PassPORT manual here
Contents
1. 25 APPENDIX B READING THE TRIP DETAIL SCREEN 26 APPENDIX C TRIP REASONS 26 TRIP REASONS SINGLE TRIPS emi eate etie ie eee eee 27 TRIP REASONS RECURRING TRIPS 29 PassPORT User Manual Page 2 of 29 A INTRODUCTION TO PASSPORT PassPORT is a free web portal developed by First Transit for use with the Non Emergency Transportation Services Prior Authorization Program of Illinois directed by HFS the IL Department of Healthcare and Family Services PassPORT enables LTC Facilities Dialysis Centers and NET Providers to view the approved denied and pending requests as stored in the ADEPT prior authorization system Providers can also submit Single Trips and Standing Prior Authorizations SPAs online The purpose of this document is to educate you the User on the Log In procedures and features of PassPORT Note however that information displayed through this web portal even prior authorization does not guarantee payment by IDPA HFS PassPORT is available 24 hours a day 7 days a week and there is no limit on the amount of transactions allowed In order to function properly you will need high speed access to the Internet DSL Cable modem or T 1 line and an Internet browser such as Internet Explorer Mozilla Firefox etc PassPORT User Manual Page 3 of 29 B CREATING A NEW ACCOUNT If you do no2. Change Password Help An unsuccessful attempt will bring the following screen Click on the Return to Login link to try again or if you have forgotten your Password or require any further assistance send an email message to ILPassPORT firstgroup com PassPORT Windows Internet Explorer gt TT GO e File Edit View Favorites Ft passport il com login aspx ReturnUrl 2fhome aspx X EJ Em x LO Live Search Tools Help Favorites 3 e Suggested Sites Free Hotmail Web Slice Gallery v f PassPORT Bp Safety Tools Q PASSPORT Member Log In The provided user name or password is incorrect For help please write to ILPassPORT Gfirstgroup com Return to Login To provide feedback about the website please write to ILPassPORT gfirstaroup com Copyright 2007 PassPORT LLC All Rights Reserved Terms cf Use Privacy Statement 1 7887 PassPORT User Manual Page 7 of 29 D THE HOME PAGE The Home page contains links to the latest news policy updates HFS and the PassPORT User Manual For additional info visit www netspap com F PassPORT Windows Internet Explorer EM __ ET x lo Live Search p A E https fw FE passport il camjhome aspx File Edit View Favorites Tools we Favorites nt suggested Sites Free Hotmail A Web Slice Gallery ce
3. CLUB FOOT COLONOSCOPY CONSTIPATION CONTRACTURES CORONARY ARTERY BYPASS GRAFT CABG CORONARY ARTERY DISEASE CAD CRANIAL FACIAL DEFORMITY CROHN S DISEASE CVA CEREBROVASCULAR ACCIDENT STROKE CYSTIC FIBROSIS DCFS BHS DEGENERATIVE JOINT DISEASE DJD DENTAL WORK DEPARTMENTAL OVERRIDE DERMATOLOGY DEVELOPMENTALLY DELAYED DIABETES DIALYSIS DIARRHEA DIFFICULTY SPEAKING APHASIA DIFFICULTY SWALLOWING DYSPHAGIA DIVERTICULITIS DIZZINESS VERTIGO DYSKINESIA DYSTONIA EAR INFECTION ECT AND EECP EDEMA END STAGE RENAL FAILURE DISEASE ENDOSCOPY ENT EAR NOSE amp THROAT EPILEPSY SEIZURES ERB S PALSY FAILURE TO THRIVE FAINTING SYNCOPE FAMILY PLANNING FIBROMYALGIA FRACTURE OPEN CLOSED G TUBE CHANGE GALL STONE EXAMINATION REMOVAL GASTROINTESTINAL CONDITION S GERD GASTROESOPHAGEAL REFLUX DISEASE HEMOPHILIA HEMORRHOIDS HERNIA HIP FRACTURE HIP REPLACEMENT HIV AIDS HODGKIN S DISEASE HOSPITAL ADMIT HOSPITAL DISCHARGE HTN HYPERTENSION HUMP IN BACK KYPHOSIS HYPERGLYCEMIA HYPERTENSION HTN HYPERTHYROIDISM HYPOGLYCEMIA HYPOTENSION HYPOTHYROIDISM IMMUNIZATION INFECTION INFLUENZA INJECTIONS IRRITABLE BOWEL SYNDROME IV INFUSION JAUNDICE KIDNEY DISEASE FAILURE KNEE REPLACEMENT LEUKEMIA LIVER DISEASE LIVER CIRRHOSIS LIVER HEPATITIS LOU GHERIG S DISEASE LTC ADMIT LTC DISCHARGE LUMPECTOMY LUPUS MACULAR DEGENERATION MASTECTOMY MENINGITIS MENOPAUSE MORBID OBESITY MULTIPLE SCLE
4. T BRACHIAL PLEXUS LESION 39 T BRAIN TUMOR 39 T CARPAL TUNNEL SYNDROME 26 T CENTRAL CORD SYNDROME 39 T CEREBELLAR ATAXIA 26 T CEREBROVASCULAR ACCIDENT 39 T CLOSED HEAD INJURY 39 T COMMULATIVE TRAUMA 39 T COMPRESSION SYNDROME 39 T DEGENERATIVE JOINT DISEASE 39 T DEGLOVING INJURY 39 T DEQUERVIAN S DISEASE 39 T DERMATOMYOCITIS 39 T DIABETES NEUROLOGICAL 26 T DUPUYTREN S PARALYSIS 39 T ENCEPHALOPATHY 26 T ERBS PALSY 39 T FACIAL AND TRUNK BURNS 39 T FACIAL TRUNK RECON SURGERY 39 T FRACTURE OF VERTEBRAL COLUMN 8 T GUILLAIN BARRE SYNDROME 26 T HEMIPARESIS 39 T HEMIPLEGIA 39 T HYPERTONIA 39 T HYPOTONIA 39 T INCOMP CAUDA EQUINA SYNDROME 39 T JUVENILE RHEUMATOID ARTHRITIS 39 T KLUMPKE S PARALYSIS 39 T LUPUS ERYTHEMATOSIS 39 T LYMPHEDEMA 39 T MENINGITIS 26 T MULTIPLE FRACTURES 39 T MULTIPLE SCLEROSIS 26 T MUSCLE RUPTURE 39 T MUSCULAR DYSTROPHY 39 T MYASTHENIA GRAVIS 26 T OSTEOARTHRITIS 39 T PARAPLEGIA PARAPARESIS 39 T PARKINSONS DISEASE 26 T PERIPHERAL NERVE INJURY 39 T POSTPOLIO SYNDROME 26 T PSORIATIC ARTHRITIS 39 T QUADRIPLEGIA QUADRIPARESIS 39 T REFLEX SYMPATHETIC DYSTROPHY 39 T RHEUMATOID ARTHRITIS 39 T ROTATOR CUFF 39 T SCLERADERMA 39 T SENSORY INTEGRATIVE DYSFNCTION 39 T SHOULDER DISLOCATION 39 T SHOULDER GLENHUMERAL FRACTURE 39 T SINGLE FRACTURE WRIST ARMS 39 T SPINAL RADICULOPATHY 39 T SPINAL STENOSIS 39 T SPIN
