ID

25619

Beschreibung

Muster 56 - Antrag auf Kostenübernahme (Freigabe 01.09.2014). Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php --- Template 56 - Cost Absorption Application Form (Released 01-09-2014). Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

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Versionen (4)
  1. 16.01.17 16.01.17 -
  2. 16.01.17 16.01.17 -
  3. 28.01.17 28.01.17 -
  4. 07.09.17 07.09.17 -
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7. September 2017

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KBV Cost Coverage Application form Template 56

Deutsch Englisch

KBV Cost Coverage Application form Template 56

1 Formulare  
Header
Beschreibung

Header

Health Insurance name
Beschreibung

Health Insurance name

Datentyp

text

Alias
UMLS CUI [1]
C0021682
Patient surname
Beschreibung

Patient surname

Datentyp

text

Alias
UMLS CUI [1]
C0421448
Patient Name
Beschreibung

Patient Name

Datentyp

text

Alias
UMLS CUI [1]
C1299487
Patient address
Beschreibung

Patient address

Datentyp

text

Alias
UMLS CUI [1]
C0421449
Patient Birth Date
Beschreibung

Patient Birth Date

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Insurance ID
Beschreibung

Insurance ID

Datentyp

integer

Alias
UMLS CUI [1]
C1547687
Insurance number
Beschreibung

Insurance number

Datentyp

integer

Alias
UMLS CUI [1]
C1549712
Status
Beschreibung

Status

Datentyp

integer

Alias
UMLS CUI [1]
C0449438
Facility number
Beschreibung

Facility number

Datentyp

integer

Alias
UMLS CUI [1]
C1549700
Physician ID number
Beschreibung

Physician ID number

Datentyp

integer

Alias
UMLS CUI [1]
C1548646
Date
Beschreibung

Date

Datentyp

date

Alias
UMLS CUI [1]
C0011008
Cost coverage application form
Beschreibung

Cost coverage application form

Cost coverage application form
Beschreibung

Cost coverage application form

Datentyp

integer

Alias
UMLS CUI [1]
C1555849
Medical prescription for rehabilitation sports / functional training
Beschreibung

Medical prescription for rehabilitation sports / functional training

diagnoses
Beschreibung

diagnoses

Datentyp

text

Alias
UMLS CUI [1]
C0011900
body malfunction
Beschreibung

body malfunction

Datentyp

text

Alias
UMLS CUI [1]
C0231174
rehabilitation sports objective
Beschreibung

rehabilitation sports objective

Datentyp

text

Alias
UMLS CUI [1]
C0679840
Recommended sport
Beschreibung

Recommended sport

gymnastics
Beschreibung

gymnastics

Datentyp

boolean

Alias
UMLS CUI [1]
C0018409
swimming
Beschreibung

swimming

Datentyp

boolean

Alias
UMLS CUI [1]
C0039003
athletics
Beschreibung

athletics

Datentyp

boolean

Alias
UMLS CUI [1]
C1510656
movement games
Beschreibung

movement games

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0150593
UMLS CUI [1,2]
C0026649
other sport
Beschreibung

other sport

Datentyp

text

Alias
UMLS CUI [1]
C0038039
Self-confidence enhancement
Beschreibung

Self-confidence enhancement

Datentyp

boolean

Alias
UMLS CUI [1]
C2315340
Rehabilitation sports indication
Beschreibung

Rehabilitation sports indication

50 workout
Beschreibung

50 workout

Datentyp

boolean

Alias
UMLS CUI [1]
C0220931
120 workouts if indicated
Beschreibung

120 workouts if indicated

Datentyp

boolean

Alias
UMLS CUI [1]
C0220931
rehabilitation sport indication
Beschreibung

rehabilitation sport indication

Datentyp

integer

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
28 workouts for self-confidence enhancement
Beschreibung

