ID

25646

Description

Muster 70 - Behandlungsplan für Maßnahmen zur künstlichen Befruchtung gem. § 27a SGB V sowie der „Richtlinien über künstliche Befruchtung“ des Gemeinsamen Bundesausschusses für die hier genannten Ehegatten (Freigabe 01.09.2014). Formulare für die vertragsärztliche Versorgung - 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 70 - Treatment Plan (Released 09-01-2014). 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

Link

www.kbv.de

Keywords

Versions (9)
  1. 1/3/17 1/3/17 -
  2. 1/3/17 1/3/17 -
  3. 1/3/17 1/3/17 -
  4. 1/28/17 1/28/17 -
  5. 8/19/17 8/19/17 -
  6. 9/7/17 9/7/17 -
  7. 9/8/17 9/8/17 -
  8. 9/8/17 9/8/17 -
  9. 9/8/17 9/8/17 -
Copyright Holder

KBV

Uploaded on

September 8, 2017

DOI

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License

Creative Commons BY-NC 3.0
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KBV Treatment Plan In-vitro fertilization Template 70

German

KBV Treatment Plan In-vitro fertilization Template 70a

2 forms  
Briefkopf Weiblich
Description

Briefkopf Weiblich

Krankenkasse bzw. Kostenträger
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1,1]
C0021682
UMLS CUI [1,2]
C0086287
Name, Vorname des Versicherten
Description

Patient Name

Data type

text

Alias
UMLS CUI [1,1]
C1299487
UMLS CUI [1,2]
C0086287
Adresse des Versicherten
Description

Patient address

Data type

text

Alias
UMLS CUI [1,1]
C0421449
UMLS CUI [1,2]
C0086287
geb. am
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1,1]
C0421451
UMLS CUI [1,2]
C0086287
Kostenträgerkennung
Description

Insurance Company ID

Data type

integer

Alias
UMLS CUI [1,1]
C1547687
UMLS CUI [1,2]
C0086287
Versicherten-Nr.
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1,1]
C1549712
UMLS CUI [1,2]
C0086287
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1,1]
C0449438
UMLS CUI [1,2]
C0086287
Betriebsstätten-Nr.
Description

Facility ID

Data type

integer

Alias
UMLS CUI [1,1]
C1549700
UMLS CUI [1,2]
C0086287
Arzt-Nr.
Description

Physician ID

Data type

integer

Alias
UMLS CUI [1,1]
C1548646
UMLS CUI [1,2]
C0086287
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0086287
Briefkopf Männlich
Description

Briefkopf Männlich

Krankenkasse bzw. Kostenträger
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1,1]
C0021682
UMLS CUI [1,2]
C0086582
Name, Vorname des Versicherten
Description

Patient Name

Data type

text

Alias
UMLS CUI [1,1]
C1299487
UMLS CUI [1,2]
C0086582
Adresse des Versicherten
Description

Patient address

Data type

text

Alias
UMLS CUI [1,1]
C0421449
UMLS CUI [1,2]
C0086582
geb. am
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1,1]
C0421451
UMLS CUI [1,2]
C0086582
Kostenträgerkennung
Description

Insurance Company ID

Data type

integer

Alias
UMLS CUI [1,1]
C1547687
UMLS CUI [1,2]
C0086582
Versicherten-Nr.
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1,1]
C1549712
UMLS CUI [1,2]
C0086582
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1,1]
C0449438
UMLS CUI [1,2]
C0086582
Betriebsstätten-Nr.
Description

Facility ID

Data type

integer

Alias
UMLS CUI [1,1]
C1549700
UMLS CUI [1,2]
C0086582
Arzt-Nr.
Description

Physician ID

Data type

integer

Alias
UMLS CUI [1,1]
C1548646
UMLS CUI [1,2]
C0086582
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1,1]
C0011008
UMLS CUI [1,2]
C0086582
I Indikation(en)
Description

I Indikation(en)