5. Enter the first letter or two of the city name then click Search to populate Destination Code Select a Destination Code the selection box TEE HE PassPORT User Manual Page 17 of 29 The Location Name Phone and Pick Up Address fields all default to the Recipient s information based on HFS files You may change this information if necessary Location RESIDENCE 630 123 4567 Pick Up Street Number Address Address h23 SOME STREET Suite Apt Bldg City zip Code 50547 CHICAGO Enter the first letter or two of the city name then click Search to populate the selection box If the Recipient is traveling on the same day to another medical appointment select Yes on the section shown below and enter the details of the other medical transportation on the Please indicate field that will subsequently appear Is the recipient travelling to Please indicate any other medical location on Yes common appointment days If the Recipient is not traveling on the same day to another medical appointment leave selected Is the recipient travelling to any other medical location on Yes No common appointment days Enter the Medical Provider Name f e Dr Williams that the Recipient is being transported to as well as the Medical Provider s Most Direct Phone Number needed to validate the appointment Medical Provider DR
6. X f PassPORT fy gt E Page gt Safety Toos amp C dk 5 16 2010 1 31 15 Welcome Test LTC PASSPORT Prior approval does NOT gua rantee payment by HFS News Click for Details News Link 5 1 2009 p 10 35 32 AM AM Visit www NETSPAP com News Link 12 10 2007 11 01 00 AM News Link 8 25 2007 8 42 59 PM News Link 9 25 2007 8 42 58 PM PassPORT User Manual CTS Form required for ALS and BLS Prior and Post Approvals Link to the Department of Healthcare and Family Services HFS web site Change Password Contact Support Logoff Help a E SEARCH TRIPS The Trips tab at the top of the Home page gives you the following viewing options Trips by RTN Trips by Date or Trips by Client Dialysis Users will also see the Renew Trip and Renew by RTN options Ed NET Providers amp e Dialysis Centers Tnps by Date Tnps by Date LTC Facilities Trips by Client Trips by Client Enter Trip Renew Trip Renew y RTN PassPORT User Manual Page 8 of 29 TRIPS BY RTN The Trips by RTN screen allows you to look up a single request by its Request Tracking Number RTN an all numeric number assigned by First Transit to the request when it was first entered into the system Please note that NET Providers will only be able to see those requests assigned to their specific NET Provider Medicaid ID Enter a Request T
7. respectively The Drop off address of the first and Company used for the request assigned by HFS to the Participant second leg respectively may be a Non Employee or Employee Attendant or both PassPORT User Manual Page 26 of 29 APPENDIX TRIP REASONS TRIP REASONS SINGLE TRIPS ACUPUNCTURE NON APPROVABLE SERVICE ALZHEIMER S DISEASE AMPUTATION ARM AMPUTATION FINGER AMPUTATION FOOT AMPUTATION LEG AMPUTATION TOE ANEMIA ANEURYSM ANOREXIA AQUA THERAPY ARTHRITIS ASTHMA AUTISM BACK CONDITIONS BCHS RECOMMENDATION BELL S PALSY BHS ADHD BHS AGGRESSIVE DISORDER BHS BIPOLAR DISORDER BHS DEMENTIA BHS DEPRESSION BHS GROUP THERAPY BHS INDIVIDUAL BHS MENTALLY CHALLENGED BHS PHOBIAS BHS PSYCHOSIS BHS SCHIZOPHRENIA BHS SUBSTANCE ABUSE BLADDER INFECTION BLIND BLOOD CLOT EMBOLISM BLOOD DISORDER BRACHIAL PLEXUS INJURY BRAIN INJURY BREATHING ASTHMA BREATHING BRONCHITIS BREATHING COPD BREATHING DIFFICULTY BREATHING EMPHYSEMA BREATHING SHORTNESS BREATH BREATHING TRACHEOTOMY BURNS CANCER BLADDER CANCER BONE CANCER BRAIN CANCER BREAST CANCER CERVICAL CANCER COLON CANCER KIDNEY CANCER LIVER CANCER LUNG CANCER SPLEEN CANCER STOMACH CANCER TESTICULAR CANCER THROAT CANCER THYROID CANCER UTERINE CARPAL TUNNEL SYNDROME CATARACT CATHETER CELLULITIS CEREBRAL PALSY CHEST PAIN CHF CONGESTIVE HEART FAILURE CHIROPRACTIC CARE CIRCULATORY ISSUES CIRCUMCISION CLEFT PALATE LIP
8. AIDS NEUROLOGICAL INVOLVEMENT 26 T AMPUTATION 39 T AMYOTOPIC LATERAL SCLEROSIS 26 T ANKYLOSING SPONDYLITIS 39 T ANOXIC BRAIN INJURY 39 T ARTHROGYPOSIS 39 T BRACHIAL PLEXUS LESION 39 T BRAIN TUMOR 39 T CARPAL TUNNEL SYNDROME 26 T CENTRAL CORD SYNDROME 39 T CEREBELLAR ATAXIA 26 T CEREBROVASCULAR ACCIDENT 39 T CLOSED HEAD INJURY 39 T COMMULATIVE TRAUMA 39 T COMPRESSION SYNDROME 39 T DEGENERATIVE JOINT DISEASE 39 T DEGLOVING INJURY 39 T DEQUERVIAN S DISEASE 39 T DERMATOMYOCITIS 39 T DIABETES NEUROLOGICAL 26 T DUPUYTREN S PARALYSIS 39 T ENCEPHALOPATHY 26 T ERBS PALSY 39 T FACIAL AND TRUNK BURNS 39 T FACIAL TRUNK RECON SURGERY 39 T FRACTURE OF VERTEBRAL COLUMN 8 T GUILLAIN BARRE SYNDROME 26 T HEMIPARESIS 39 T HEMIPLEGIA 39 T HYPERTONIA 39 T HYPOTONIA 39 T INCOMP CAUDA EQUINA SYNDROME 39 T JUVENILE RHEUMATOID ARTHRITIS 39 T KLUMPKE S PARALYSIS 39 T LUPUS ERYTHEMATOSIS 39 T LYMPHEDEMA 39 T MENINGITIS 26 T MULTIPLE FRACTURES 39 T MULTIPLE SCLEROSIS 26 T MUSCLE RUPTURE 39 T MUSCULAR DYSTROPHY 39 T MYASTHENIA GRAVIS 26 T OSTEOARTHRITIS 39 T PARAPLEGIA PARAPARESIS 39 T PARKINSONS DISEASE 26 T PERIPHERAL NERVE INJURY 39 T POSTPOLIO SYNDROME 26 T PSORIATIC ARTHRITIS 39 T QUADRIPLEGIA QUADRIPARESIS 39 T REFLEX SYMPATHETIC DYSTROPHY 39 T RHEUMATOID ARTHRITIS 39 T ROTATOR CUFF 39 T SCLERADERMA 39 T SENSORY INTEGRATIVE DYSFNCTION 39
