACT
8.Classification and Detail / 9. Date Needed / 11. Facilities Impacted / 12.Departments Impacted
Select a Classification and provide detail in the designated box.
Adjustment Code (Section C)
Denial Code (Section C)
Coded Comments (Section D)
Payer (Section E)
Scheduling – Soarian (Section F)
Explain Below:
aMPI (Not Payer)
Soarian Activity
Untimely Filing
Other / ALL
AMH
BHC
BJH
BSP
BWC
CHN / MBH
MBS
PHC
PGP
PWH
SLC
WUSM / Patient Access
Revenue Management
HIM
Scheduling
UM
Physician Office
Entity Finance
Finance
Managed Care
IT
CDM
Other
10. System/App to be Modified
aMPI (BJH/SLC)
SMS / Soarian
Description of Proposed Change / Rationale / Expected Benefits / General Comments:
IRB#
Industry or Federal:
DEPT #
DIVISION #
C. ADJUSTMENT AND DENIAL CODES
13.Avoidable Adjustment Mapping / 14.Non-Avoidable Adjustment Mapping / 15.Denial / Rejection Code Mapping
Authorization/Medical Necessity
Untimely
Eligibility
Benefits
Diagnosis Doesn’t Support
Reimbursement/Contractual / Administrative
Bad Debt
Charity
Contractual HCC/PRIM
Contractual Manual
Customer Service
Self Pay
Settlement
Unknown / Authorization
Benefits
Billing
Coding/CDM
Documentation Requested
Eligibility / Level of Care
Medical Necessity
Information Only (No Usage Expected)
Reimbursement/Contractual
TPA/COB
Untimely
Description of Proposed Change / Rationale / Expected Benefits / General Comments:
D. CODED COMMENTS
16. CODED COMMENT NAME / 17. CODED COMMENT DESCRIPTION
Patient Access
PA______
Revenue Management
RM______
NOTE: Maximum character length including PA/RM and spaces is 15 characters
IF CODED COMMENT(S) WILL DRIVE A WORKLIST ACTION, SUBMIT YOUR REQUEST VIA SERVICE NOW.
Description of Proposed Change / Rationale / Expected Benefits / General Comments:
E. PAYER CODES
18. Payer and Health Plan Name
Example: Anthem / Access Choice PPO / 19. Plan Address / 20. Plan Phone / 21. Effective Date
22. Plan ID (Non Soarian Systems Only) / 23. Paper or Elec. Payor ID/Sub ID / 24. Type of Billing
Paper Electronic: / UB 1500 Organizational
NON SOARIAN FACILITIES ONLY (BOX 25 - 31)
25. Managed Care Contract Name / 26. HCC Contract ID / 27. Contract on File? / 28. HCC Transaction Code / 29. HCC Budget Low
YES NO
30. Budget Advisor Payer Mapping (Managed Care)
Advantra
Aetna HMO
Aetna PPO
BC Alliance
BC Alliance Choice
BC Other
BC Traditional
Champus
Cigna HMO / Cigna PPO
Commercial
GHP
Healthlink HMO
Healthlink PPO
Managed Care Other-Contracted
Managed Care Other-Non-Contracted
MC+ HCUSA
MedicaidIL / MedicaidMO
Medicaid Other
Medicaid Risk Other
Medicare Complete
Medicare Risk Other
Medicare Traditional
Mercy
Other / Other Government
Self Pay
UHC HMO
UHC PPO
UMR-BJC Employees
Unmapped
Workers Compensation
31. Payer Mapping (Finance)
Commercial
HMO / Medicaid
Medicaid Risk / Medicare
Medicare Risk / Other
PPO / Self Pay
Workers Compensation
SOARIAN FACILITIES ONLY (BOX 32 - 38)
32. Managed Care Contract Name / 33. Contract on File? / 34. Rates
YES NO / YES Rate to Use: NO (Scan and attach Contract)
35. Soarian Reporting Group Mapping / 36. HIDI Code(Hospital Industry Data Institute) / 37. UHC(United Hospital Consortium)
Blues
Cigna
Commercial
Contracted
Great West
Industrial
Managed Care
Medicaid
Medicaid HMO / Medicare
Medicare HMO
Medicare Part B
Other
Other Government
PPO
