PA/DVS Request
PA/DVS RequestA DVS Request may be submitted by either an individual Provider or a Provider Group. If submitted for a Group, the ID must be entered on the claim which applies to the request. A Prior Approval (non-DVS) request must be submitted under an individual provider. The following data may be entered when generating a DVS or Non-DVS request.
Enter the desired Client ID and click Go, this will return the associated Client information below the prompt. The client's full name, gender, and birth date will be displayed as confirmation that the correct ID was entered. If this is not the desired client, re-enter the ID and search again.
Patient Control #: Individual Patient Control Numbers are usually assigned to each visit a client makes to a provider. This may also be referred to as the Patient Account Number in the provider's billing system.
Transaction Type: Select the appropriate transaction type from the drop down. The following options are available Dental -DVS; Dental - Non DVS; Non Dental - DVS; or Non Dental - Non DVS.
Address Line 1/line 2: Address Line 1/line 2: The street and, optionally, building name in the provider's service address.
City: The city or town name in the provider's address.
State: The state name in the provider's address.
Zip: Enter the postal code (Zip + 4) associated with the provider's service address being entered.
Contact Name: An optional name, normally identifying clerical or technical staff.
Telephone: The contact's telephone number.
Ext: The contact's extension number.
E-Mail: The contact's e-mail address.
Fax #: The contact's fax number.
Use an Existing Provider
Select a Name: From the available drop-down list, select a name of a previously used provider available in the support file to indicate a Referring provider.
Last Name: Enter a Last Name to search for an existing Medicaid provider. This will return a list of providers that match the search criteria. Click the radio button for the desired provider.
Provider Number: Enter the provider number to search for an existing Medicaid provider.
Enter a New Non-Medicaid Provider
NPI #: Enter the NPI to indicate a New Non-Medicaid provider that is not listed as an option in the Select a Name drop down.
Use an Existing Provider
Select a Name: From the available drop-down list, select a name of a previously used provider available in the support file to indicate an Ordering provider.
Last Name: Enter a Last Name to search for an existing Medicaid provider. This will return a list of providers that match the search criteria. Click the radio button for the desired provider.
Provider Number: Enter the provider number to search for an existing Medicaid provider.
Enter a New Non-Medicaid Provider
NPI #: Enter the NPI to indicate a New Non-Medicaid provider that is not listed as an option in the Select a Name drop down.
Facility Type: Select appropriate Facility Type radio button of either Professional/Dental or (UB) Institutional.
Service Type: Enter the appropriate service type for what service you are getting a PA/DVS for. Please pick an option from the list.
Release of Information: Pick the appropriate option to indicate whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
Accident Date: If any of the Related Causes boxes will be checked, the date of the accident must be entered. The date may not be greater than the current date. The format of the date is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field.
Service Date From: Enter proposed or actual begin date of service.
Service Date To: Service Date To: Enter proposed or actual end date of service.
Onset Date: If the onset date differs from the date of service, enter the date here. The date may not be greater than the current date.
Admission Date: If applicable, enter the date of admission.
Discharge Date: If applicable, enter the date of discharge.
Related Causes Information
Related Causes: You may select up to three related causes for this claim. If one or more of the options applies to the situation, mark the appropriate check box(es) and enter the Accident Date.
Accident Location: If Auto Accident is selected as a Related Cause, enter the state and country in which the accident occurred, 'NY' and 'USA' are the corresponding default values.
Diagnosis
Primary: Enter the Primary Diagnosis code. Only ICD-9-CM diagnosis codes are acceptable.
Secondary: Enter the Secondary Diagnosis code. Only ICD-9-CM diagnosis codes are acceptable.
* Private Duty Nursing (PDN) providers should not enter any information in these fields. Entering information in these fields prohibits the ability to make future adjustments to the prior approval.
The Pattern of Delivery section contains fields used to define units of service to be provided over specific periods of time. The following fields are provided:
Unit Count: These fields include a units value on the top and a type field on the bottom. The type field is a drop-down that allows you to choose either Days, Units, Hours, Month, or Visits.
Frequency: These fields include a frequency value on the top and a frequency type field on the bottom. The type field is a drop-down that allows you to choose either Days, Months, or Weeks.
Duration: These fields include a duration value on the top and a duration type field on the bottom. The type field is a drop-down that allows you to choose either Hour, Day, Years, Episode, Visit, Month, Week.
Calendar Pattern: This field establishes the frequency (e.g., 1st Week of the Month) that the requested service is to be rendered as it relates to calendar days/weeks.
Unit Qualifier: This field is a drop-down that allows you to choose either Days, Units, Hours, Month, or Visits.
Freq. Type: This field is a drop-down that allows you to choose either Days, Months, or Weeks.
Duration Type: This field is a drop-down that allows you to choose either Hour, Day, Years, Episode, Visit, Month, Week.
Time Pattern: This field establishes the time (e.g., 2nd Shift) that the requested service is to be rendered.
Oxygen Equipment type: These fields allow you to identify the requested equipment type. You must populate at least one of these fields using the adjacent pop-up.