9. Number RIN cea Q Callback Phone Trip Frequency Single Recurring Trip Type One way Round trip Tap Dake Appointment Select Hour v Select Minute gt lt lt August2010 gt gt SM TW TF S T 2 34 5 B T 810111212 14 Trip Reason ACUPUNCTURE NON APPROVABLE SERVICE 15 18 19 20 21 22 23 24 25 28 27 28 m i d Select the Trip Type The options available are One way for example a hospital admit or hospital discharge and Round trip going to an appointment and back Trip Frequency Single Recurring One way Round trip Trip Date 09 16 2010 Appointment Select Hour gt Select Minute gt mmidd Time Trip Reason ACUPUNCTURE APPROVABLE SERVICE Enter the time of the medical appointment by selecting from the hour and minute fields under Appointment Time For Round trip also enter the approximate return time Appointment Hour z tH ZL Time Select Hour select Minute Select Haur Midniaht 2 4 5 AM 8 AM 8 10 11 AM 1PM 2PM 3PM 4PM 5 PM 8 PM TPM B PM 10 On the Trip Reason pull down menu select the most appropriate diagnosis that pertains to specific medical appointment or visit Pressing the first letter of the desired trip reason will take you to that selection on the menu If the specific diagnosis is no
10. WILLIAMS WILLIAMS Medical Provider s 217 222 1234 Mast Direct Phone Number Name PassPORT User Manual Page 18 of 29 Under the Destination Address enter the Location St Mary s Hospital Street Number Address and Suite Apt Bldg Location Name ST MARY S HOSPITAL Street Number 100 t Bld Enter the first letter s of the city in the City field Click on the Search button and select the appropriate city from the pull down menu The State will automatically populate based on the city you select Enter the Zip Code City Search Enter the first letter or two of the city name then click Search to populate the selection box ORIGIN DESTINATION CODES RESIDENCE home long term care shelter or any facility that is not a medical facility MEDICAL SERVICE non hospital appointments where no specific doctor is seen PHYSICIAN appointments with a specific doctor whether at hospital clinic or private practice HOSPITAL hospital visits when not seeing a specific doctor MRI radiology lab chemo radiation outpatient inpatient treatments etc Destination Code Select a Destination Code PassPORT User Manual Page 19 of 29 If the request is One Way and Hospital Discharge is selected as the Trip Reason Pick and Destination information will be flipped All fields may be edited to reflect the actual information With One
11. any other therapy reasons begin with T and may be selected from the pull down menu If no appropriate reason is available the request will have to be processed as a Departmental Override and has to be faxed to First Transit on a paper SPA form forms are available at www netspap com Please note Physical Therapy Occupational Therapy Soeech Therapy Aqua Therapy and Group Psychotherapy requests 2 or more times in a month are considered SPAs and will be processed as such Recurring trips that are a continuation of a SPA will be processed as a SPA See appendix C to see Trip Reasons for a current list of Trip Reasons available on the Single Trips and Recurring Trips drop down menus For any questions recurring trips and SPAs or any other policies and procedures please contact First Transit at the Provider line 866 503 9040 PassPORT User Manual Page 16 of 29 STEP 2 PAGE Phone 217 555 1212 Location Name RESIDENCE Pick Up Address Street Number Address 1 00 CEDAR ST Suite Apt Bld City GREENVILLE v Enter the first letter or two of the city name then click Search to populate the selection box RESIDENCE MEDICAL SERVICE PHYSICIAN Is the recipient travelling to any other medical location on C Yes No HOSPITAL common appointment days Medical Provider Medical Provider s Name Mast Direct Phone Number Location Name Street Number Destination Address Suite Apt Bld
12. Level of Date the Service or Transportation Category of Link to the Request Tracking Status of the Request may be Billing Detail Number Reference A Approved D Denied or screen took or will take Service for place the request number assigned to Denied Requests the request will include a Denial Reason Trips Windows Internet Explorer E x ee a https Ft passpor 4 Aa EVE gt Live Search Favorites e Suggested Sites 7 Free Hotmail wb Slice Gallery x Thips gi Page Safety Tools a all i Prior approva does NOT guarantee payment by HFS Fi rst r Trip Date service Level From To Billing Detail 9 26 2009 Service Car RESIDENCE TOTAL RENAL CARE INC RIN RIN 123 SOME STREET 4557 LINCOLN HIGHWAY SUITE B 111111111 1234557 HOPKINS PARK IL IL 60964 MATTESON IL IL 60443 Trip Status amp Appraved Provider Attendant TOTAL RENAL CARE INC RESIDENCE 123 TRANSPORTATION INC None 4557 LINCOLN HIGHWAY SUITE 123 SOME STREET MATTESON IL IL 60443 HOPKINS PARK IL IL 60964 Internet way 10D g Name of the NET Provider Transportation Recipient Identification Number Attendants The Pickup assigned to address of the assist the first and Participant for second leg this request
