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1 | C:\AraxisMergeCompare\Pub_un | Claims Processing and Eligibility Enhancements_Build 8_stories(CPE).xlsx | Thu Jul 26 16:53:16 2018 UTC |
2 | C:\AraxisMergeCompare\Pub_re | Claims Processing and Eligibility Enhancements_Build 8_stories(CPE).xlsx | Fri Jul 27 15:47:53 2018 UTC |
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1 | SHEET: She et1 | |
2 | Epic,Story #,Rationa l,Descript ion, | |
3 | Bene Calc, CRU__SNF10 3,986073, Pay Claims Using the CMS Skill ed Nursing (SNF) Pay ment Metho dology, | |
4 | Bene Calc, CRU_SNF033 ,743018, A s a Commun ity Care S pecialist, I require a capabil ity for th e CPE syst em to auto matically run a data conflict check when the user selects to sort a su bmission i nto claims , so I am prompted t hat the cl aim is mis sing an Oc currence S pan Codes. , | |
5 | Bene Calc, CRU_SNF040 ,743019,As a Communi ty Care Sp ecialist, I require a capabili ty for the CPE syste m to autom atically r un a data conflict c heck when the user s elects to sort a sub mission in to claims, so I am p rompted th at the cla im is miss ing a comp liant RUG code (RUG IV codeset )., | |
6 | Bene Calc, CRU_SNF100 3,743024,A s a Nurse Reviewer, I require a capabili ty to rout e SNF clai ms in the upper RUG groups to be reviewe d, so I ca n approve that the b eneficiary level of SNF care r equirement s are met and the cl aim can pr oceed to S NF claim f inalizatio n. Rules a ssociated with this section ru n after th e benefit calculatio n has been completed ., | |
7 | Bene Calc, CRU_SNF 10 07,743025, As a Nurs e Reviewer , when the RUG group is the de fault HIPP S code AAA 00 or in t he lower 1 8 RUGs {i. e., IB2, I B1, IA2, I A1, BB2, B B1, BA2, B A1, PE2, P E1, PD2, P D1, PC2, P C1, PB2, P B1, PA2, P A1 (AAA)}, for servi ces prior to October 1, 2010, or the low er 14 RUGs {i.e., BB 2, BA2, BB 1, BA1, PE 2, PD2, PC 2, PB2, PA 2, PE1, PD 1, PC1, PB 1, PA1 (AA A)}, I nee d the syst em to queu e the clai m, so I ca n review t he claim t o determin e medical necessity to determi ne if the beneficiar y meets th e criteria for skill ed service s., | |
8 | Bene Calc, CRU_SNF100 8,743026, As a Nurse Reviewer, I require the syste m to queue SNF claim s for bene ficiaries who have M edicare A and/or Med icare B Ty pe of OHI Coverage, so I can m anually re view if th ey have ex hausted Me dicare SNF benefits and submit ted a Medi care denia l EOB. Rul es associa ted with t his sectio n run afte r the bene fit calcul ation has been compl eted., | |
9 | Bene Calc, CRU_SNF 10 09,743027, As a Nurs e Reviewer , I requir e the syst em to queu e SNF clai ms for ben eficiaries who are u nder age 6 5, so I ca n manually review me dical nece ssity for the SNF se rvices pro vided., | |
10 | Claim Reje ct,CRU_SNF 060,988078 ,As a Comm unity Care Specialis t, I requi re a CPE s ystem capa bility to auto-rejec t SNF clai ms that do n't meet t he minimum requireme nts necess ary to pay the claim , so the p rovider ca n optional ly resubmi t the clai m with the correct d ata and I can pay th e claim ac curately., | |
11 | Claim Reje ct,CRU_SNF 061,727758 ,As a Comm unity Care Specialis t, I requi re a CPE s ystem capa bility to auto-rejec t SNF clai ms that do n't meet t he require ments nece ssary to p ay the cla im, so the provider can option ally resub mit the cl aim with r evised/cor rected dat a., | |
12 | Claim Reje ct,CRU_SNF 062,727761 ,As a Comm unity Care Specialis t, I requi re a capab ility for the CPE sy stem to au to-reject claims tha t don't me et the min imum requi rements ne cessary to pay the c laim, so I can pay c laims accu rately., | |
13 | Claim Reje ct,CRU_SNF 063,727759 ,As a Comm unity Care Specialis t, I requi re a capab ility for the CPE sy stem to au to-reject claims tha t don't me et the min imum requi rements ne cessary to pay the c laim, so I can pay c laims accu rately., | |
14 | Payment In dicators,C RU_SNF1021 ,743061,As a Communi ty Care Sp ecialist, I require a capabili ty for the system to edit SNF Rate Table s, | |
15 | Payment In dicators,C RU_SNF1022 ,743062,As a Communi ty Care Sp ecialist, I require a capabili ty for the system to view SNF Rate Table s, | |
