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pdf Non-visible Questions
Label
PDF Name
(step)
Location
Response
Input
Item
Visibility Trigger
Other
Date of Death
Health Plan
(1)
Below "Is this
person
deceased?"
Text
Entry
Organization
Description
Health Plan
(1)
Below
Organization
Type
Text Entry The field is
displayed if the user
selects an
organization type
that requires a
description.
Name of
Occupation
Health Plan
(1)
Beside
Text entry The field is
Profession or
displayed if the user
Field of Licensure
selects a profession
or field of licensure
that does not
require information
for a specialty.
“Specialty” is
displayed in place
of “Name of
Occupation” if the
selected profession
or field of
licensure requires
specialty
information.
Specialty
Health Plan
(1)
Beside
Drop List
Profession or
Field of Licensure
“Name of
Occupation” is
displayed in place
of “Specialty” if the
selected profession
or field of licensure
does not require
information for a
specialty.
The field is
displayed if the user
selects the
"Yes" radio
button for "Is this
person deceased?"
The field is
displayed if the user
selects a profession
or field of licensure
that requires
information for
specialty.
FEIN (Federal
Employer
Identification
Number)
Health Plan
(1)
Below checkbox
"Does the
subject have an
FEIN, or UPIN
identification
number?"
Text Entry The field is
displayed in the
individual report
if the user selects
the checkbox for
"Does the subject
have an FEIN, or
UPIN identification
number?"
Selecting the
checkbox displays
FEIN and UPIN text
entry fields.
UPIN (Unique
Physician
Identification
Numbers)
Health Plan
(1)
Below FEIN text
entry
Text Entry The field is
displayed in the
individual report
if the user selects
the checkbox for
"Does the subject
have an FEIN, or
UPIN identification
number?"
Selecting the
checkbox displays
FEIN and UPIN text
entry fields.
FDA (Federal
Health Plan
Food and Drug (1)
Administration)
Below checkbox
"Does the
subject have a
FDA or CLIA
identification
number?"
Text Entry The field is
displayed in the
organization report
form if the user
selects the checkbox
for "Does the
subject have a FDA
or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.
CLIA (Clinical
Laboratory
Improvement
Act)
Below text entry Text Entry
FDA (Federal
Food and Drug
Administration)
Health Plan
(1)
The field is
displayed in the
organization report
form if the user
selects the checkbox
for "Does the
subject have a FDA
or CLIA
identification
number?"
Selecting the
checkbox displays
FDA and CLIA, and
text entry fields.
Type of
Affiliation
Health Plan
(1)
Below "Is the
practitioner
affiliated with a
health care
entity?"
checkbox
Drop List
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
Entity Name
Health Plan
(1)
Below Type of
Affiliation
Text
Entry
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
Country
Health Plan
(1)
Below "Is the
practitioner
affiliated with a
health care
entity?"
checkbox
Drop List
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries. United
States is the default
selection.
Address
Health Plan
(1)
Below Country
Text
Entry
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
Address Line 2
Health Plan
(1)
Below Address
Text
Entry
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
City
Health Plan
(1)
Below Address
Line 2
Text Entry The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
State
Health Plan
(1)
Below City
Drop List
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
ZIP
Health Plan
(1)
Below State
Text
Entry
The field is
displayed if the user
selects the "Is the
practitioner
affiliated with a
health care entity?"
checkbox.
Selecting the
checkbox displays
Type of Affiliation,
Entity Name,
Country, Address,
Address Line 2,
City, State, and ZIP
entries.
Description
Health Plan
(2)
Below an action
requiring a
description
Text Entry The field is
displayed if the user
selects an action
that requires a
description.
Description
Health Plan
(2)
Below Basis of
Action(s)
Text Entry The field is
displayed if the user
selects a basis of
action that requires
a description.
Period of time
number
Health Plan
(2)
Below “How long Text Entry The field is
will it remain in
displayed if the user
effect?”
selects “A specific
period of time”
option for “How
long will it remain in
effect?”
Selecting the radio
button displays the
number text entry
and type of time
period drop list.
Period of time
type
Health Plan
(2)
Below “How long Drop List
will it remain in
effect?”
The field is
displayed if the user
selects “A specific
period of time”
option for “How
long will it remain in
effect?”
Selecting the radio
button displays the
number text entry
and type of time
period drop list.
Is
Health Plan
reinstatement (2)
automatic after
this period of
time?
Below “How long Radio
will it remain in Buttons
effect?”
The fields are
displayed if the user
selects “A specific
period of time” for
“Is reinstatement
automatic after this
period of time?
Available options
are “No,” “Yes” and
“Yes with
conditions
(Requires a
Revision to Action
report when status
changes)
Date of Appeal Health Plan
(2)
Below Is the
action on
appeal?
Text Entry The field is
displayed if the user
selects Yes option
for “Is the action on
appeal?”
State Changes
Label
PDF Name
Item Type
Trigger
Public Burden
Statement
Government
Administrative
Modal
When the user selects the Public Burden Statement
link the modal is displayed.
Select a
Profession or
Field of
Licensure
Government
Administrative
Modal
When the user sets focus on the Profession or Field of
Licensure text entry, the modal to select a profession
is displayed and focus is set on the Search text
entry. The user can enter text in the Search text box
to find a specific profession or select a profession
from the list without searching. The modal is hidden
once the user selects a profession from the list. The
user's selection populates the Profession or Field of
Licensure text entry.
Name of
Occupation
Government
Administrative
Text Entry
Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.
License
Number
Government
Administrative
Text Entry
Text entry is disabled if the user selects the "No/ Not
sure" option for "Does the subject have a license for
the selected profession or field of licensure?"
Select a Basis
for Action
Government
Administrative
Modal
When the user sets focus on the Basis for Action(s)
text entry, the modal to select an act is displayed and
focus is set on the Search text entry. The user can
enter text in the Search text box to find a
specific basis or select a basis from the list without
searching. The modal is hidden once the user selects
a basis from the list. The user's selection populates
the Basis for Action(s) text entry.
| File Type | application/pdf |
| File Modified | 2017-11-09 |
| File Created | 2017-09-25 |