Administrator Manual rev 1.0
TABLE OF CONTENTS Setting Up Users... 4 User Roles... 8 Denial Code... 13 Sub Denial Code... 17 Action Message... 21 (CRE)Clinical Rules... 24 3
Tutorial 1 Setting Up Users STEP 1 TYPE your AdminID and Password, CLICK submit (fig 1.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 1.2) 4
Tutorial 1 Setting Up Users STEP 3 Users on the Main Menu Screen (fig 1.3) RESULT: The Add/Edit User Screen will appear (fig 1.2) (fig 1.2) 5
Tutorial 1 Setting Up Users STEP 4 New on the drop-down menu and fill out the form. Note: It is possible for employees to have multiple roles. Uou will need to assign a unique User ID for each role. (fig 1.3) Note: The User ID is usually the the same as the LAN ID assigned to all new employees at Blue Shield. TIP: There are no password assignment rules, however,when you assign a password to the new user make sure you write it down as the form will not allow you to see the password as you enter it. Note: The Division is either SF or EDH. 6
Tutorial 1 Setting Up Users STEP 5 CLICK Update to save. (fig 1.4) End of Tutorial 7
Tutorial 2 User Roles The Role function of the Admin Screen is used to assign or update the roles or levels of access (usually related to job title/responsibilities) that a User will have. STEP 1 TYPE your AdminID and Password, CLICK submit Note: Since the User Roles (access levels) have been previously defined, you will most likely not need to change them. (fig 2.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 2.2) 8
Tutorial 2 User Roles STEP 2 CLICK Roles on the Main Menu Screen. (fig 2.3) STEP 3 CLICK Roles on the Main Menu Screen. RESULT: The Add/Edit User Screen will pop up. (fig 2.4) 9
Tutorial 2 User Roles STEP 4 CLICK Roles on the Main Menu Screen RESULT: The Add/Edit User Screen will pop up. (fig 2.5) 10
Tutorial 2 User Roles STEP 4 SELECT a Role and CLICK Edit on the Main Menu Screen. RESULT: The Available and Accessible Queues, Menus and Privileges will populate the screen. (fig 2.6) Note: See a Manager before giving a User access to the Unlock function. 11
Tutorial 2 User Roles STEP 4 ADD or REMOVE Queues, Menus or Privileges as needed. CLICK Update. Choose One (fig 2.7) End of Tutorial 12
Tutorial 3 Denial Code The Denial Code function of the Admin Screen is used to assign or update the codes associated with drugs. STEP 1 TYPE your AdminID and Password, CLICK submit (fig 3.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 3.2) 13
Tutorial 3 Denial Code Note: Since the Denial Codes have been previously defined, you will most likely not need to change them. Use this tutorial for setting up denial codes for new drugs. STEP 2 CLICK Denial Code on the Main Menu Screen. (fig 3.3) RESULT: The Add/Edit Denial Code Screen will pop up. STEP 3 SELECT a Denial Code Option on the Drop Down Menu. Note: Choose Existing to review a drug that is already in the system. (fig 3.4) 14
Tutorial 3 Denial Code STEP 4 SELECT a Drug from the Drop Down Menu. (fig 3.4) RESULT: The Add/Edit Denial Code Screen will populate with denial code information on the selected drug. STEP 5 EDIT Denial Code information as appropriate. (fig 3.5) 15
Tutorial 3 Denial Code Note: Make sure that you check the ACTIVATE box to activate the drug. Otherwise the drug will be saved but inactive. STEP 6 CLICK Update to save. (fig 3.6) End of Tutorial 16
Tutorial 4 Sub Denial Code The Sub Denial Code function of the Admin Screen is used to assign or update the sub denial codes associated with denial codes. STEP 1 TYPE your AdminID and Password, CLICK submit (fig 4.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 4.2) 17