Indikation(en)
Description

gemäß Nummern 11.1-11.5 der Richtlinien über künstliche Befruchtung

Data type

text

Alias
UMLS CUI [1]
C3146298
II Geplante Behandlungsmaßnahme
Description

II Geplante Behandlungsmaßnahme

Insemination im Spontanzyklus (gemäß Nr. 10.1)
Description

Artificial insemination

Data type

boolean

Alias
UMLS CUI [1]
C0021587
Insemination nach hormoneller Stimulation (gemäß Nr. 10.2)
Description

insemination after hormonal stimulation

Data type

boolean

Alias
UMLS CUI [1,1]
C0021587
UMLS CUI [1,2]
C2250373
In-Vitro-Fertilisation mit Embryotransfer (gemäß Nr. 10.3)
Description

in-vitro-fertilization

Data type

boolean

Alias
UMLS CUI [1,1]
C0015915
UMLS CUI [1,2]
C0013938
Intratubarer-Gameten-Transfer (gemäß Nr. 10.4)
Description

Gamete Intrafallopian Transfer

Data type

boolean

Alias
UMLS CUI [1]
C0016999
Intracytoplasmatische Spermieninjektion (gemäß Nr. 10.5)
Description

Intracytoplasmic Sperm Injection

Data type

boolean

Alias
UMLS CUI [1]
C0455164
Anzahl und Art bereits erfolgter Behandlungen (gemäß Nr. 10.1-10.5)
Description

number and type of treatment

Data type

text

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0021587
III Kostenschätzung, a) Kosten für eimalig im Reproduktionsfall anfallende Leistungen
Description

III Kostenschätzung, a) Kosten für eimalig im Reproduktionsfall anfallende Leistungen

Ärztliche Behandlung (EBM-Positionen), männlich
Description

physician service, male

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0086582
Ärztliche Behandlung (EBM-Positionen), weiblich
Description

physician service , female

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0086287
Summe Ärztliche Behandlung, männlich
Description

overall medical costs, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085552
UMLS CUI [1,2]
C0086582
Euro
Summe Ärztliche Behandlung, weiblich
Description

overall medical costs, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085552
UMLS CUI [1,2]
C0086287
Euro
Sachkosten und Sprechstundenbedarf, männlich
Description

administrative costs, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C1517106
UMLS CUI [1,2]
C0086582
Euro
Sachkosten und Sprechstundenbedarf, weiblich
Description

administrative costs, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C1517106
UMLS CUI [1,2]
C0086287
Euro
Gesamtsumme für einmalig im Reproduktionsfall anfallende Leistungen, männlich
Description

overall treatment costs for single treatment, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0087112
UMLS CUI [1,2]
C0086582
Euro
Gesamtsumme für einmalig im Reproduktionsfall anfallende Leistungen, weiblich
Description

overall treatment costs for single treatment, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0087112
UMLS CUI [1,2]
C0086287
Euro
Ort
Description

location

Data type

text

Alias
UMLS CUI [1]
C0450429
Datum
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
III Kostenschätzung, b) Kosten pro Zyklusfall (ohne einmalig im Reproduktionsfall anfallende Leistungen)
Description

III Kostenschätzung, b) Kosten pro Zyklusfall (ohne einmalig im Reproduktionsfall anfallende Leistungen)

Ärztliche Behandlung (EBM-Positionen), männlich
Description

physician service , male

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0086582
Ärztliche Behandlung (EBM-Positionen), weiblich
Description

physician service, female

Data type

text

Alias
UMLS CUI [1,1]
C0087111
UMLS CUI [1,2]
C0086287
Summe Ärztliche Behandlung, männlich
Description

overall medical costs, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085552
UMLS CUI [1,2]
C0086582
Euro
Summe Ärztliche Behandlung, weiblich
Description

overall medical costs, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085552
UMLS CUI [1,2]
C0086287
Euro
Medikamentenkosten, männlich
Description

Drug costs, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085123
UMLS CUI [1,2]
C0086582
Euro
Medikamentenkosten, weiblich
Description

Drug costs, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0085123
UMLS CUI [1,2]
C0086287
Euro
Sachkosten und Sprechstundenbedarf, männlich
Description

administrative costs, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C1517106
UMLS CUI [1,2]
C0086582
Euro
Sachkosten und Sprechstundenbedarf, weiblich
Description

administrative costs, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C1517106
UMLS CUI [1,2]
C0086287
Euro
Gesamtsumme pro Zyklusfall, männlich
Description

overall treatment costs per cycle, male

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0087112
UMLS CUI [1,2]
C0086582
Euro
Gesamtsumme pro Zyklusfall, weiblich
Description

overall treatment costs per cycle, female

Data type

float

Measurement units
  • Euro
Alias
UMLS CUI [1,1]
C0087112
UMLS CUI [1,2]
C0086287
Euro
IV Genehmigung durch die Krankenkasse(n), männlich
Description

