Supporting medical documents

Both HCA MAGI-based and DSHS Classic AEM require the following supporting documents based on emergent condition:

Emergency room care: Emergency room treatment page(s) Copy of the completed hospital claim form (UB04)

Outpatient surgery care: Operative notes (description of procedure completed) Emergency room treatment page(s); and Copy of the completed hospital claim form (UB04)

Inpatient admission: History and physical Hospital discharge summary Copy of the completed hospital claim form (UB04)

Cancer treatment: Cancer treatment plan

Dialysis treatment: Current dialysis flow charts from dialysis center; Treatment plan from the attending physician

Antirejection treatment for a post organ transplant Treatment plan from the attending physician or provider