Form 16 Health Plan Action

Health Plan Action Forms and Instructions

Non-visible Questions
Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Date of Death

Health Plan
Action (1)

Below "Is this
person
deceased?"

Text
Entry

Organization
Description

Health Plan
Action (1)

Below
Organization
Type

Text Entry The field is
displayed if the user
selects an
organization type
that requires a
description.

Specialty

Health Plan
Action (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 “Description” if
the selected
profession or field
of
licensure requires
specialty
information.

Description

Health Plan
Action (1)

Beside
Drop List
Profession or
Field of Licensure

“Description” 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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

FEIN (Federal
Employer
Identification
Number)

Health Plan
Action (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
Action (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 Action (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
Action (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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Type of
Affiliation

Health Plan
Action (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
Action (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
Action (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
Action (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.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Address Line 2

Health Plan
Action (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
Action (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
Action (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
Action (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
Action (2)

Below an action
requiring a
description

Text Entry The field is
displayed if the user
selects an action
that requires a
description.

Label

PDF Name
(step)

Location

Response
Input
Item

Visibility Trigger

Other

Description

Health Plan
Action (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
Action (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
Action (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 Action (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
Action (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

OMB Number:
0915-0126
Expiration
Date:
mm/dd/yyyy

Health Plan Action

Modal

When the user selects the link the modal is displayed
with the public burden statement content.

Select a
Profession or
Field of
Licensure

Health Plan Action

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

Health Plan Action

Text Entry

Text entry is disabled if the user does not select a
profession or field of licensure requiring a
description.

License
Number

Health Plan Action

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

Health Plan Action

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.