MMIS SERVICE AGMT - ASA3

The ASA3 panel lists the services that have been authorized. Each line includes the dates the service may be provided and claims paid for. The designated provider of those services and the rate and units prior authorized are also included on each line.

Up to 99 lines may be entered on a service agreement, however only two lines are displayed on the ASA3 panel at a time.

The table below displays lines 01 and 02 on the first screen The remaining lines 03 through 06 follow. Line 06 is blank.

Table of MMIS SERVICE AGREEMENT - ASA3 panel
NEXT: ADHS MMIS SERVICE AGMT - ASA3 AUTHORIZATION NBR: 0000 000 0 000 AGMT TYPE/STAT: J A APPROVED PROV NBR/TYPE: RECIP NAME/ID: LAST FIRST I 00000000 SEX: F AGE/LA: 00 00 LINENAV:00 + LI COMMENTS/PROCEDURE DESCRIPTION PROC MOD1-4 REV DRUG DAANES 01 T1016 UC CASE MANAGEMENT 15 MINUTES START/END DT: MMDDYY MMDDYY REQ RATE/UNIT: 00.00 REQ TOT UNITS/AMT: 00 0000.00 PROV NBR/NAME: 0000000000 COUNTY PUBLIC HLTH SHR/FREQ: APP RATE/UNIT: 00.00 SRC: RQ TOT USED UNITS/AMT: 00.000 000.00 STAT CD/DATE: A APPROVED MMDDYY RSN CD: 499 RFE: CTY: RPT: 02 T1016 TF UC CASE MGMT PARAPROFESS 15 MIN START/END DT: MMDDYY MMDDYY REQ RATE/UNIT: 0.00 REQ TOT UNITS/AMT: 00 000.00 PROV NBR/NAME: 0000000000 COUNTY PUBLIC HLTH SHR/FREQ: APP RATE/UNIT: 0.00 SRC: RQ TOT USED UNITS/AMT: 0.000 00.00 STAT CD/DATE: A APPROVED MMDDYY RSN CD: 499 RFE: CTY: RPT: LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID 04 274 F 0000000 274 RECIPIENT IS ELIGIBLE FOR MEDICARE. YOU NEED TO CHECK WHETHER THESE SERVICES ARE PAID BY MEDICARE. ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12 PAGE HELP S/EXT NAVIG SLIST N/EXT PREV NEXT OOPS
LINENAV: 00 +/- LI COMMENTS/PROCEDURE DESCRIPTION PROC MOD1-4 REV DRUG DAANES 03 S5130 HOMEMAKER SERVICES, NOS; 15 MI START/END DT: MMDDYY MMDDYY REQ RATE/UNIT: 0.00 REQ TOT UNITS/AMT: 000 0000.00 PROV NBR/NAME: 0000000000 PROVIDER NAME SHR/FREQ: APP RATE/UNIT: 0.00 SRC: RQ TOT USED UNITS/AMT: 000.000 0000.00 STAT CD/DATE: A APPROVED MMDDYY RSN CD: 499 RFE: CTY: RPT: 04 T2029 EXT HOME HEALTH MED SUPP/EQUIP START/END DT: MMDDYY REQ RATE/UNIT: 00.00 REQ TOT UNITS/AMT: 00 000.00 PROV NBR/NAME: 0000000000 PROVIDER NAME L SHR/FREQ: APP RATE/UNIT: 00.00 SRC: RQ TOT USED UNITS/AMT: 0.000 000.00 STAT CD/DATE: A APPROVED MMDDYY RSN CD: RFE: CTY: RPT:
LINENAV: 00 +/- LI COMMENTS/PROCEDURE DESCRIPTION PROC MOD1-4 REV DRUG DAANES 05 T2003 UC TRANSPORTATION ONEWAY START/END DT: MMDDYY MMDDYY REQ RATE/UNIT: 0.00 REQ TOT UNITS/AMT: 00 000.00 PROV NBR/NAME: 0000000000 CONTY PUBLIC HLTH SHR/FREQ: APP RATE/UNIT: 0.00 SRC: RQ TOT USED UNITS/AMT: 00.000 000.00 STAT CD/DATE: A APPROVED 102008 RSN CD: 499 RFE: CTY: RPT: 06 START/END DT: REQ RATE/UNIT: REQ TOT UNITS/AMT: PROV NBR/NAME: SHR/FREQ: APP RATE/UNIT: SRC: TOT USED UNITS/AMT: STAT CD/DATE: RSN CD: RFE: CTY: RPT:

Table of MMIS SERVICE AGREEMENT - ASA3 panel

NEXT: ADHS                    MMIS SERVICE AGMT - ASA3  
                     AUTHORIZATION NBR: 0000 000 0 000                       
 AGMT TYPE/STAT: J A APPROVED     PROV NBR/TYPE:                                
  RECIP NAME/ID: LAST              FIRST        I 00000000 SEX: F AGE/LA:  00 00
  LINENAV:00                                                              +     
 LI COMMENTS/PROCEDURE DESCRIPTION   PROC    MOD1-4           REV  DRUG  DAANES 
 01                                 T1016     UC                                
    CASE MANAGEMENT 15 MINUTES               START/END DT: MMDDYY MMDDYY        
    REQ RATE/UNIT:     00.00            REQ TOT UNITS/AMT:         00    0000.00
    PROV NBR/NAME: 0000000000 COUNTY PUBLIC HLTH                   SHR/FREQ:   
    APP RATE/UNIT:     00.00 SRC: RQ   TOT USED UNITS/AMT:     00.000     000.00
    STAT CD/DATE: A APPROVED   MMDDYY RSN CD: 499         RFE:   CTY:   RPT:    
 02                                 T1016     TF  UC                            
    CASE MGMT PARAPROFESS 15 MIN             START/END DT: MMDDYY MMDDYY        
    REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:         00     000.00
    PROV NBR/NAME: 0000000000 COUNTY PUBLIC HLTH                   SHR/FREQ:   
    APP RATE/UNIT:      0.00 SRC: RQ   TOT USED UNITS/AMT:      0.000      00.00
    STAT CD/DATE: A APPROVED   MMDDYY RSN CD: 499         RFE:   CTY:   RPT:    
 LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID     
 04 274  F 0000000                                                              
 274 RECIPIENT IS ELIGIBLE FOR MEDICARE.  YOU NEED TO CHECK WHETHER             
     THESE SERVICES ARE PAID BY MEDICARE.                                       
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12 
PAGE  HELP        S/EXT NAVIG SLIST N/EXT PREV  NEXT         OOPS