13. OCEREBELLAR DEGENERATION 26 T SUBARACHNOID HEMORRHAGE 39 T SYRINGOMYELIA 26 T TENDON REPAIR 26 T TENDONITIS 26 T UPPER EXTREMITY BURNS 39 T UPPER EXTREMITY JOINT CONT 39 T UPPER EXTREMITY RECON SURGERY 39 PassPORT User Manual Page 29 of 29
14. PASSPORT USER MANUAL This manual was created for the Illinois Department of Healthcare and Family Services HFS s Non Emergency Transportation Services Prior Authorization Program NETSPAP Created and Revised by First 9 Transit Table of Contents A INTRODUCTION TO PASSPORT a a TUER ReE deb 3 B ANEW ACCOUNT 4 C H1 91 0 ee a ee yO Se aC 8 E ae 2 TM 8 GIN e c 9 e L P ccc 10 s TPIP DY ez e 11 F ENTER TP sce 99 5 89109200299 0290 090 039 039 13 TEP TRAGE 13 ROUND TRIP ME Oe 15 E amp EN lc Cu u 15 STANDING PRIOR AUTHORIZATION 3 16 S ouem OUI MM DM 17 ORIGIN A DESTINA TION CODES ipaum c nea u lll aetas bU ee pert ean S det ME 19 dog t D c 21 t 23 5 RENEW TRIP RENEW BY RTN a r SINCERE 24 APPENDIX A READING THE BILLING DETAIL SCREEN
15. ROSIS MUSCLE SPASM MUSCULAR DYSTROPHY CONGENITAL MYASTENIA GRAVIS NECK INJURY NEUROLOGICAL DISORDER NEUROPATHY NON HODGKIN S DISEASE NOSE BLEED EPISTAXIS OB GYN OCCUPATIONAL THERAPY ORGANIC BRAIN SYNDROME ORTHOPEDIC PROBLEM OSTEOARTHRITIS OSTEOMYELITIS OSTEOPOROSIS PAIN INDICATE TYPE IN NOTES PARALYSIS PARAPLEGIA 1 sui imer ad CANCER METASTATIC GOUT PHYSICAL THERAPY CANCER ORAL THROAT GUN SHOT WOUND PINCHED NERVE CANCER OVARIAN HEADACHE PNEUMONIA CANCER PANCREATIC HEARING PROBLEM PODIATRIST FEET CONDITIONS CANCER PROSTATE HEART ATTACK POLIO CANCER RECTAL HEART CONDITION PRENATAL CANCER SKIN HEMIPLEGIA HEMIPARESIS PROSTATE PROBLEM PassPORT User Manual Page 27 of 29 PROSTHETIC FITTING OR ADJUSTMENT PULMONARY PROBLEM QUADRIPLEGIA RENAL FAILURE RHEUMATOID ARTHRITIS SASS SERVICES SCLERODERMA SEIZURE DISORDER NEC SICKLE CELL ANEMIA SKIN CONDITION SKIN GRAPH SLEEP DISORDER SPAO CARDIAC REHAB PHASE II SPAO COPD SPAO COUMADIN THERAPY SPAO ECT AND EECP SPAO HIGH RISK PRENATAL SPAO IV INFUSION SPAO OBESITY SPAO PULMONARY REHAB PHASE II SPAO WOUND THERAPY SPEECH THERAPY SPINA BIFIDA SPINAL CORD INJURY SPINAL PROBLEM STANDING ORDER AQUA THERAPY STANDING ORDER BHS STANDING ORDER CHEMOTHERAPY STANDING ORDER DIALYSIS STANDING ORDER OCCUPATIONAL STANDING ORDER PHYSICAL THERAPY STANDING ORDER RADIATION THERAPY STANDING ORDER SPEECH THERAPY SURGERY T ADHESIVE CAPSULITIS SHOULDER 39 T
16. T SHOULDER DISLOCATION 39 T SHOULDER GLENHUMERAL FRACTURE 39 T SINGLE FRACTURE WRIST ARMS 39 T SPINAL RADICULOPATHY 39 T SPINAL STENOSIS 39 T SPINOCEREBELLAR DEGENERATION 26 T SUBARACHNOID HEMORRHAGE 39 T SYRINGOMYELIA 26 T TENDON REPAIR 26 T TENDONITIS 26 T UPPER EXTREMITY BURNS 39 T UPPER EXTREMITY JOINT CONT 39 T UPPER EXTREMITY RECON SURGERY 39 TEST BLOOD DRAW TEST CAT SCAN TEST COUMADIN TEST ECHO CARDIOGRAM TEST EEG TEST EKG TEST MAMMOGRAM TEST MRA TEST MRI TEST PRE OP TEST SLEEP STUDY TEST SWALLOW STUDY TEST ULTRASOUND TEST X RAY THROMBOPHLEBITIS THYROID PROBLEM TORN LIGAMENTS TOURETTE S SYNDROME TRANSPLANT BONE MARROW TRANSPLANT ORGANS TUBERCULOSIS TUMOR ULCER DECUBITUS ULCER DIABETIC ULCER GASTRIC ULCER LOWER EXTREMITY URINARY TRACT INFECTION UROLOGICAL PROBLEM VARICOSIS VISUAL IMPAIRMENT WELL CHILD CARE WIC NON APPROVABLE WOUND CARE PassPORT User Manual Page 28 of 29 TRIP REASONS RECURRING TRIPS DEPARTMENTAL OVERRIDE STANDING ORDER AQUA THERAPY STANDING ORDER BHS STANDING ORDER CHEMOTHERAPY STANDING ORDER DIALYSIS STANDING ORDER OCCUPATIONAL STANDING ORDER PHYSICAL THERAPY STANDING ORDER RADIATION THERAPY STANDING ORDER SPEECH THERAPY T ADHESIVE CAPSULITIS SHOULDER 39 T AIDS NEUROLOGICAL INVOLVEMENT 26 T AMPUTATION 39 T AMYOTOPIC LATERAL SCLEROSIS 26 T ANKYLOSING SPONDYLITIS 39 T ANOXIC BRAIN INJURY 39 T ARTHROGYPOSIS 39
17. Way Hospital Discharge requests Step 2 will look as follows Medical Provider DR JONES Medical Provider s 312 555 1414 Most Direct Phone Mumber Location Name EMORIAL MEDICAL CENTER Street Number Address Pick Up Address 100 BROADWAY Suite Apt Bldg City i cH Search 60601 CHICAGO Enter the first letter or two of the city name then click Search to populate the selection box Location Name RESIDEN CE 773 555 4433 Destination YES Street Number Address WESTERN AVE Suite Apt B cH CHICAGO Enter the first letter or two of the city name then click Search to populate the Destination Code Select a Destination Code selection box Is the recipient travelling to any other medical location on C Yes No common appointment days PassPORT User Manual Page 20 of 29 3 Erie Jute Category of Service The category of service MUST meet the medical needs of the recipient at the most economical level appropriate Search Com Additional Information Mon Applicable ts ip rae arabe Specifically bri ud the Or RE ail Select the appropriate Category of Service for the request Had do Category of Service The category of service MUST meet the medical needs of the recipient at the most economical level appropriate Private Auto Taxi Semice Car LE Search Medicar Stret