28 workouts for self-confidence enhancement

Datentyp

boolean

Alias
UMLS CUI [1]
C2315340
other workout volume
Beschreibung

other workout volume

Datentyp

integer

Alias
UMLS CUI [1]
C0220931
120 workouts
Beschreibung

120 workouts

Datentyp

boolean

Alias
UMLS CUI [1]
C0220931
Recommended functional sports
Beschreibung

Recommended functional sports

dry gymnastics
Beschreibung

dry gymnastics

Datentyp

boolean

Alias
UMLS CUI [1]
C0018409
water gymnastics
Beschreibung

water gymnastics

Datentyp

boolean

Alias
UMLS CUI [1]
C0018409
Functional sports indication
Beschreibung

Functional sports indication

12 months of training
Beschreibung

12 months of training

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0038039
24 months of training
Beschreibung

24 months of training

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0038039
impairment as indication for functional training
Beschreibung

impairment as indication for functional training

Datentyp

integer

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
24 months training
Beschreibung

24 months training

Datentyp

boolean

Alias
UMLS CUI [1]
C0220931
other indications for rehabilitation sports
Beschreibung

other indications for rehabilitation sports

Datentyp

text

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
Rehabilitation sports
Beschreibung

Rehabilitation sports

rehabilitation sport
Beschreibung

rehabilitation sport

Datentyp

integer

Alias
UMLS CUI [1]
C1555849
other workout volume
Beschreibung

other workout volume

Datentyp

integer

Alias
UMLS CUI [1]
C0220931
Recommended workout frequency for rehabilitation sports/functional training
Beschreibung

Recommended workout frequency for rehabilitation sports/functional training

Datentyp

text

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0439603
justification
Beschreibung

justification

Datentyp

text

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0439603
UMLS CUI [1,3]
C0392360
Footer
Beschreibung

Footer

Signature date
Beschreibung

Signature date

Datentyp

date

Alias
UMLS CUI [1]
C0807937
Cost Coverage application
Beschreibung

Cost Coverage application

service provider
Beschreibung

service provider

Datentyp

text

Alias
UMLS CUI [1]
C0679886
rehabilitation sport since
Beschreibung

rehabilitation sport since

Datentyp

date

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C2708155
Signature date
Beschreibung

Signature date

Datentyp

date

Maßeinheiten
  • TT-MM-JJ
Alias
UMLS CUI [1]
C0807937
TT-MM-JJ
Cost Coverage declaration
Beschreibung

Cost Coverage declaration

rehabilitation sports
Beschreibung

rehabilitation sports

Datentyp

boolean

Alias
UMLS CUI [1]
C1555849
rehabilitation sports volume
Beschreibung

rehabilitation sports volume

Datentyp

integer

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0220931
other rehabilitation sport volume
Beschreibung

other rehabilitation sport volume

Datentyp

integer

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0220931
Functional training
Beschreibung

Functional training

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0203967
UMLS CUI [1,2]
C0332307
functional training volume
Beschreibung

functional training volume

Datentyp

integer

Alias
UMLS CUI [1,1]
C0589106
UMLS CUI [1,2]
C0439603
functional training duration
Beschreibung

functional training duration

Datentyp

integer

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0589106
other functional training duration
Beschreibung

other functional training duration

Datentyp

integer

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0589106
physical therapy start date
Beschreibung

physical therapy start date

Datentyp

date

Alias
UMLS CUI [1]
C2708155
physical therapy end date
Beschreibung

physical therapy end date

Datentyp

date

Alias
UMLS CUI [1]
C2708157
Footer
Beschreibung

Footer

Signature date
Beschreibung

Signature date

Datentyp

date

Alias
UMLS CUI [1]
C0807937
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Ähnliche Modelle