 
  LINENAV: 00                                                             +/-   
 LI COMMENTS/PROCEDURE DESCRIPTION   PROC    MOD1-4           REV  DRUG  DAANES 
03                                 S5130                                       
   HOMEMAKER SERVICES, NOS; 15 MI           START/END DT: MMDDYY MMDDYY        
   REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:        000    0000.00
   PROV NBR/NAME: 0000000000 PROVIDER NAME                       SHR/FREQ:    
   APP RATE/UNIT:      0.00 SRC: RQ   TOT USED UNITS/AMT:    000.000    0000.00
   STAT CD/DATE: A APPROVED   MMDDYY RSN CD: 499         RFE:   CTY:   RPT:    
04                                 T2029                                       
   EXT HOME HEALTH MED SUPP/EQUIP           START/END DT: MMDDYY        
   REQ RATE/UNIT:     00.00            REQ TOT UNITS/AMT:         00     000.00
   PROV NBR/NAME: 0000000000 PROVIDER NAME               L       SHR/FREQ:    
   APP RATE/UNIT:     00.00 SRC: RQ   TOT USED UNITS/AMT:      0.000     000.00
   STAT CD/DATE: A APPROVED   MMDDYY RSN CD:             RFE:   CTY:   RPT:

 
  LINENAV: 00                                                             +/-   
 LI COMMENTS/PROCEDURE DESCRIPTION   PROC    MOD1-4           REV  DRUG  DAANES 
05                                 T2003     UC                                
   TRANSPORTATION ONEWAY                    START/END DT: MMDDYY MMDDYY        
   REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:         00     000.00
   PROV NBR/NAME: 0000000000 CONTY PUBLIC HLTH                   SHR/FREQ:    
   APP RATE/UNIT:      0.00 SRC: RQ   TOT USED UNITS/AMT:     00.000     000.00
   STAT CD/DATE: A APPROVED   102008 RSN CD: 499         RFE:   CTY:   RPT:    
06                                                                        
                                            START/END DT:       
   REQ RATE/UNIT:                      REQ TOT UNITS/AMT:        
   PROV NBR/NAME:                                                SHR/FREQ:   
   APP RATE/UNIT:           SRC:       TOT USED UNITS/AMT:                      
   STAT CD/DATE:                      RSN CD:            RFE:   CTY:   RPT:

How to read the ASA3 panel

The LI, COMMENTS/PROCEDURE DESCRIPTION, PROC and MOD1-4 field names are displayed above the data and field names apply to both lines on the page.
The LI field refers to the line number.
The PROC field is for entry of the procedure code (HCPC) assigned to the service being authorized.
The MOD1-4 fields are for any modifiers that may apply. Modifiers with a procedure code change the service being authorized.
REV, DRUG and DAANES fields are not used on waiver, AC or Home Care service agreements.
REQ RATE/UNIT field is for entry of requested rate per unit of service.
REQ TOT UNITS field is for entry of total requested units of service.
AMT field is auto calculated and entered by MMIS.
PROV NBR field is for entry of provider's NPI (National Provider Index) number.
PROV NAME field is auto-populated by MMIS based on NPI entered in PROV NBR field.
SHR field is only used with PCA (Personal Care Attendant) or PDN (Private Duty Nurse) services when there is shared care.
FREQ field is only used with PCA services to describe frequency of service.
APP RATE/UNIT (approved rate per unit), SRC (rate source), RFE and CTY fields are populated by MMIS.
RPT field allows line to be copied the same number of times as number entered in this field.
TOT USED UNITS/AMT is populated by MMIS with the total units used and the total amount that has been paid on claims for the line.
STAT CD is for entry of line status code and MMIS enters DATE.
RSN field is for entry of reason codes. Reason codes are entered by worker and sometimes auto-populated by MMIS.

MMIS navigation on the ASA3 panel

To view additional lines when there is a + or +/- on the screen press F8 to advance and F7 to return.
Enter a two-digit number in the LINENAV field to go directly to that line. LINENAV field will only navigate to completed lines.
In add or change mode press F11 to navigate to the next blank line to enter a new line.
F4 function key is helpful on the ASA3 panel for looking up additional information.
- Place cursor on procedure code and press F4 to navigate to the REFERENCE FILE and look up information about that procedure code including valid place of service, rate, provider types that can provide that service and much more.
- Place cursor on provider NPI number and press F4 to navigate to the PROVIDER APPLICATION FILE.
- Place cursor on PMI and press F4 to navigate to the RECIPIENT FILE APPLICATION.
- Place cursor on reason code and press F4 to navigate to view the reason code text that will display on service agreement letters.
F6 exits current location and returns to MMIS panel where F4 function key navigated from.
To exit and save data entered use function key F3. Use F3 key only when completely finished entering data and are ready to finalize document.

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