18. assport il com get TripsByDate aspx TripBeginDate 02 01 201 1 amp TripEndD 02 X 1 Live Search File Edit View Favorites Tools Favorites 53 e Suggested Sites Free Hotmail Web Slice Gallery v A Billing Detail F M 171 Safety Tools e First 2 Transit Trip Date Service Level rom To Billing Detail 9 1 2010 Service Car RESIDENCE MEDICAL SERVICE RIN RTN 123 SOME STREET 1111 E 87TH STREET SUITE 700 111111111 1111111 CHICAGO IL IL 60617 CHICAGO IL IL 60619 Trip Status A Approved Recipient Name Attendant MEDICAL SERVICE ae YNTH None 1111 E 87TH STREET SUITE 700 123 SOME EET CHICAGO IL IL 60619 CHICAGO IL IL 60617 Prior approval does NOT guarantee payment by HFS Trip Date Service Level rom To Billing Detail 8 27 2010 Medicar Transportation RESIDENCE MEDICAL SERVICE RIN RTN 123 SOME STREET 1111 E 87TH STREET 700 222222222 2222222 CHICAGO IL IL 60637 CHICAGO IL IL 60619 Trip Status A Approved Recipient Name Attendant MEDICAL SERVICE RESIDENCE Employee 1111 87TH STREET 700 123 SOME STREET WILLIAM DOE CHICAGO IL IL 60619 CHICAGO IL IL 60637 Prior approval does NOT guarantee payment by HFS Trip Date Service Level From To Billing Detail 8 7 2010 Service Car RESIDENCE MEDICAL SERVICE RIN RTN 123 SOME STREET 1111 E87TH ST 333333333 3333333 CHICAGO IL 60609 CHICAGO IL 60619 Trip Status A Approved Recipient Name Attenda
19. brought to the Home Page PassPORT Windows Internet Explorer FO amp Z https vivow fE passport il com home aspx 161 15 35 J E LI E 8 16 2010 3 38 16 PM Welcome Test Dialysis News Click for Details News Link 5 1 2009 News Link 12 10 2007 11 01 00 AM News Link 9 25 2007 8 42 59 PM News Link 9 25 2007 8 42 59 PM Prior approval does NOT guarantee payment by HFS Visit www NETSPAP com CTS Form required for ALS and BLS Prior and Post Approvals Link to the Department of Healthcare and Family Services HFS web site PassPORT User Manual PassPORT User Manual Page 6 of 29 Note if there is a period of inactivity PassPORT will log you out of the system iT S s 2815 https www Ft passport il com default aspx Live Search Edit Favorites Tools Help Ly Favorites 53 Suggested Sites gt Free Hotmail Web Slice Gallery f PassPORT F 6 omm v Safety Tools Prior approval does NOT guarantee payment by HFS News Click for Details News Link 5 1 2009 10 35 32 News Link 12 10 2007 CTS Form required for ALS and BLS Prior and 1111 10 M Dact Annrawale Message from webpage Visit www NETSPAP com x T There has been no activity For some time For your security you will be logged out automatically in 2 minutes if there is no Further activity
20. cher b Medicar Wheelchair BLS Ambulance ALS Ambulance Non Applicable Enter the Company Type in the first few letters of the desired NET Provider in the text box and click on the Search button The city and phone number will display next to the name to help you differentiate between similar names or service areas The pull down list will be reduced to the NET Providers that match your search criteria click on the appropriate option If your desired NET provider does not display reduce the number of letters you searched for and confirm that you have selected the appropriate Category of Service A Search lt SRV aa durius d Company A AND A TRU STPORTATION m UTON 8 6997669 A AND B UNIVERSAL SERVICES EVANSTON 773 4108568 A AND C TRANSPORTATION INC SOUTH HOLLAND 708 2504461 A AND J EASYWAY SERVICES COUNTRY CLUB HI 709 2992970 A AND LIMO ZION 647 7313924 PassPORT User Manual Page 21 of 29 Select the attendants if applicable under Additional Information Oxygen Supplies will only be viewable for ALS and BLS transportation requests Additional Information Non Applicable Both Employee and Non Employee Attendant Provider Employee Attendant Non Employee Attendant Enter the Trip Notes with information necessary for First Transit to complete the transportation adjudication Information should substantiate the need for the category of service r
21. d Password and click on the Log In button PassPORT Windows Internet Explorer https www Ft passport il com login aspx ReturnUrl 2fhome aspx m X Io Live Search File Edit view Favorites Tools Help F Favorites 95 f Suggested Sites gt Free Hotmail Web Slice Gallery PassPORT F gt f Safety Tool PASSPORT Member Log In Username LTC Password Iri Request a New Account To provide feedback about the website please write to ILPassPORT gfirstgroup com Copyright 2007 PassPORT LLC All Rights Reserved Terms cf Use Privacy Statement zi ee The first time you log to 5 and before you can continue you will be asked to review the Terms of Use and validate your acceptance PassPORT User Manual Page 5 of 29 successful attempt will bring you to the following welcome screen Click on Proceed to Passport link PassPORT Windows Internet Explorer 1D https Jvwww ft passport il com login aspx ReturnLlrl s2Fhome aspx 18 x PassPORT PASSPORT Member Log In Welcome to the First Transit NETSPAP prior authorization review center Proceed To Passport To provide feedback about the website please Copyright 2007 PassPORT LLC All Reserved Terms of Use Privacy State alBje xewse You will be
