2009 008 Ordinance - Laserfiche WebLink

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APPENDIX D LIST OF DATA ELEMENTS FOR EMS BILLING* Client's failure to provide Life Force complete, accurate and timely elements for each account could negatively impact billing and collections of Ambulance Services. Life Force shall not be responsible for the failure to invoice, bill, file a claim or collect payment on Ambulance Services due to the inaccuracy of any information or Client's negligence in failing to timely provide the information to Life Force. Alarm Date Incident Number Scene Address - Zip code of origin required Response Code to Scene Patient Name Patient Address - City, State, Zip Patient Phone Number - Necessary for proper contact Gender - male/female Date of Birth - Payors require Social Security Number - Necessary to locate patient Dispatch For - Determine BLS vs. ALS Chief Complaint - Necessary for claim payment LOC - (Excellent for medical necessity) Bleeding - (Excellent for medical necessity) Vitals - BP/Pulse/Resp/Temp Sp02 - diagnosis code for low pulse ox Skin Appearance - Diaphoretic, pale, cyanotic Cardiac - Sinus, Tach, A-fib Procedures - IV, Cardiac, Pulse Ox, Immob, Glucose Level. (Helps justify level of service). Medications - How administered N/IM/SQ Transported to - Receiving hospital Lights/Siren from Scene? Patient Narrative - Purpose of stretcher, reason for transport, symptoms of patient. Reason patient had to lie flat. Location Type - Residents / Nursing Home, Scene (Other) On Scene Time - Medicaid requires Loaded Mileage-Accurate Mutual Aid -(Only necessary if Client is following billing policies of mutual aid community.) USER and PROGRAM FIELDS ALSBLS/ALS2 Resident Status - Yes - No Signature - Patient's signature authorizing bill to a Payor Bill - defaulted "YES" (changed if Client does not want a bill being sent). 22068l513664-1