DVS Revise/Cancel Request

Revise or Cancel Request

Revise/Cancel ServiceRequest:

Client Information

Enter a Client ID:

Patient Account #:

Name:

Gender:

DOB:

Transaction Type

Transaction Type:

Provider Service Address

Address Line 1/Line 2:

City:

State:

Zip:

Contact Information

Contact Name:

Telephone:

Ext:

E-Mail:

Fax #:

Referring Provider

Use an Existing Provider

Select a Name:

Last Name:

Provider Number:

Enter a New Non-Medicaid Provider

NPI #:

Ordering Provider

Use an Existing Provider

Select a Name:

Last Name:

Provider Number:

Enter a New Non-Medicaid Provider

NPI #:

Event Information

Facility Type:

Service Type:

Release of Information:

Accident Date:

Service Date From/To:

Onset Date:

Admission Date:

Discharge Date:

Related Causes Information

Related Causes:

Accident Location:

Diagnosis

Primary:

Secondary:

Pattern of Delivery

Unit Count:

Frequency:

Duration:

Calendar Pattern:

Unit Qualifier:

Freq. Type:

Duration Type:

Time Pattern:

Home Oxygen Therapy

Oxygen Equipment type:

Equipment Reason:

Oxygen Delivery System:

Oxygen Flow Rate:

Portable Oxygen System Flow Rate:

Test Type Results:

Test Condition:

Test Findings:

Daily Oxygen Use count:

Oxygen Use Period Hour Count:

Respiratory Therapist Order:

Home Health Care

Physician Order Date:

Start Date:

Last Visit Date:

Physician Contact Date:

Certification Period From/To:

Admission Period From/To:

Discharge Facility Type:

Related Surgery Date:

Related Surgical Procedure:

Attachments

Type:

Transmission Code:

Control Number:

Description:

Certification Category

Certification Category:

Condition Codes:

Comments

Comments:

You may need to cancel a DVS Request once it has been sent for a variety of reasons. This process however is quite simple.

1. Click on DVS Responses on the left-hand menu to display the DVS Activity Worklist.

2. Use the Search Criteria to find the DVS Request you wish to cancel.

3. Click the Cancel button in the far right column.

   • NOTE: If a request does not have a Cancel button, this would mean that it is a DVS Cancellation Request which may not be cancelled.

4. Confirm the cancellation request.  

5. You will notice a new request has been added to the list. This new request is the Cancel Request you submitted by clicking the Cancel button and it has no Cancel button.

6. Once a response has been received from NY Medicaid, the Result column will display the value 'A6' with the associated descriptive text indicating a cancellation, the Status will be updated to Received, and the Client ID will become a hyperlink which may be clicked to view the Response.