IV Genehmigung durch die Krankenkasse(n), männlich

Der Behandlungs-/Kostenplan wird für maximal ___ Zyklen/Zyklus genehmigt.
Description

Insurance authorization

Data type

integer

Alias
UMLS CUI [1,1]
C0376629
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0021587
UMLS CUI [1,4]
C0086582
Der Behandlungs-/Kostenplan wird nicht genehmigt.
Description

(separate Begründung anbei)

Data type

boolean

Alias
UMLS CUI [1,1]
C0376629
UMLS CUI [1,2]
C0086582
Ort
Description

location

Data type

text

Alias
UMLS CUI [1]
C0450429
Datum
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
IV Genehmigung durch die Krankenkasse(n), weiblich
Description

IV Genehmigung durch die Krankenkasse(n), weiblich

Der Behandlungs-/Kostenplan wird für maximal ___ Zyklen/Zyklus genehmigt.
Description

insurance authorization

Data type

integer

Alias
UMLS CUI [1,1]
C0376629
UMLS CUI [1,2]
C0449788
UMLS CUI [1,3]
C0021587
UMLS CUI [1,4]
C0086287
Der Behandlungs-/Kostenplan wird nicht genehmigt.
Description

(separate Begründung anbei)

Data type

boolean

Alias
UMLS CUI [1,1]
C0376629
UMLS CUI [1,2]
C0086287
Ort
Description

location

Data type

text

Alias
UMLS CUI [1]
C0450429
Datum
Description

date

Data type

date

Alias
UMLS CUI [1]
C0011008
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Similar models

