Scheduled Outages: The HCAI system will be unavailable from 5:00 p.m. (EDT) September 29 to 8:00 a.m. (EDT) October 2
Scheduled Outages: The HCAI system will be unavailable from 5:00 p.m. (EDT) September 29 to 8:00 a.m. (EDT) October 2
Health Care Facility | Insurers | Related Initiatives  

Adjudicating the Form 1


HCAI has a lot of built-in flexibility with respect to how an adjuster can render a decision on a Form 1. A decision can be rendered at the line item level, at the level of attendant care, or at the form level.

Adjudicating the Form 1

Click through the side menu for step-by-step guides on submitting your decision for a Form 1 in HCAI.

Adjudicating the Form 1


Approving a Form 1

To approve the Form 1 without any modifications:

  1. Scroll to Tab 6.
  2. Press the ‘Approve All’ button. (View screenshot)
  3. The screen will refresh with the ‘Total Approved Benefit’ and ‘Total Calculated Benefit’ displaying the same values/selections as proposed by the facility.
  4. Scroll down to the ‘Adjuster Details’ section and press the ‘Approve’ button
  5. The screen will refresh and a message will confirm that the document has been approved.

Adjudicating the Form 1


Partially Approving a Form 1

When you want to approve some (but not all) line items, you are partially approving the document. You can choose to make your partial approval decision at the individual line item level or at the ‘level of attendant’ care level.

To decline at the individual line item level:

* Note: if you wish to approve the majority of the items, you may wish to press the ‘Approve All’ button on Tab 6 and go back and override the individual line items you wish to decline. Likewise, if you are declining the majority of items on a Form 1 with the same reason code, you can press the ‘Set Reason for Declining’ button on Tab 6 and go back and override the individual line items you wish to approve.

  1. Scroll through the line items in the three levels of attendant care on Tabs 3-5. When you have identified an item which you would like to decline, press the checkbox next to the item and press the ellipsis (…) button to select a reason code. (View screenshot)
  2. When you have finished reviewing a tab, scroll to the bottom of the tab and press the ‘Calculate’ button to update the approved monthly care benefit total for the tab.
  3. Continue reviewing the remaining levels of care.
  4. When you are ready to render your decision, Scroll to Tab 6 and review the ‘Total Monthly Attendant Care Benefit—ensure that the ‘Total Calculated Benefit’ matches the ‘Total Approved Benefit’. (View screenshot)
  5. When you have finished, press the ‘Partially Approve’ button at the bottom of the Tab.
  6. The screen will refresh and a message will confirm that the document has been partially approved.

To decline an individual level of attendant care:

  1. Scroll to the Tab containing the level of attendant care you wish to decline.
  2. Scroll to the bottom of the Tab and press the ‘Decline all for Part [1/2/3]’ button.
  3. Press the blue ellipsis button (…) in the ‘Part [1/2/3] Totals’ section to add a single reason code for the entire part.
  4. Once the reason code is added, the screen will refresh and the reason code entered will appear next to the ellipsis button.
  5. Continue reviewing the plan, ensuring you approve or deny the remainder of the parts.
  6. When you are ready to mark your decision on the form, scroll to Tab 6, review the ‘Total Monthly Attendant Care Benefit’ section and enter a reason code by pressing the blue ellipsis button.
  7. The system will automatically calculate the benefit on the form based on the decisions you made in each tab. To confirm the calculation, enter the calculated benefit into the ‘Approved Benefit’ field. (View screenshot)
  8. When you are ready, press the ‘Partially Approve’ button.
  9. The screen will refresh and a message will confirm that the document has been partially approved.

Adjudicating the Form 1


Denying a Form 1

To decline the entire plan for the same reason:

  1. Scroll to Tab 6.
  2. Press the ‘Set Reason Code for Declining’ button. A reason code screen will open. Select a reason code from the list, it will be added at form level i.e. Total Approved Benefit.
  3. The screen will refresh and the ‘Total Calculated Benefit’ field will be updated to zero. (View screenshot)
  4. Press the ‘Do Not Approve’ button at the bottom of the tab.
  5. The screen will refresh and a message will confirm that the document has been declined.

To decline the entire plan with different reasons for each line item:

  1. Scroll to Tab 6.
  2. Press the ‘Set Reason Code for Declining’ button (View Screenshot) and select the reason code that is most common.
  3. The screen will refresh and all line items in tabs 3-5 will be checked off as ‘Declined’.
  4. Press the blue ellipsis button next to each line item if you wish to add a reason code on an individual line item. (View screenshot)
  5. Update the reason code.
  6. Repeat this process for each line item you wish to add a reason code to.
  7. When you are ready, scroll back to Tab 6.
  8. Press the ‘Do Not Approve’ button at the bottom of the Tab.
  9. The screen will refresh and a message will confirm that the document has been declined.