22. equested and any additional information requested If this is the first time request remember to provide First Assessment information or contact First Transit to perform this assessment over the phone Trip Notes List any medical conditions diagnoses or reasons which explain the requested category of service and or need for attendants Specifically explain the need for wheelchair or stretcher transport DETATLED INFORMATION FOR THE DIAGNOSIS WHICH JUSTIFIES THE REQUESTED CATEGORY OF SERVICE AND ANY ADDITIONAL INFORMATION REQUESTED When all the fields have been entered correctly click on the Next Button lt lt Back PassPORT User Manual Page 22 of 29 REVIEW PAGE The Review page allows you to verify all of the requested information entered in the previous 3 steps If any section requires modification click on the Edit Section number button If all information has been entered correctly click on the Proceed to Confirm button This will bring you to the below screen Read the agreement and click on the check box next to I have read and understand this agreement Pressing the Save button will finalize the request Note Save will not be available until the box has been checked PassPORT User Manual Page 23 of 29 The Trip Confirmation or Trip Detail screen will appear can be printed for records of the PassPORT User and or the Requesting Organization See appendix B for de
23. ification Tracking Name of the Number Number or Participant for assigned by Beginning Reference whom HFS to the number transportation Participant Date of Date of Birth the f the is requested ine pine Request Participant TE Trips Windows Internet Explorer EC E lalz a hktps wvewift passportal com get TripsByRef aspxTRIN amp TripBeg File View Favorites Tools e Trips First Transit NAME JOHN DOE RIN 111111311 09 19 1955 RTN 1234567 TRIP STATUS PROC CODE cos ORIGIN DESTINATION QTY BEGIN DATE END DAT 0120 054 F D 13 05 26 2005 10 25 2009 0425 054 R D E 05 26 2005 10 25 2009 A Approved A0120 054 D R 09 26 2009 10 25 2009 amp Approvaed ADAZS 054 D R 10 25 2009 Prior approva Gods NOT guarantee payment by HFS The The The The Procedure Origin Destination number of Codes Code for Code for the trips in the attached to the request request Status of the Ending Date of the Request Request may be D Denied or P Pending Denied Requests will include a Denial Reason the request request The Category of Service or Level of Service requested Note Approved Requests that have a negotiated rate will display an Amount on the Right Hand side of the screen PassPORT User Manual Page 25 of 29 APPENDIX B READING THE TRIP DETAIL SCREEN
24. ites Tools Help x Snag r Favorites 35 suggested sites Free Hotmail Web Slice Gallery Trips Prior approval does NOT guarantee payment by HFS Fi rst To Trip Date Service Level From 5 26 2005 Service Car RESIDENCE TOTAL RENAL CARE INC Transit Billing Detail RIN RTN 123 SOME STREET 4557 LINCOLN HIGHWAY SUITE B 111111111 1234567 HOPKINS PARK IL IL 60964 MATTESON IL IL 60443 Trip Status A Approved NET Provider Attendant TOTAL RENAL CARE INC RESIDENCE 123 TRANSPORTATION INC None 4557 LINCOLN HIGHWAY SUITEB 123 SOME STREET MATTESON IL IL 60443 HOPKINS PARK IL IL 60964 ramai awr ms PassPORT User Manual Page 9 of 29 To print these or any other screens click on File on the Internet Explorer Menu Print and The screen will print in the default printer Screens can be closed at any time by clicking on the X button in the upper right hand corner TRIPS BY DATE The Trips by Date screen allows you to look up trips for a single date or date range Please note that NET Providers will only be able to see the requests assigned to their specific NET Provider Medicaid ID Select a Trip Type standing Orders Enter begin date for trips to review mm dd yyvy Trips By RTN Enter end date for trips to review mmy dd yyyy Approved Enter Trip Select a Trip Status Denied C C Continue The search result will pop up in a separate browse
25. le RTN requests going to the same medical facility 2 or more times per month Whenever you select Recurring on the Trip Frequency the screen will change to the shown below Fill in the From Date begin date To Date end date and Appointment Days Days of the week fields to continue Trip Frequency C Single Recurring Requests 2 or 3 times per month should be E submitted with a Single Trip Reason for example mm dd vyvyl ORTHOPEDIC PROBLEM They will be processed RE dd su Th Fr sa PassPORT User Manual Page 15 of 29 STANDING PRIOR AUTHORIZATION SPA Recurring trips going 4 times or more per month to the same medical facility are considered and processed as Standing Prior Authorizations SPAs If the SPA is for any of the below reasons the appropriate SPA Trip Reason should be selected STANDING ORDER AQUA THERAPY STANDING ORDER BHS STANDING ORDER CHEMO THERAPY STANDING ORDER DIALYSIS STANDING ORDER OCCUPATIONAL STANDING ORDER PHYSICAL THERAPY STANDING ORDER RADIATION THERAPY STANDING ORDER SPEECH THERAPY T ADHESIVE CAPSULITIS SHOULDER 38 T AIDS NEUROLOGICAL INVOLVEMENT 26 T AMPUTATION 39 T AMYOTOPIC LATERAL SCLEROSIS 26 T ANKYLOSING SPONDYLITIS 39 T ANOXIC BRAIN INJURY 39 T ARTHROGYPOSIS 39 T BRACHIAL PLEXUS LESION 39 T BRAIN TUMOR 39 T CARDIAC REHAB Il T CARPAL TUNNEL SYNDROME 26 T CERNITDAI CODD CSMRNI3DA ARAE ER 30 SPAs for
