Health plan received a request for authorization that included 3 services: request for authorization of ambulance transportation to the doctor’s office, X-Ray and MRI services in 2000F. The health plan provided authorization including separate authorization numbers for the X-Ray and the MRI in HCR, 2000F but it didn't provide authorization for the ambulance transportation. Since the health plan is required to include HCR in 2000E loop, what value should be populated in HCR01 A1 or A2? What value should be populated in the HCR02 since the two services that have been authorized have different authorization numbers?
There are two scenarios that could have happened based on how the ambulance portion was requested. If the ambulance services was requested at the HLEV (Event Level using the CR1 with the UM03=56) and those services were not approved, then the expectation would be that an HCR01=A3 would be provided at the HLEV loop in the response and in some cases an HCR02 may not be returned at this level.
The other scenario would be that all of the services were requested and returned at the HLSS level. In this instance the HLEV should have an HCR01=A2 (Certified partial) and the HCR02 can be a value at the UMO’s discretion and does not necessarily have to equal any of the values at the HLSS level. However please note that the HCR01 and HCR02 at the HLSS overrides any values that were at the HLEV for those specific services only.