Equipment Reason: Allows you to enter optional free form text that justifies the use of the equipment.
Oxygen Delivery System: This required field can only be populated by the associated pop-up and identifies the method of oxygen delivery.
Oxygen Flow Rate: This required field specifies a patient's oxygen flow rate in liters per hour.
Portable Oxygen System Flow Rate: This optional field specifies a device's oxygen flow rate in liters per hour.
Test Type Results: These required fields include a radio button set that establishes the test type and a text field used to record the test results.
Test Condition: These fields allow you to identify the condition in which the test was administered. At least one of these fields must be populated using the associated popup.
Test Findings: These fields allow you to identify the test findings. At least one of these fields must be populated using the associated pop-up.
Daily Oxygen Use count: The number of times per day a patient must use oxygen.
Oxygen Use Period Hour Count: The number of hours in a period of oxygen use.
Respiratory Therapist Order: Optional free form text describing treatment to be provided by the respiratory therapist.
Prognosis: This field captures the patient's prognosis (Good, Fair, etc.) and can be populated by the associated pop-up.
Physician Order Date: The date that a physician ordered the home health care.
Start Date: The date that the home health care is to begin.
Last Visit Date: The date that the physician last saw the patient.
Physician Contact Date: The date that contact was last made with the physician.
Certification Period From/To: These From and To dates establish the period within which the home health care is certified.
Admission Period From/To: These From and To dates establish admission and discharge dates, if any, from a facility prior to start of home health care.
Discharge Facility Type: The type of facility (e.g., Acute Care Facility) from which the patient was or will be discharged prior to the home health care.
Related Surgery Date: The date of a surgery, if any, related to the home health care.
Related Surgical Procedure: These radio buttons and related text field capture whether the procedure is a HCPCS or a ICD-9-CM procedure and the procedure code, respectively.
Type: This field can only be populated by the associated pop-up and identifies the type of attachment.
Transmission Code: This field can only be populated by the associated pop-up and identifies the method by which the attachment will be transmitted to eMedNY.
Control Number: This field identifies the attachment's control number in your records. It is an internal number that is for the provider's office use only and does not correspond to the subsequent PA number issued by NYS Medicaid.
Description: This field describes the attachment.
Certification Category: This field is required if when health care services review is requesting Ambulance Certification, Chiropractic Certification, Durable Medical Equipment, Oxygen Therapy, Functional Limitations, Activities Permitted or Mental Status when relevant to review.
Condition Codes: If entering a certification category, select the appropriate condition code in the list.
Comments: Allows you to enter free form text that clarifies the request.
Once all the necessary information has been entered, click the "next" button.
Line: This is a system generated value to uniquely identify the Service Line on the claim. The counter will start with 1 and increment with each new Service Line entered. A minimum of 1 Service Line is required on all claims. Note: If requesting a DVS, only one line will display. If requesting a Non DVS, 5 lines will display.
Service Dates: If requesting a procedure/service on a single date, enter this date in the From Date. However, if the procedure/service will transpire over a period of time, enter the start and end dates in the From and To fields respectively. The date(s) may not be greater than the current date. The format is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field. At a minimum, a From Date is required for all Service Lines.
NDC/Proc & Modifiers: Enter the Health Care Financing Administration Common Procedural Coding System identifier(or National Drug Code) for the product/service. This code value is required. Optionally, up to 4 modifiers identifying special circumstances related to the performance of the service may be entered for each code. Note: If entered, the Modifier must be a 2 character code.
Unit Count: Enter the service quantity in this field.
Oral Cav Area: A two-digit code may be entered or selected to identify the area of the oral cavity in which the indicated service is rendered. Additional codes may be entered by clicking the More icon.
Tooth Number: Enter or select the tooth number/code for the tooth related to this service. If multiple teeth are affected by the procedure, additional Tooth Numbers may be entered by clicking the More icon. A Tooth Number may not be repeated on a single line.
Line Amount: The submitted charge amount for this procedure/service must be entered. Note: Zero dollars is a valid charge amount.
More Details: For each Prior Approval Item Line, you may view/enter additional details by clicking the More icon. However you may only view these additional details once all required elements have been entered. Navigating off this summary page, either by clicking the More icon or moving to another tab, will trigger validation of the data entered on this page. Validation is done one line at a time, so if there are errors on multiple lines you will have to fix each line before seeing the next set of errors.
Remove: If a Prior Approval Line must be removed for any reason, clicking the Delete icon will remove the line and re-sequence the remaining Prior Approval Lines.
The top of the screen will display information on what service line more button you are on. This includes: Line Number, Service Dates, NDC/Proc & Modifiers, Unit Count, and Line Amount that was enter on the Prior Approval Items line.
Oral Cavity Areas: A two-digit code may be entered or selected to identify the area of the oral cavity in which the indicated service is rendered.