Self Pay
Workers Comp / Medicare
Medicaid
Maternal/Child Health
Blue Cross/Blue Shield
Workers Comp
Self Pay
Commercial/Private
Charity/No Charge
Other Government / Other
Medicare Managed Care
Medicaid Managed Care
Maternal/Child Hlth Mngd Care
Blue Cross/Shield Mngd Care
Workers Comp Managed Care
All Commercial Payers Mngd Care
Other Government Managed Care
Other Managed Care / Medicaid
Medicare
Military
Auto Insurance
Workers Comp
Research / Charity
Other
Unknown
Self Pay / Uninsured
Self Pay Cash in Full
Commercial/Private
Government – Assisted Healthcare
Title V, Maternal & Child Health
County Medically Indigent Svc
38. Soarian Product Line
Advantra
Aetna HMO
Aetna PPO
Auto
BC Alliance
BC Alliance Choice
BC Other
BC Traditional
Cigna HMO
Cigna PPO
EPO (Exclusive Provider Org)
FEP (Federal Employee Pgm)
First Health
GHP / Global Transplant
Grants
HCUSA
HMO
Healthlink HMO
Healthlink PPO
Indemnity
IPA
HIS (Indian Health Svc)
Mngd Care Other Contract
Mngd Care Other NON Contract
Medicaid HMO
Medicaid IL
Medicaid Other / Medicaid Pending
Medicaid Risk
Medicaid Traditional
Medicare HMO
Medicare PPO
Medicare FFS (Fee for Svc)
Medicare Traditional
Medigap
Mercy
Other
Other Government
Other Liability
PHO (Phys Hosp Org)
POS / PPO
Self Pay
Self Pay Other
St Louis Connect Care
Other State
TPA
Tricare
UHC HMO
UHC PPO
UMR-BJC Employees
Veterans Admin
Workers Comp
39. For new Payer/Plan, please provide existing Plan to mirror for required authorizations. If there is no existing Plan to mirror complete box 40. If new Payer/Plan does not require authorizations, enter N/A.
40. List ALL CPT codes which require authorization under the new Payer/Plan:
Description of Proposed Change / Rationale / Expected Benefits / General Comments:
F. SCHEDULING ACTIVITY
41. Activity Start Date
(Room Closing Starts) / 42. Activity Stop Date
(Room Closing Stops) / 43. Activity Name (Procedure) / 44. HCPC / CPT Code
45. Days / Times / 46. Duration
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday / Time:
Time:
Time:
Time:
Time:
Time:
Time: / 10 Minutes
15 Minutes
20 Minutes
30 Minutes
40 Minutes / 45 Minutes
60 Minutes
90 Minutes
120 Minutes
Other
47. List all Resources (Person or Room for Requested Activity/Procedure)
48. List New or Revised Prep Note Instructions.
49. List New or Revised Instructions for Patient Notice.
50. Document any Activity/Procedurethat must always be completed with this Activity. (List Activities in proper sequence)
51. List all Activity Names and Associated Times, if this activity requires more than one part and a waiting period of hours and/or days,
Description of Proposed Change / Rationale / Expected Benefits / General Comments:
COMPLETE THIS SECTION ONLY IF MOVING AN ACTIVITY FROM ONE DEPARTMENT TO ANOTHER
52. Name of Activity / 53. Current Department Name (Moving From) / 54. New Department Name (Moving To)
55. Days / Times / 56. Duration
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday / Time:
Time:
Time:
Time:
Time:
Time: / 10 Minutes
15 Minutes
20 Minutes
30 Minutes
40 Minutes / 45 Minutes
60 Minutes
90 Minutes
120 Minutes
Other
57. List all Resources (Person or Room for Requested Activity/Procedure)
Last Update: Thursday, October 11, 2018Page 1 of 3
H:\RCAST\Blank Forms\Clinical Trials Change Request Form_3.9.2016.doc