KBV Treatment Plan In-vitro fertilization Template 70a

2 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Briefkopf Weiblich
Health Insurance name
Item
Krankenkasse bzw. Kostenträger
text
C0021682 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Patient Name
Item
Name, Vorname des Versicherten
text
C1299487 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Patient address
Item
Adresse des Versicherten
text
C0421449 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Patient Birth Date
Item
geb. am
date
C0421451 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Insurance Company ID
Item
Kostenträgerkennung
integer
C1547687 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Insurance number
Item
Versicherten-Nr.
integer
C1549712 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Status
Item
Status
integer
C0449438 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Facility ID
Item
Betriebsstätten-Nr.
integer
C1549700 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Physician ID
Item
Arzt-Nr.
integer
C1548646 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Item Group
Briefkopf Männlich
Health Insurance name
Item
Krankenkasse bzw. Kostenträger
text
C0021682 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Patient Name
Item
Name, Vorname des Versicherten
text
C1299487 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Patient address
Item
Adresse des Versicherten
text
C0421449 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Patient Birth Date
Item
geb. am
date
C0421451 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Insurance Company ID
Item
Kostenträgerkennung
integer
C1547687 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Insurance number
Item
Versicherten-Nr.
integer
C1549712 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Status
Item
Status
integer
C0449438 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Facility ID
Item
Betriebsstätten-Nr.
integer
C1549700 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Physician ID
Item
Arzt-Nr.
integer
C1548646 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Item Group
I Indikation(en)
Indications
Item
Indikation(en)
text
C3146298 (UMLS CUI [1])
Item Group
II Geplante Behandlungsmaßnahme
Artificial insemination
Item
Insemination im Spontanzyklus (gemäß Nr. 10.1)
boolean
C0021587 (UMLS CUI [1])
insemination after hormonal stimulation
Item
Insemination nach hormoneller Stimulation (gemäß Nr. 10.2)
boolean
C0021587 (UMLS CUI [1,1])
C2250373 (UMLS CUI [1,2])
in-vitro-fertilization
Item
In-Vitro-Fertilisation mit Embryotransfer (gemäß Nr. 10.3)
boolean
C0015915 (UMLS CUI [1,1])
C0013938 (UMLS CUI [1,2])
Gamete Intrafallopian Transfer
Item
Intratubarer-Gameten-Transfer (gemäß Nr. 10.4)
boolean
C0016999 (UMLS CUI [1])
Intracytoplasmic Sperm Injection
Item
Intracytoplasmatische Spermieninjektion (gemäß Nr. 10.5)
boolean
C0455164 (UMLS CUI [1])
number and type of treatment
Item
Anzahl und Art bereits erfolgter Behandlungen (gemäß Nr. 10.1-10.5)
text
C0449788 (UMLS CUI [1,1])
C0021587 (UMLS CUI [1,2])
Item Group
III Kostenschätzung, a) Kosten für eimalig im Reproduktionsfall anfallende Leistungen
physician service, male
Item
Ärztliche Behandlung (EBM-Positionen), männlich
text
C0087111 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
physician service , female
Item
Ärztliche Behandlung (EBM-Positionen), weiblich
text
C0087111 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
overall medical costs, male
Item
Summe Ärztliche Behandlung, männlich
float
C0085552 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
overall medical costs, female
Item
Summe Ärztliche Behandlung, weiblich
float
C0085552 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
administrative costs, male
Item
Sachkosten und Sprechstundenbedarf, männlich
float
C1517106 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
administrative costs, female
Item
Sachkosten und Sprechstundenbedarf, weiblich
float
C1517106 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
overall treatment costs for single treatment, male
Item
Gesamtsumme für einmalig im Reproduktionsfall anfallende Leistungen, männlich
float
C0087112 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
overall treatment costs for single treatment, female
Item
Gesamtsumme für einmalig im Reproduktionsfall anfallende Leistungen, weiblich
float
C0087112 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
location
Item
Ort
text
C0450429 (UMLS CUI [1])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
Item Group
III Kostenschätzung, b) Kosten pro Zyklusfall (ohne einmalig im Reproduktionsfall anfallende Leistungen)
physician service , male
Item
Ärztliche Behandlung (EBM-Positionen), männlich
text
C0087111 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
physician service, female
Item
Ärztliche Behandlung (EBM-Positionen), weiblich
text
C0087111 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
overall medical costs, male
Item
Summe Ärztliche Behandlung, männlich
float
C0085552 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
overall medical costs, female
Item
Summe Ärztliche Behandlung, weiblich
float
C0085552 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Drug costs, male
Item
Medikamentenkosten, männlich
float
C0085123 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
Drug costs, female
Item
Medikamentenkosten, weiblich
float
C0085123 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
administrative costs, male
Item
Sachkosten und Sprechstundenbedarf, männlich
float
C1517106 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
administrative costs, female
Item
Sachkosten und Sprechstundenbedarf, weiblich
float
C1517106 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
overall treatment costs per cycle, male
Item
Gesamtsumme pro Zyklusfall, männlich
float
C0087112 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
overall treatment costs per cycle, female
Item
Gesamtsumme pro Zyklusfall, weiblich
float
C0087112 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
Item Group
IV Genehmigung durch die Krankenkasse(n), männlich
Insurance authorization
Item
Der Behandlungs-/Kostenplan wird für maximal ___ Zyklen/Zyklus genehmigt.
integer
C0376629 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0021587 (UMLS CUI [1,3])
C0086582 (UMLS CUI [1,4])
no Insurance authorization
Item
Der Behandlungs-/Kostenplan wird nicht genehmigt.
boolean
C0376629 (UMLS CUI [1,1])
C0086582 (UMLS CUI [1,2])
location
Item
Ort
text
C0450429 (UMLS CUI [1])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
Item Group
IV Genehmigung durch die Krankenkasse(n), weiblich
insurance authorization
Item
Der Behandlungs-/Kostenplan wird für maximal ___ Zyklen/Zyklus genehmigt.
integer
C0376629 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
C0021587 (UMLS CUI [1,3])
C0086287 (UMLS CUI [1,4])
no Insurance authorization
Item
Der Behandlungs-/Kostenplan wird nicht genehmigt.
boolean
C0376629 (UMLS CUI [1,1])
C0086287 (UMLS CUI [1,2])
location
Item
Ort
text
C0450429 (UMLS CUI [1])
date
Item
Datum
date
C0011008 (UMLS CUI [1])
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