Tutorial 4 Sub Denial Code Note: As with the Denial Codes, the Sub Denial Codes have been previously defined, you will most likely not need to change them. Use this tutorial for setting up denial codes for new drugs. STEP 2 CLICK Sub Denial Code on the Main Menu Screen. (fig 4.3) RESULT: The Add/Edit Sub Denial Code Screen will pop up. STEP 3 SELECT a Denial Code Option on the Drop Down Menu. Note: Choose Existing to review a code that is already in the system. (fig 3.4) 18
Tutorial 4 Sub Denial Code STEP 4 SELECT a Drug Name from the Drop Down Menu. (fig 3.4) RESULT: The Add/Edit Sub Denial Code Screen will populate with denial code information on the selected drug. STEP 5 SELECT an Alpha Code. CLICK SELECT. (fig 3.5) 19
Tutorial 4 Sub Denial Code RESULT: The Add/Edit Sub Denial Code Screen will populate with sub denial code information on the selected drug. Note: Make sure that you check the ACTIVATE box to activate the drug. Otherwise the drug will be saved but inactive. STEP 6 CLICK Update to save. (fig 3.6) End of Tutorial 20
Tutorial 5 Action Message The Action Message function of the Admin Screen is used to assign or update the messages that appear in AutoAuth. STEP 1 TYPE your AdminID and Password, CLICK submit (fig 5.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 5.2) 21
Tutorial 5 Action Message STEP 2 CLICK Action Messages on the Main Menu Screen. (fig 5.3) RESULT: The Add/Edit Messages Screen will pop up. STEP 3 SELECT Message Type and Message Option on the Drop Down Menu. (fig 5.4) 22
Tutorial 5 Action Message RESULT: The Add/Edit Messages Screen will pop up. STEP 4 TYPE Action Messages as appropriate. CLICK Update. (fig 5.5) End of Tutorial 23
Tutorial 6 (CRE)Clinical Rules STEP 1 TYPE your Clinical AdminID and Password, CLICK submit (fig 6.1) RESULT: You will be logged into the system and automatically taken to the Admin Main Menu Screen. (fig 6.2) 24
Tutorial 6 (CRE)Building Clinical Rules Note: When you are working in CRE it is important to have the Visio diagram provided by the Clinical Department. STEP 2 CLICK Action Messages on the Main Menu Screen. (fig 6.3) RESULT: The Rule Administration Screen will appear. STEP 3 SELECT Rule with Versions on Drop Down Menu. RESULT: The screen will populate with current versions of the drug rules. (fig 6.4) 25
Tutorial 6 (CRE)Building Clinical Rules STEP 4 CLICK Add at the bottom of the screen. (fig 6.5) 26
Tutorial 6 (CRE)Building Clinical Rules STEP 4 COMPLETE all sections. CLICK Save. Type Rule Name Here Type Clinical URL Here (fig 6.6) Note: Get Criteria URL from Pharmacy Home Page/Drug Criteria Page. Copy and Paste it in the Criteria URL box. If there is more than one criteria click SHIFT/BACKSPACE after each entry and enter the next one. RESULT: After you click save more buttons will become available. 27
Tutorial 6 (CRE)Building Clinical Rules STEP 4 CLICK Add (Under Existing Clinical Code). RESULT: The Drug Search Screen will appear. (fig 6.7) STEP 5 SEARCH for appropriate drug from the bottom of the screen. CLICK Save. Note: You will have multiple search options. (fig 6.8) 28
Tutorial 6 (CRE)Building Clinical Rules RESULT: The Existing Clinical Codes will populate the screen. STEP 5 SELECT Appropriate GCNs. CLICK Save. (fig 6.9) Note: There may be multiple GCNs for each Rule. RESULT: Your selections will appear. 29
Tutorial 6 (CRE)Building Clinical Rules STEP 6 CLICK New Version the bottom of the screen. (fig 6.10) RESULT: The Manage Versions Screen will appear. STEP 7 CLICK Save. Note: The buttons will only become activated once you click SAVE. (fig 6.11) 30