26. nt MEDICAL SERVICE RESIDENCE None 1111 E87TH ST 123 SOME STREET JESSICA DOE CHICAGO IL 60619 CHICAGO IL 60609 Prior approval does NOT guarantee payment by HFS Trip Date Service Level CANCELLED DENIED Billing Detail internet 100 7 TRIPS BY CLIENT The Trips by Client screen allows you to search for a particular Recipient ID Number RIN the 9 digit number assigned by HFS to the Participant Enter a Recipient ID Number Select a Trip Standing Orders Enter Begin Date mm dd vyyy Enter End Date mm dd yyyyi Y Approved Enter Trip b Select a Trip Status Denied C Continue PassPORT User Manual Page 11 of 29 Once in the Trips by Client screen do the following 1 Enter the Recipient ID Number Enter a Recipient ID Number 2 Select a Trip Type The available options are Standing Orders Single Trips or All Select a Trip standing Orders bd 3 Enter the Begin Date of the trip s to review The difference between begin date and end date cannot exceed 31 days Enter Begin Date mm dd yyyy 4 Enter the End Date of the trips s to review Enter End Date mm dd yyyy 5 Select a Trip Status The available options are Approved Denied or AI Approved Select a Trip Status Denied C 6 Click on the Continue button Continue The Billing Detail screen will
27. open in a different window See appendix A for instructions on how to rea d t h IS SC re e n Trips Windows Internet Explorer 181 I V3 1 Live Searc File Edit View Favorites Tools Help Favorites 93 Suggested Sites Free Hotmail Web Slice Gallery v Trips D 7 gt Pager Safety Tools NAME JOHN DOE RIN 111111111 DOB 07 21 1940 RTN 1234567 TRIP STATUS PROC CODE cos ORIGIN DESTINATION QTY BEGIN DATE END DATE P Pencing 40130 052 79 08 19 2010 02 17 2011 P Panding A0425 052 R D 08 19 2010 02 17 2011 P Pending 0130 052 79 08 19 2010 02 17 2011 P Pending 40425 052 08 19 2010 02 17 2011 Trip Detail Disclaimer The trip that you submitted is presently neither approved nor denied You may use this RTN to check the status of your submitted request through PassPORT The RTN may be used for billing only when the trip is displayed with Approved status NAME JOHN DOE RIN 111111111 DOB 07 21 1940 RTN 1234570 CANCELLED DENIED REASON Data entry error TRIP STATUS PROC CODE cos ORIGIN DESTINATION QTY BEGIN DATE END DATE D Denied 40130 052 R D 79 08 19 2010 02 17 2011 D Denied 40425 052 R 08 19 2010 02 17 2011 D Deniec A0130 052 D R 79 08 19 2010 02 17 2011 D Denied A0425 052 D R 08 19 2010 02 17 2011 Trip Detail Prior approval does NOT guarantee payment by HFS Done oT Mg internet Za 100 7 PassPORT U
28. r window Your pop up blocker may prevent the window from appearing Please adjust your pop up blocker s settings Once in the Trips by Date page do the following 1 Select a Trip Type The available options are Standing Orders Single Trips or AW Select a Trip standing Orders 2 Enter the Begin Date for the Trips to Review The date can be entered manually or through the date selection pull down box Searches are limited to one calendar week Enter begin date for trips to review mm dd yvyy 3 Enter the End Date for the Trips to Review Enter end date for trips to review mm dd yyyy 4 Select a Trip Status The available options are Approved Denied or All Clicking All will show all approved denied and trips pending HFS authorization Approved Select a Trip Status Denied C AIL C 5 Click on the Continue button Continue PassPORT User Manual Page 10 of 29 comprehensive Trip Detail screen will open in different window The trip information is displayed in ascending RTN order This means that the oldest RTNs will be listed first This feature should assist you in identifying RTNs that may have previously been approved but are now denied Requests in a Pending status are reported at the end of the Denials See appendix B for further instructions on how to read a Trip Detail screen Billing Detail Windows Internet Explorer www ft p
29. racking Number Continue Enter Trip Once in the Trips by RTN page enter the RTN in the Enter a Request Tracking Number field and click on the Continue button The Billing Detail screen will open in a different window It will display all trips matching the RTN entered See Appendix A for instructions on how to read this screen Trips Windows Internet Explorer Ka GA 5 www fFE passport il com get TripsByReF aspx RIN amp TripBeginDate amp TripEndDate amp Provider w r1 X LO Live Search File Edit view Favorites Tools Help Favorites pt e Suggested Sites g Free Hotmail web Slice Gallery a gt gt trips F Safety Tools P NAME JOHN DOE RIN 111111111 DOB 09 19 1955 1234567 TRIP STATUS PROC CODE COS ORIGIN DESTINATION QTY BEGIN DATE END DATE A Approved A0120 054 R D 13 09 26 2009 10 25 2009 A Approved A0425 054 R D 09 26 2009 10 25 2009 A Approved A0120 054 D R 13 09 26 2009 10 25 2009 A Approved A0425 054 D R 09 26 2009 10 25 2009 Trip Detail Prior approval dx arantee payment by HFS Ra toe 7 Done Clicking on the Trip Detail link will open the Trip Detail screen in a different window See Appendix B for instructions on how to read this screen Trips Windows Internet Explorer V 13 https wvww ft passport il com TripDetail aspx ic 4444444 m EIS X 6 Live Search Fie Edit view Favor