KBV Cost Coverage Application form Template 56

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Health Insurance name
Item
text
C0021682 (UMLS CUI [1])
Patient surname
Item
text
C0421448 (UMLS CUI [1])
Patient Name
Item
text
C1299487 (UMLS CUI [1])
Patient address
Item
text
C0421449 (UMLS CUI [1])
Patient Birth Date
Item
date
C0421451 (UMLS CUI [1])
Insurance ID
Item
integer
C1547687 (UMLS CUI [1])
Insurance number
Item
integer
C1549712 (UMLS CUI [1])
Status
Item
integer
C0449438 (UMLS CUI [1])
Facility number
Item
integer
C1549700 (UMLS CUI [1])
Physician ID number
Item
integer
C1548646 (UMLS CUI [1])
Date
Item
date
C0011008 (UMLS CUI [1])
Item
integer
C1555849 (UMLS CUI [1])
Cost absorption application form
Code List
Cost coverage application form
CL Item
 (1)
CL Item
 (2)
diagnoses
Item
text
C0011900 (UMLS CUI [1])
body malfunction
Item
text
C0231174 (UMLS CUI [1])
rehabilitation sports objective
Item
text
C0679840 (UMLS CUI [1])
gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
swimming
Item
boolean
C0039003 (UMLS CUI [1])
athletics
Item
boolean
C1510656 (UMLS CUI [1])
movement games
Item
boolean
C0150593 (UMLS CUI [1,1])
C0026649 (UMLS CUI [1,2])
other sport
Item
text
C0038039 (UMLS CUI [1])
Self-confidence enhancement
Item
boolean
C2315340 (UMLS CUI [1])
50 workout
Item
boolean
C0220931 (UMLS CUI [1])
120 workouts if indicated
Item
boolean
C0220931 (UMLS CUI [1])
Item
integer
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
rehabilitation sport indication
Code List
rehabilitation sport indication
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
CL Item
 (8)
CL Item
 (9)
CL Item
 (10)
CL Item
 (11)
CL Item
 (12)
CL Item
 (13)
CL Item
 (14)
CL Item
 (15)
CL Item
 (16)
CL Item
 (17)
28 workouts for self-confidence enhancement
Item
boolean
C2315340 (UMLS CUI [1])
other workout volume
Item
integer
C0220931 (UMLS CUI [1])
120 workouts
Item
boolean
C0220931 (UMLS CUI [1])
dry gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
water gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
12 months of training
Item
boolean
C0449238 (UMLS CUI [1,1])
C0038039 (UMLS CUI [1,2])
24 months of training
Item
boolean
C0449238 (UMLS CUI [1,1])
C0038039 (UMLS CUI [1,2])
Item
integer
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
impairment as indication for functional training
Code List
impairment as indication for functional training
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
24 months training
Item
boolean
C0220931 (UMLS CUI [1])
other indications for rehabilitation sports
Item
text
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Item
integer
C1555849 (UMLS CUI [1])
rehabilitation sport
Code List
rehabilitation sport
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
other workout volume
Item
integer
C0220931 (UMLS CUI [1])
Item
text
C1555849 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Recommended workout frequency for rehabilitation sports/functional training
Code List
Recommended workout frequency for rehabilitation sports/functional training
CL Item
 (1 mal)
CL Item
 (2 mal)
CL Item
 (3 mal)
justification
Item
text
C1555849 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Item Group
Signature date
Item
Signature date
date
C0807937 (UMLS CUI [1])
service provider
Item
text
C0679886 (UMLS CUI [1])
rehabilitation sport since
Item
date
C1555849 (UMLS CUI [1,1])
C2708155 (UMLS CUI [1,2])
Signature date
Item
date
C0807937 (UMLS CUI [1])
rehabilitation sports
Item
boolean
C1555849 (UMLS CUI [1])
Item
integer
C1555849 (UMLS CUI [1,1])
C0220931 (UMLS CUI [1,2])
rehabilitation sports volume
Code List
rehabilitation sports volume
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
other rehabilitation sport volume
Item
integer
C1555849 (UMLS CUI [1,1])
C0220931 (UMLS CUI [1,2])
Functional training
Item
boolean
C0203967 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Item
integer
C0589106 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
functional training volume
Code List
functional training volume
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Item
integer
C0449238 (UMLS CUI [1,1])
C0589106 (UMLS CUI [1,2])
functional training volume
Code List
functional training duration
CL Item
 (1)
CL Item
 (2)
other functional training duration
Item
integer
C0449238 (UMLS CUI [1,1])
C0589106 (UMLS CUI [1,2])
physical therapy start date
Item
date
C2708155 (UMLS CUI [1])
physical therapy end date
Item
date
C2708157 (UMLS CUI [1])
Item Group
Signature date
Item
Signature date
date
C0807937 (UMLS CUI [1])
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