Adjudicating the Form 1


Jump to:

HCAI has a lot of built-in flexibility with respect to how an adjuster can render a decision on a Form 1. A decision can be rendered at the line item level, at the level of attendant care, or at the form level.


Approving a Form 1

To approve the Form 1 without any modifications:

  1. Scroll to Tab 6.
  2. Press the ‘Approve All’ button. (View screenshot)
  3. The screen will refresh with the ‘Total Approved Benefit’ and ‘Total Calculated Benefit’ displaying the same values/selections as proposed by the facility.
  4. Scroll down to the ‘Adjuster Details’ section and press the ‘Approve’ button
  5. The screen will refresh and a message will confirm that the document has been approved.

Partially Approving a Form 1

When you want to approve some (but not all) line items, you are partially approving the document. You can choose to make your partial approval decision at the individual line item level or at the ‘level of attendant’ care level.

To decline at the individual line item level:

* Note: if you wish to approve the majority of the items, you may wish to press the ‘Approve All’ button on Tab 6 and go back and override the individual line items you wish to decline. Likewise, if you are declining the majority of items on a Form 1 with the same reason code, you can press the ‘Set Reason for Declining’ button on Tab 6 and go back and override the individual line items you wish to approve.

  1. Scroll through the line items in the three levels of attendant care on Tabs 3-5. When you have identified an item which you would like to decline, press the checkbox next to the item and press the ellipsis (…) button to select a reason code. (View screenshot)
  2. When you have finished reviewing a tab, scroll to the bottom of the tab and press the ‘Calculate’ button to update the approved monthly care benefit total for the tab.
  3. Continue reviewing the remaining levels of care.
  4. When you are ready to render your decision, Scroll to Tab 6 and review the ‘Total Monthly Attendant Care Benefit—ensure that the ‘Total Calculated Benefit’ matches the ‘Total Approved Benefit’. (View screenshot)
  5. When you have finished, press the ‘Partially Approve’ button at the bottom of the Tab.
  6. The screen will refresh and a message will confirm that the document has been partially approved.

To decline an individual level of attendant care:

  1. Scroll to the Tab containing the level of attendant care you wish to decline.
  2. Scroll to the bottom of the Tab and press the ‘Decline all for Part [1/2/3]’ button.
  3. Press the blue ellipsis button (…) in the ‘Part [1/2/3] Totals’ section to add a single reason code for the entire part.
  4. Once the reason code is added, the screen will refresh and the reason code entered will appear next to the ellipsis button.
  5. Continue reviewing the plan, ensuring you approve or deny the remainder of the parts.
  6. When you are ready to mark your decision on the form, scroll to Tab 6, review the ‘Total Monthly Attendant Care Benefit’ section and enter a reason code by pressing the blue ellipsis button.
  7. The system will automatically calculate the benefit on the form based on the decisions you made in each tab. To confirm the calculation, enter the calculated benefit into the ‘Approved Benefit’ field. (View screenshot)
  8. When you are ready, press the ‘Partially Approve’ button.
  9. The screen will refresh and a message will confirm that the document has been partially approved.

Denying a Form 1

To decline the entire plan for the same reason:

  1. Scroll to Tab 6.
  2. Press the ‘Set Reason Code for Declining’ button. A reason code screen will open. Select a reason code from the list, it will be added at form level i.e. Total Approved Benefit.
  3. The screen will refresh and the ‘Total Calculated Benefit’ field will be updated to zero. (View screenshot)
  4. Press the ‘Do Not Approve’ button at the bottom of the tab.
  5. The screen will refresh and a message will confirm that the document has been declined.

To decline the entire plan with different reasons for each line item:

  1. Scroll to Tab 6.
  2. Press the ‘Set Reason Code for Declining’ button (View Screenshot) and select the reason code that is most common.
  3. The screen will refresh and all line items in tabs 3-5 will be checked off as ‘Declined’.
  4. Press the blue ellipsis button next to each line item if you wish to add a reason code on an individual line item. (View screenshot)
  5. Update the reason code.
  6. Repeat this process for each line item you wish to add a reason code to.
  7. When you are ready, scroll back to Tab 6.
  8. Press the ‘Do Not Approve’ button at the bottom of the Tab.
  9. The screen will refresh and a message will confirm that the document has been declined.
Top