Tutorial 6 (CRE)Building Clinical Rules STEP 8 CLICK Add Component. SELECT Component Type QUESTION and appropriate Component Sub Type. Note: The Visio Diagram will help you determine what type of Component Sub Type to select. SELECT TIP: Your Question Component Sub Type will usually be a Multiple-Choice Question. (fig 6.11) Note: Select Diagnosis Multiple Choice ONLY for questions related to the diagnosis. (fig 6.12) TIP: AutoAuth DOES NOT HAVE SPELL. Check Your Spelling BEFORE you hit Save. 31
Tutorial 6 (CRE)Building Clinical Rules STEP 9 TYPE Your Question. CLICK Save. Note: Use standard Question formatting conventions established by Blue Shield. TIP: Answer Value 1=True or YES, Value 2=False or NO. (fig 6.13) RESULT: Your Question Component will appear. (fig 6.14) STEP 10 REPEAT STEPS 8 & 9 for each Question. When you have completed all of your questions proceed to STEP 11. 32
Tutorial 6 (CRE)Building Clinical Rules STEP 11 CLICK Add Component. SELECT Component Type Auto Check and appropriate Component Sub Type. SELECT (fig 6.15) STEP 12 COMPLETE with Auto Check History information from the decision tree flowchart. CLICK Save. Note: Use standard AutoCheck formatting conventions established by Blue Shield. Note: AutoCheck can check Paid Claims based on GCN Codes or Data-to- Elements. TIP: You should probably use 730 days as a search parameter. (fig 6.16) 33
Tutorial 6 (CRE)Building Clinical Rules RESULT: Your AutoCheck Component will appear. (fig 6.17) STEP 13 REPEAT STEPS 11 & 12 for each AutoCheck. When you have completed all of your AutoCheck Compononents proceed to STEP 14. STEP 14 CLICK Add Component. SELECT Component Type DECISION and appropriate Component Sub Type AUTHORIZATION. Note: The Visio Diagram will help you determine what type of Component Sub Type to select. SELECT (fig 6.18) 34
Tutorial 6 (CRE)Building Clinical Rules RESULT: The Authorization Information Screen will appear. STEP 15 COMPLETE All Sections with information from the Visio Diagram provided by Clinical. CLICK Save. (fig 6.19) RESULT: Your Authorization Component will appear. 35
Tutorial 6 (CRE)Building Clinical Rules (fig 6.20) STEP 15 CLICK Add Component. SELECT Component Type DECISION and appropriate Component Sub Type DENIAL. SELECT (fig 6.21) 36
Tutorial 6 (CRE)Building Clinical Rules RESULT: The Denial Information Screen will appear. (fig 6.22) STEP 16 COMPLETE All Sections with information from the Visio Diagram provided by Clinical. CLICK Save. (fig 6.23) RESULT: Your Denial Component will appear. 37
Tutorial 6 (CRE)Building Clinical Rules (fig 6.24) Note: Verify against your Visio Diagram that you have correctly entered all of your Question, AutoCheck and Decision components, once you have verfied everything you can proceed to STEP 16. STEP 17 CLICK Checkbox of the first component that you want to link. CLICK Link Component. (fig 6.25) RESULT: Next Steps Links dialogue box will appear. 38
Tutorial 6 (CRE)Building Clinical Rules STEP 18 LINK Component as appropriate by answering questions. CLICK Save. Note: Verify against your Visio Diagram that you correctly linking all of your Question, AutoCheck and Decision components. (fig 6.25) RESULT: Your linked component will appear under next component. (fig 6.26) 39
Tutorial 6 (CRE)Building Clinical Rules STEP 19 REPEAT STEPS 17 & 18 for each component. When you have completed linking all of your Compononents proceed to STEP 20. STEP 20 CLICK Validate Version. RESULT: The Validate Successful Dialogue Box will Appear. (fig 6.27) Note: A Validation Failure Dialogue Box means that something was incorrect in your linking logic. Verify your links against the Visio Diagram. Correct as appropriate then repeat STEP 19. End of Tutorial 40