16 | Payment In dicators,C RU_SNF1023 ,743063,As a Communi ty Care Sp ecialist, I require a capabili ty for the system to print SNF Rate Tabl es, | |
17 | Payment In dicators,C RU_SNF1000 ,743050,As a Communi ty Care Sp ecialist, I require a menu tha t allows m e to add, update, an d edit ski lled nursi ng rate da ta, so I c an maintai n the corr ect paymen t rate dat a., | |
18 | Payment In dicators,C RU_SNF999, 743065,As a Communit y Care Spe cialist, I require a capabilit y to calcu late the l abor porti on of the federal ra tes adjust ed for geo graphic va riation in wages usi ng the hos pital wage index by CBSA Wage Index, so I can pay claims acc urately., | |
19 | Medicare B eneficiary Identifie r (MBI), CC4044,920 222,MBI Di splay MBI on Edit Hi story Scre en, | |
20 | MBI,CC4001 ,896714,As CMS, I ne ed to rece ive E01 fi les contai ning the M edicare Be neficiary Identifer (MBI) for added CHAM PVA recipi ents so th at our sec ondary pay er records continue to be up t o date., | |
21 | MBI,CC4002 ,896715,As CMS, I ne ed to rece ive E01 fi les contai ning the M edicare Be neficiary Identifer (MBI) for updated CH AMPVA reci pients so that our s econdary p ayer recor ds continu e to be up to date., | |
22 | MBI,CC4003 ,896716,As CMS, I ne ed to rece ive E01 fi les contai ning the M edicare Be neficiary Identifer (MBI) for deleted CH AMPVA reci pients so that our s econdary p ayer recor ds continu e to be up to date., | |
23 | MBI,CC4004 ,896718,As CMS, I ne ed to rece ive E02 fi les contai ning the M edicare Be neficiary Identifer (MBI) for added CHAM PVA recipi ents so th at our sec ondary pay er records continue to be up t o date., | |
24 | MBI,CC4005 ,896719,As CMS, I ne ed to rece ive E02 fi les contai ning the M edicare Be neficiary Identifer (MBI) for updated CH AMPVA reci pients so that our s econdary p ayer recor ds continu e to be up to date., | |
25 | MBI,CC4006 ,896720,As CMS, I ne ed to rece ive E02 fi les contai ning the M edicare Be neficiary Identifer (MBI) for deleted CH AMPVA reci pients so that our s econdary p ayer recor ds continu e to be up to date., | |
26 | MBI,CC4007 ,896722,As a CP&E Pr ocessor I need the C P&E Applic ations Pro cessing sc reen to di splay the Medicare B eneficiary Identifie r (MBI) so that I ca n verify t he MBI on beneficiar y records. , | |
27 | MBI,CC4008 ,896723,As a CP&E Pr ocessor I need the C P&E Applic ations Pro cessing sc reen to ac cept the M edicare Be neficiary Identifier (MBI) so that I can record th e MBI on b eneficiary records., | |
28 | MBI,CC4009 ,896725,As a CP&E Pr ocessor I need to ha ve CP&E au tomaticall y updated with all a n accurate Medicare Beneficiar y Identifi er (MBI) f or all CHA MPVA benef iciaries w ith Medica re benefit s so that their data will be c urrent., | |
29 | MBI,CC4010 ,899939,As CMS, I ne ed to rece ive E01 fi les contai ning the D ELETE indi cator for CHAMPVA re cipients w ho have lo st their b enefits so that our secondary payer reco rds contin ue to be u p to date. , | |
30 | MBI,CC4011 ,899940,As CMS, I ne ed to rece ive E02 fi les contai ning the D ELETE indi cator for CHAMPVA re cipients w ho have lo st their b enefits so that our secondary payer reco rds contin ue to be u p to date. , | |
31 | MBI,CC4012 ,910787,Fr om the tim e we get t he crosswa lk file an d ingest i t, use MBI in place of HICN in the E01 / E02 file, if it is available. If it is not availa ble contin ue to use MBI., | |
32 | MBI,CC4013 ,910795,On ce crosswa lk file re ceived I w ant to ing est in the CP&E syst em and upd ate bene r ecords wit h MBI from the cross walk., | |
33 | MBI,CC4014 ,910798,As we ingest the cross walk file, create a log file t o include a list of benes with existing HICN numbe rs that di d not resu lt in an M BI match s o user can analyze. Generate E 01 file to determine if there is a HICN / MBI file , | |
34 | MBI,CC4015 ,914276,As a CMS COB A partner, I want to upgrade C P&E to be compliant with the C MS SSN rep lacement i nitiative as it rela tes to COB A., | |
35 | MBI,CC4016 ,902976,As the CPE s ystem, I n eed to und erstand wh at records to send w hen a date is modifi ed via 'ad d', 'chang e', 'delet e' or 'upd ate' so th at I can m aintain co rrect bene ficiary re cords., |
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