UM & CM Screen Catalog — Search, Case Workspaces, Worklists

Windows the UR nurses and case managers use day to day: the search hub, the five case-maintenance workspaces, the response windows they open, and the follow-up worklist. Reference-data and reporting screens are in Screen Catalog — Administration & Reports.

Search & entry (um_main)

UM Search (um_main/w_um_search)

• Launch: frame menu (homersys/m_sys_frame opens w_um_search); MDI sheet with menu m_um_search.
• Purpose: the hub of the domain — locate a member or a case, review history and warnings, and open/create cases.
• Field groups:
  • Search criteria: Last Name, Soc Sec No, Member ID, Group ID, From/Through date, As-of Date, and Notification No (direct case-number lookup) (sle_notification_no, criteria labels at the search pane).
  • Group banner: division Group ID and name, Examiner + extension, Stop Loss Carrier (dddw um_main/dddw_um_stoploss_carrier from carriers + group_stoploss_parms), Confidential Contact + phone — the contact is walked up the group hierarchy until found, else "Unknown" (wf_urcm_search).
  • Family member list (um_main/d_um_member_list) with the searched member highlighted.
  • Tabs: UM Record History (um_main/d_um_record_list — case number, category, status, disposition, overall dates, case manager, lock info, by subscriber + patient set + date range) and Demographics (um_main/d_um_demographics, member address/phone DataWindows), plus COBRA info.
• Validations / rules: per-group security check against security_user_class_user before showing anything; notification numbers not on file are rejected ("is not in the system") (wf_urcm_search_notification).
• Actions:
  • Search populates family, history, group info and pops the warnings window (below), and checks member notes (n_notes, entity MEMBER).
  • Clicking a history row surfaces case notes (entity CASE); double-click opens the case's maintenance window by category (dw_history_record::doubleclicked → wf_record_maintenance).
  • New (pfc_addrow) requires a selected member, opens the case-type chooser and then the proper workspace with the full member/group context passed along (dw_history_record::pfc_addrow).
• Windows opened: w_um_warning_display, w_um_new_case, w_um_admission_notification, w_um_case_management, w_um_referral, w_um_pre_certification, w_um_authorization.

New Case chooser (um_main/w_um_new_case)

• Response window "Select New Case Type": radio buttons for Admission Notification Pre/Post, Authorization, Case Management, Certification Pre/Post-Occurrence, Referral; Dental Pre-Determination, Medical Necessity and Medical Pre-Determination are present but disabled. Returns the chosen type string to w_um_search.

Warning display (um_main/w_um_warning_display)

• Hidden sheet opened alongside search; shown whenever a member is selected.
• Master list: one row per Medical plan package election (plan description, network, UR firm, CM firm — um_main/d_warning_master); detail list: the warnings attached to those UR/CM entities (um_main/d_warning_detail on um_entity_warnings/um_warnings).
• Synthesizes system warnings: "Member not active as of <date>" (from members.mbr_term_dt), "Utilization Review Not Done" (no UR firm on the plan package), "Case Management Not Done" (no CM firm) (wf_warning_display).

Member / patient / code select responses (um_main)

Small response windows used by the workspaces:

Window	Purpose
um_main/w_um_member_select	"UM Member Select window" — member pick list.
um_main/w_um_case_patient_select	Pick the patient "from members of current family" — used to assign a real member to an unassigned-patient case (w_um_pre_certification dw_case::buttonclicked).
um_main/w_um_diagnosis_cd_select	Resolve a diagnosis-code prefix to a full code + description; sets the OK flag on return (w_um_pre_certification dw_diagnosis_info::buttonclicked).
um_main/w_um_procedure_cd_select	Same pattern for procedure codes.
um_main/w_um_diag_group_cd_select, w_um_proc_group_cd_select	Select diagnosis / procedure group codes for services that are coded at group level (referral/authorization group DataWindows um_ur/d_um_ref_diag_groups, d_um_auth_proc_groups).
um_main/w_um_benefit_def_select	Select benefit definitions to scope a service (um_cm/d_um_cm_service_benefit_defs, um_ur/d_um_auth_service_benefit_defs).
um_main/w_um_hold_rule_child	Edit one hold rule's scope list — the same window serves PROC, DIAG, BENEFIT, PROVIDER and SPECIALTY child lists, parameterized by type (w_um_hold_rule_child case branches).
um_main/w_medical_director_review	Rule-level reviews grid (shared-data with the parent's review DataWindow d_um_medical_director_review): review type, appealer type, request/response dates, director, outcome; add generates the review key from the sequence.