Tooth Information: Tooth Number/Tooth Surface Codes: A single Tooth Number and associated Surface Code may be entered/viewed on the main Service Line Summary page; you may add/view a maximum of 32 Tooth Number/Surface Code combinations, however a Tooth Number may not be repeated on an individual Service Line. If a Tooth Number or Surface Information was entered on the Prior Approval Items page, the values will default to the first corresponding field on this page.
Attachments: This group allows you to apply attachments to the line. The Enter More Attachments link allows for the entry of 5 additional attachment fields.
Copy Attachments from line: If you want to copy attachments from a previous line, enter the line number here.
Type: This field may be populated by using the associated pop-up and identifies the type of attachment.
Transmission Code: This field may be populated by using the associated pop-up and identifies the method by which the attachment will be transmitted or sent to eMedNY.
Control Number: This field identifies the attachment's control number in your records. It is an internal number that is for the provider's office use only and does not correspond to the subsequent PA number issued by NYS Medicaid.
Description: This field describes the attachment.
Copy Comments from line: If you want to copy comments from a previous line, enter the line number here.
Comments: The Comments field allows you to enter free form text that clarifies the request. You may copy comments into the current line from another line in the current PA.
Close: After you have completed the additional items for the current line, choose Close to save the information and return to the previous page. If you wish to abandon the additional items for the current line, choose Clear and you will return to the previous page.
Line: This is a system generated value to uniquely identify the Service Line on the claim. The counter will start with 1 and increment with each new Service Line entered. A minimum of 1 Service Line is required on all claims. Note: If requesting a DVS, only one line will display. If requesting a Non DVS, 5 lines will display.
Service Dates: If requesting a procedure/service on a single date, enter this date in the From Date. However, if the procedure/service will transpire over a period of time, enter the start and end dates in the From and To fields respectively. The date(s) may not be greater than the current date. The format is: MM/DD/YYYY and may either be entered in the field or selected from the calendar available by pressing the button to the right of the field. At a minimum, a From Date is required for all Service Lines.
NDC/Proc & Modifiers: Enter the Health Care Financing Administration Common Procedural Coding System identifier(or National Drug Code) for the product/service. This code value is required. Optionally, up to 4 modifiers identifying special circumstances related to the performance of the service may be entered for each code. Note: If entered, the Modifier must be a 2 character code.
Unit Count Basis Meas.: Enter the service quantity in this field.
Line Amount: The submitted charge amount for this procedure/service must be entered. Note: Zero dollars is a valid charge amount.
More Details: For each Prior Approval Item Line, you may view/enter additional details by clicking the More icon. However you may only view these additional details once all required elements have been entered. Navigating off this summary page, either by clicking the More icon or moving to another tab, will trigger validation of the data entered on this page. Validation is done one line at a time, so if there are errors on multiple lines you will have to fix each line before seeing the next set of errors.
Remove: If a Prior Approval Line must be removed for any reason, clicking the Delete icon will remove the line and re-sequence the remaining Prior Approval Lines.
The top of the screen will display information on what service line more button you are on. This includes: Line Number, Service Dates, NDC/Proc & Modifiers, Unit Count, and Line Amount that was enter on the Prior Approval Items line.
DX Pointer: Enter the applicable DX pointer
* Private Duty Nursing (PDN) providers should not enter any information in these fields. Entering information in these fields prohibits the ability to make future adjustments to the prior approval.
Unit Count: These fields include a units value on the top and a type field on the bottom. The type field is a drop-down that allows you to choose either Days, Units, Hours, Month, or Visits.
Frequency: These fields include a frequency value on the top and a frequency type field on the bottom. The type field is a drop-down that allows you to choose either Days, Months, or Weeks.
Duration: These fields include a duration value on the top and a duration type field on the bottom. The type field is a drop-down that allows you to choose either Hour, Day, Years, Episode, Visit, Month, Week.
Calendar Pattern: This field establishes the frequency (e.g., 1st Week of the Month) that the requested service is to be rendered as it relates to calendar days/weeks.
Time pattern: This field establishes the time (e.g., 2nd Shift) that the requested service is to be rendered.
Facility Type Code: Select appropriate Facility Type radio button of either Professional/Dental or (UB) Institutional.
Attachments: This group allows you to apply attachments to the line. The Enter More Attachments link allows for the entry of 5 additional attachment fields.
Copy Attachments from line: If you want to copy attachments from a previous line, enter the line number here.
Type: This field may be populated by using the associated pop-up and identifies the type of attachment.
Transmission Code: This field may be populated by using the associated pop-up and identifies the method by which the attachment will be transmitted or sent to eMedNY.
Control Number: This field identifies the attachment's control number in your records. It is an internal number that is for the provider's office use only and does not correspond to the subsequent PA number issued by NYS Medicaid.
Description: This field describes the attachment.
Copy Comments from line: If you want to copy comments from a previous line, enter the line number here.
Comments: The Comments field allows you to enter free form text that clarifies the request. You may copy comments into the current line from another line in the current PA.
Close: After you have completed the additional items for the current line, choose Close to save the information and return to the previous page. If you wish to abandon the additional items for the current line, choose Clear and you will return to the previous page.