30. ser Manual Page 12 of 29 F ENTER TRIPS Use the Enter Trip screen used to enter Single Trip and Recurring Standing Prior Authorization requests Home elp Logout Trips By Trips by Trips by Clie nt STEP 1 PAGE Requesting Person s Name Recipient Identification Number RIN Participant s First Name Trip Frequency Single Recurring Trip Type One way Round trip 1 1 a From Date ES jas ointment Select Hour Select Minute mmydd ime CY To Date mmiddivvvy Osu Omo Otu Owe Om Orf Osa Trip Reason STANDING ORDER DIALYSIS The Requesting Person s Name and Requesting Organization fields are entered automatically with your account information these fields are non editable Requesting Person s Name Requesting Organization mum Dialysis Accoun Recipient Identification Number RIN Callback Phane Enter the Callback Phone field with the most direct phone number to reach YOU the requesting user Requesting Person s Name Test Test Dialysis Requesting Organization Test Dialysis Accoun Recipient Identification Number RIN Callback Phone eso 123 4567 T Enter the Recipient Identification Number RIN Participant s First Name and Participant s Last Name This information must be an exact match of the Recipient data in the HFS system PassPORT User Manual Page 13 of 29 Recipient Identification
31. t available or to find out which is the best reason to use for a particular trip email ilpassport firstgroup com Trip Reason ACUPUNCTURE NON APPROVABLE SERVICE PassPORT User Manual Page 14 of 29 ACUPUNCTURE NON APPROVABLE SERVICE ALZHEIMER S DISEASE AMPUTATION ARM AMPUTATION FINGER AMPI ITATIONLE AAT Once you have filled in all fields click on the Next button Next gt A If any of the required information is missing you will see an error message in the bottom left hand corner of the screen Correct the information before proceeding Recipient Identification Number RIN asse Callback Phone 630 123 4567 Client Name and RIN entered do not match those on file with First Transit PLEASE contact the Provider Line at 1 866 503 9040 for further assistance in completing this online request Trip Frequency f single C Recurring Trip Type One way Round trip Trip Date 09 16 2010 Appointment Select Hour 15 mm dd vyyy Time Trip Reason HOSPITAL DISCHARGE ROUND TRIPS Whenever you select Round Trip on the Trip Type the screen will change to the shown below Enter the hour and minute fields under the Approximate Return Time Trip Type One way Round trip Appointment Select Hour lew alert Mini Time Select Hour Select Minute Approximate EHE 4 Reham Time Select Hour Select Minute RECURRING TRIPS Recurring trips are those sing
32. t yet have a PassPORT account follow the steps below to create one 1 Click on the Request a New Account link PASSPORT Member Log In Username Password Request a New Account 2 Enter the information requested Once you select a Provider type you will be asked to provide your Medicaid Provider ID This is the 12 digit number you use to bill IL Medicaid PagsPUIRT Account Request Windows Internet Explorer 3 QE pedi E pito Lc am quet aspa 4 m x Ede View Faworbes Toot Help p Vswenkes 33 Suggested Fees Hele P Wib Sher foley M Pass PORT Account E mm Pages Seye Tons e Firet Lert Entar your first and last nari 204 Enb amp r yur mua dirett oe 133 phone number wa Enter your amall address plasms check gpelling JANE NET Select your Brevicar Enter your First first and last name JANE DOE Enter your most direct sss 123 4587 phone number ida JANE DOEGIPROVIDER NET please check spelling Select your Provider type Dislysis Center Enter a Medicaid ee 4111111111 3 Click on the Submit request button You will receive instructions by email PassPORT User Manual Page 4 of 29 C LOG IN INSTRUCTIONS 1 Open web browser window 2 Goto www ft passport il com 3 Enter your Username an
33. tails on reading this screen Trips Windows Internet Explorer 8 amp 8 x E gt e 3 5 Ee https wwnw FE passport il com TripDetkail aspx ic 4444444 x t Live Search og lll sae i l a TL File Edit View Favorites Tools Help x fg Snagi Er Favorites e Suggested Sites Free Hotmail web Slice Gallery trips fap 15 me Safety Tools dh Prior approval does NOT guarantee payment by HFS I rst r a S t Trip Date Service Level From To Billing Detail 9 26 2009 Service Car RESIDENCE TOTAL RENAL CARE INC RIN RTN 123 SOME STREET 4557 LINCOLN HIGHWAY SUITE B 111111111 1234567 HOPKINS PARK ILIL 60964 MATTESON IL IL 60443 Trip Status 4 4pproved NET Provider Attendant TOTAL RENWAL CARE INC RESIDENCE 123 TRANSPORTATION INC None 4557 LINCOLN HIGHWAY SUITE 123 SOME STREET MATTESON IL IL 60443 HOPKINS PARK IL IL 60964 Done M nene 10 RENEW TRIP RENEW BY Dialysis facilities are able to renew dialysis standing orders entered through PassPORT if all of the information in the previously approved request remains the same and no corrections are needed Home ID Logout Trips Trips RTN Enter Trip Renew Trip PassPORT User Manual Page 24 of 29 APPENDIX A READING THE BILLING DETAIL SCREEN Recipient Request Ident
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