Case workspaces (um_ur / um_cm)

All five share one blueprint (documented once here, differences noted per window): an MDI sheet opened with the member/group context from search; group banner + family list + stop-loss carrier at the top; a tab folder with Case, Service (with nested panes or sub-tabs) and Physicians; buttons Create/Edit COB (opens w_cob_select for the member — see the COB module) and, on UR windows, Create/Edit Potential CM. Case numbering, locking, defaults, validations and cascade deletes are the business rules UMC-2..UMC-17 (see module page); the per-category dropdown retrieval is wf_retrieve_dddw.

Pre-Certification (um_ur/w_um_pre_certification)

• Serves categories: Pre-Cert, Post-Cert (both radio choices open this window; the category dddw is restricted to those two — dw_case::constructor).
• Case tab (um_ur/d_um_pc_case): patient/subscriber names, unassigned patient block (name + birth date + Select Patient button), category, coverage type (member's actual elections retrieved into the dddw; default Medical), overall from/thru dates, status (per-category), disposition (default DC Plan), case manager, notified-by code/name, requestor (name/phone/member-flag), late-notification, motor-vehicle-accident and workers-compensation flags, case-level benefit terms (deductible, coinsurance pct/limit, lifetime/yearly maximums, apply-to-adjudication), CC names, response-printed date, savings totals.
• Service tab — single service (um_ur/d_um_pc_service) plus panes:
  • Service pane: request and approved date ranges, notification type, service type, unit type (UMSRVCUNIT codes), criteria/guideline units, unit totals (computed from rules), estimated last day in hospital, next follow-up date (+ override flag), follow-up done flag, discharge confirmed-by/date, actual days stayed, service resolution, claim type.
  • Provider pane (um_ur/d_um_pc_service_provider) with provider search (n_provider_search) and derived network affiliation (UMC-22).
  • Hospital contacts (um_main/d_um_hospital_contacts) — Primary/Secondary (UMC-20).
  • Diagnosis codes (um_main/d_um_diag_codes) and procedure codes (um_main/d_um_proc_codes) with master-table validation and prefix-search buttons (UMC-21).
  • Rules grid (um_ur/d_um_pc_rules) with per-row buttons: Reviews (opens w_medical_director_review filtered to the rule), Pricing (opens w_pricing_plan_maintenance_single and stores the returned pricing plan key), Exclusions ("function not available") (dw_rule_info::buttonclicked).
  • Review grid (hidden holder for all rules' reviews, um_main/d_um_medical_director_review).
• Physicians tab (um_main/d_um_physicians): ordered physician list — name, phone, type (per-category dddw), specialty (UMC-19).
• CM Potential: hidden shared DataWindow (um_cm/d_um_cm_potential_create) behind the Create/Edit Potential CM button (UMC-23).
• Save: validates every pane in order (case, potential, physicians, service, contacts, diagnoses, procedures, rules, reviews), deletes reviews of deleted rules, updates all panes in one transaction, commits, re-locks the case (ue_save).
• Windows opened: w_medical_director_review, w_pricing_plan_maintenance_single, w_um_diagnosis_cd_select, w_um_procedure_cd_select, w_um_case_patient_select, w_um_cm_potential_create, w_cob_select.

