Health Plan Action

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Health Plan Action Form and Instruction

Non-visible Questions
Label

PDF Name
(step)

Location

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.

Description

Health Plan
Action (1)

Beside
Profession or
Field of
Licensure

Text Entry The field is
“Description” is
displayed if the user displayed in place
selects a profession of “Specialty” if the
or field of licensure selected profession
that does not have or field of licensure
specialty.
does not have a
specialty. The label
is “Description” if
the selected
profession or field
of licensure
requires a
description.
Otherwise, the
label is
“Description
(Optional)”

Specialty

Health Plan
Action (1)

Beside
Profession or
Field of
Licensure

Drop List

Response
Input
Item

Visibility Trigger

Other

The field is
displayed if the user
selects the
"Yes" radio
button for "Is this
person deceased?"

The field is
“Specialty” is
displayed if the user displayed in place
selects a profession of “Description” if
or field of licensure the selected
that has a specialty. profession or field
of licensure has a
specialty,

Label

PDF Name
(step)

Location

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 The field is
FDA (Federal
displayed in the
Food and Drug
organization report
Administration)
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.

Health Plan
Action (1)

Response
Input
Item

Visibility Trigger

Other

Label

PDF Name
(step)

Type of
Affiliation

Health Plan
Action (1)

Entity Name

Health Plan
Action (1)

Location

Response
Input
Item

Visibility Trigger

Other

Below the
Drop List
checkbox "Is the
practitioner
affiliated with a
health care
entity?" or ”Is
the organization
affiliated with a
health care
entity?”

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.

Below Type of
Affiliation

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.

Text
Entry

For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

Label

PDF Name
(step)

Location

Response
Input
Item

Country

Health Plan
Action (1)

Below Entity
Name

Drop List

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries. United
States is the
For an
default selection.
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

Address

Health Plan
Action (1)

Below Country

Text
Entry

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.

Visibility Trigger

For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

Other

Label

PDF Name
(step)

Location

Address Line 2

Health Plan
Action (1)

Below Address

Response
Input
Item
Text
Entry

Visibility Trigger

Other

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.
For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

City

Health Plan
Action (1)

Below Address
Line 2

Text Entry For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.
For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

Label

State

PDF Name
(step)
Health Plan
Action (1)

Location

Beside City

Response
Input
Item
Drop List

Visibility Trigger

Other

For an individual
Selecting the
report, the field is
checkbox displays
displayed if the user Type of Affiliation,
selects the
Entity Name,
checkbox "Is the
Country, Address,
practitioner
Address Line 2,
affiliated with a
City, State, and ZIP
health care entity?" entries.
For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

ZIP

Health Plan
Action (1)

Below City

Text
Entry

The field is
Selecting the
displayed if the user checkbox displays
selects the "Is the
Type of Affiliation,
practitioner
Entity Name,
affiliated with a
Country, Address,
health care entity?" Address Line 2,
checkbox.
City, State, and ZIP
entries.
For an
organizational
report, the field is
displayed if the user
selects the
checkbox “Is the
organization
affiliated with a
health care entity?”

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

Description

Health Plan
Action (2)

Below Basis for
Action(s)

Years

Health Plan
Action (2)

Below the radio Text Entry The field is
Selecting the radio
button “A
displayed if the user button displays the
specific period of
selects “A specific
text entries for
time”
period of time”
Years, Months and
option for “How
Days.
long will it remain in
effect?”

Months

Health Plan
Action (2)

Beside Years

Text Entry The field is
Selecting the radio
displayed if the user button displays the
selects “A specific
text entries for
period of time”
Years, Months and
option for “How
Days.
long will it remain in
effect?”

Days

Health Plan
Action (2)

Beside Months

Text Entry The field is
Selecting the radio
displayed if the user button displays the
selects “A specific
text entries for
period of time”
Years, Months and
option for “How
Days.
long will it remain in
effect?”

Below “How
long will it
remain in
effect?”

Radio
Buttons

Is
Health Plan
reinstatement Action (2)
automatic after
this period of
time?

Response
Input
Item

Visibility Trigger

Other

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

The fields are
Available options
displayed if the user are “No,” “Yes”
selects “A specific
and “Yes with
period of time” for conditions
“How long will it
(Requires a
remain in effect?”
Revision to Action
report when status
changes)

Label

PDF Name
(step)

Location

Date of Appeal Health Plan
Action (2)

Below Is the
action on
appeal?

Response
Input
Item

Visibility Trigger

Text Entry The field is
displayed if the user
selects Yes option
for “Is the action on
appeal?”

Other

State Changes
Label

PDF Name

OMB Number:
0906-0081
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.

Description
(Optional)

Health Plan Action

Text Entry

Text entry is disabled until the user selects a
profession or field of licensure that allows or requires
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?"

Name of
School or
Institution

Health Plan Action

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields

Item Type

Trigger

Label

PDF Name

Item Type

Trigger

Completion
Year

Health Plan Action

Text Entry

Names of School or Institution and Completion Year
text entries are disabled by default. When the user
selects a health care-related Profession or Field of
Licensure, the Name of School or Institution and
Completion Year are enabled. If the user selects a
profession that is not related to health care, entries
for the Name of School or Institution and Completion
Year are not allowed, so Name of School or
Institution and Completion Year are cleared and
hidden. Subsequent selection of a health care-related
profession redisplays both fields

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.