Authorization (um_ur/w_um_authorization)

• Serves category: Auth. Largest of the workspaces (6,200 lines).
• Differences from pre-certification:
  • Multiple services with First/Last/Next/Previous page navigation over a rownum filter (dw_service::pfc_new and the paging events).
  • Service sub-tabs: Rules (um_ur/d_um_auth_rules + reviews), Diagnosis/ Benefit Defs (d_um_auth_diag_codes, d_um_auth_service_benefit_defs, d_um_auth_diag_groups), Procedures (d_um_auth_proc_code, d_um_auth_proc_groups), Hold Rules (d_um_auth_hold_rules with child holds for diagnosis, procedure, benefit definition, provider and specialty — d_um_auth_specialty_holds), Contacts/Provider (d_um_auth_service_provider, hospital contacts).
  • Case/service hard- and soft-savings totals roll up from the rules' computed sums (c_total_hard_savings / c_total_soft_savings).
• Rule columns are identical across all four UR case types (d_um_pc_rules = d_um_auth_rules = d_um_an_rules; d_um_ref_rules lacks only the reviews count column).

Admission Notification (um_ur/w_um_admission_notification)

• Serves categories: Pre-Adm, Post-Adm.
• Single service ("Only one Service may be created for Admission Notifications" — dw_service::pfc_new); case DataWindow um_ur/d_um_an_case, service d_um_an_service, rules d_um_an_rules.
• Emphasis on the stay: estimated last day in hospital derived from rules, next-follow-up chaining, discharge confirmation (value list Hospital / Insured//Family / Doctor's Office / Outside Case Mgt — d_um_an_service), actual days stayed computed from admission to discharge (dw_service::ue_afteritemchanged).
• Includes hold rules with specialty holds (deletes um_specialty_holds in its save path) and the Create Potential CM button.

Referral (um_ur/w_um_referral)

• Serves category: Referral.
• Case um_ur/d_um_ref_case, service d_um_ref_service, rules d_um_ref_rules, provider d_um_ref_service_provider; codes panes use diagnosis codes plus diagnosis groups (d_um_ref_diag_groups); hospital contacts and physicians as elsewhere; CM potential button present.
• Referral cases are excluded from the follow-up worklist and can be excluded from the management report (um_main/d_um_follow_up; um_cm/d_um_management_cases filter show_referral).

Case Management (um_cm/w_um_case_management)

• Serves category: CM; menu m_um_case_management_case (with service and physician variants swapped per tab).
• Case tab (um_cm/d_um_cm_case) plus a side grid of CM involvements (um_cm/d_um_cm_case_involvements over cm_case_involvements / cm_involvements) retrieved per case.
• Service tab with sub-tabs: Rules (d_um_cm_rule + medical director reviews), Diag/Proc/Defs (d_um_cm_diag_codes, d_um_cm_proc_code_no_resolution, d_um_cm_service_benefit_defs), Hold Rules (d_um_cm_hold_rules with diagnosis / procedure / benefit / provider child holds and per-rule counts; scope lists edited via w_um_hold_rule_child), Contacts/Provider (d_um_cm_service_provider, d_um_cm_hospital_contacts). Multiple services supported (page navigation events pfc_firstpage … pfc_previouspage).
• Physicians tab as in the UR windows.
• Time capture: opening/retrieving a case calls wf_start_billing (timestamp), and leaving the case (new case, close, delete) calls wf_stop_billing, which creates/updates the cm_billing record with elapsed minutes, status-at-close and time type (UMC-26). Deleted cases delete their billing rows first.
• From a potential: when opened from the potentials report with a potential key, saving the new case stamps the potential resolved CaseOpened with the case link (UMC-24).
• Validations: same case-header rules as the UR windows (UMC-8); hold rules need hold messages (UMC-28); diagnosis codes validated against the master table.

Worklists (um_main)

Follow-Up (um_main/w_um_follow_up)

• Launch: frame menu (homersys/m_sys_frame).
• Content: worklist of open cases (um_main/d_um_follow_up): case number, category, status, disposition, case manager, service type, next follow-up date, provider, patient (including unassigned names), sorted by master group, follow-up date, case number. Filter: status not Closed and not Serv%, category not Referral, member's master group within the group tree of the entered group id.
• Actions: double-click loads the member context (group banner, stop-loss carrier, examiner, confidential contact — same helpers as search) and opens the case in its category window (wf_get_case_member_info and the OpenSheetWithParm branch).
• Windows opened: all five case workspaces.