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1 | CPAC.zip\Billing Precertification for Fee Care | 03-055BillingPrecert_RSD_v1.0_fully signed.docx | Thu Feb 9 15:02:30 2017 UTC |
2 | CPAC.zip\Billing Precertification for Fee Care | 03-055BillingPrecert_RSD_v1.0_fully signed.docx | Thu Feb 9 20:41:01 2017 UTC |
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1 | Department of Vetera ns Affairs | |||||
2 | ||||||
3 | ||||||
4 | ||||||
5 | ||||||
6 | Billing Pr ecertifica tion for F ee Care | |||||
7 | ||||||
8 | ||||||
9 | Requiremen ts Specifi cation Doc ument | |||||
10 | ||||||
11 | ||||||
12 | ||||||
13 | ||||||
14 | ||||||
15 | ||||||
16 | ||||||
17 | ||||||
18 | ||||||
19 | September 2015 | |||||
20 | ||||||
21 | Version 1. 0 | |||||
22 | ||||||
23 | Revision H istory | |||||
24 | ||||||
25 | Date | |||||
26 | Version | |||||
27 | Descriptio n | |||||
28 | Author | |||||
29 | Reviewer | |||||
30 | Issue Date | |||||
31 | 07/16/2015 | |||||
32 | 0.01 | |||||
33 | Initial dr aft | |||||
34 | S. Ritter | |||||
35 | S. Ambrose | |||||
36 | 07/17/2015 | |||||
37 | 07/30/2015 | |||||
38 | 0.02 | |||||
39 | Updated to reflect V A Comments | |||||
40 | S. Ritter | |||||
41 | S. Ambrose | |||||
42 | 07/31/2015 | |||||
43 | 08/18/2015 | |||||
44 | 0.03 | |||||
45 | Updated to reflect V A Comments | |||||
46 | S. Ritter | |||||
47 | S. Ambrose | |||||
48 | 08/19/2015 | |||||
49 | 08/25/2015 | |||||
50 | 0.04 | |||||
51 | Updated to reflect V A Comments | |||||
52 | Modified f ormat and added requ irement. | |||||
53 | New Requir ement: | |||||
54 | 2.6.1.12 – Add contr act number parameter for | |||||
55 | Choice Pro gram filte ring. | |||||
56 | S. Ritter | |||||
57 | S. Ambrose | |||||
58 | 08/26/2015 | |||||
59 | 09/01/2015 | |||||
60 | 0.05 | |||||
61 | Integrate with VA re vision and format an d incorpor ate additi onal VA co mments | |||||
62 | S. Ritter | |||||
63 | S. Ambrose | |||||
64 | 09/07/2015 | |||||
65 | 09/10/2015 | |||||
66 | 1.0 | |||||
67 | First Form al Iterati on | |||||
68 | C. Dunn | |||||
69 | ||||||
70 | ||||||
71 | ||||||
72 | Table of C ontents | |||||
73 | ||||||
74 | 1.Introduc tion ..... .......... .......... .......... .......... .......... .......... .......... .......... ... 1 | |||||
75 | 1.1. Purp ose ...... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .. 1 | |||||
76 | 1.2. Scop e ........ .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .... 1 | |||||
77 | 1.3. Refe rences ... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... 6 | |||||
78 | 2.Overall Descriptio n ........ .......... .......... .......... .......... .......... .......... ........ 7 | |||||
79 | 2.1. Acce ssibility Specificat ions...... .......... .......... .......... .......... .......... .......... .......... 7 | |||||
80 | 2.2. Busi ness Rules Specifica tion ..... .......... .......... .......... .......... .......... .......... ........ 7 | |||||
81 | 2.3. Desi gn Constra ints Speci fication.. .......... .......... .......... .......... .......... .......... ..... 7 | |||||
82 | 2.4. Disa ster Recov ery Specif ication .. .......... .......... .......... .......... .......... .......... ...... 7 | |||||
83 | 2.5. Docu mentation Specificat ions...... .......... .......... .......... .......... .......... .......... ...... 7 | |||||
84 | 2.6. Func tional Spe cification s ........ .......... .......... .......... .......... .......... .......... .......... . 7 | |||||
85 | 2.6.1.Noti fication o f authoriz ed Fee Bas is care up on entry i nto VistA Fee | |||||
86 | Basis Pack age ...... .......... .......... .......... .......... .......... .......... .......... .......... .......... ....... 8 | |||||
87 | 2.6.1.1.Fu nctional r equirement FRPRE – 1 .1 ....... .......... .......... .......... .......... .......... ... 8 | |||||
88 | 2.6.1.2.Fu nctional R equirement FRPRE 1.1 .1.1 – 01 .......... .......... .......... .......... ........ 8 | |||||
89 | 2.6.1.3.Fu nctional R equirement FRPRE 1.1 .1.1 – 02 .......... .......... .......... .......... ........ 8 | |||||
90 | 2.6.1.4.Fu nctional R equirement FRPRE 1.1 .1.1 – 03 .......... .......... .......... .......... ........ 8 | |||||
91 | 2.6.1.5.Fu nctional R equirement FRPRE 1.1 .1.1 – 04 .......... .......... .......... .......... ........ 8 | |||||
92 | 2.6.1.6.Fu nctional R equirement FRPRE 1.1 .1.1 – 05 .......... .......... .......... .......... ........ 8 | |||||
93 | 2.6.1.7.Fu nctional R equirement FRPRE 1.1 .1.1 – 06 .......... .......... .......... .......... ........ 9 | |||||
94 | 2.6.1.8.Fu nctional R equirement FRPRE 1.1 .1.1 – 07 .......... .......... .......... .......... ........ 9 | |||||
95 | 2.6.1.9.Fu nctional R equirement FRPRE 1.1 .1.1 – 08 .......... .......... .......... .......... ........ 9 | |||||
96 | 2.6.1.10.F unctional Requiremen t FRPRE 1. 1.1.1 – 09 .......... .......... .......... .......... ........ 9 | |||||
97 | 2.6.1.11.F unctional Requiremen t FRPRE 1. 1.1.1 – 10 .......... .......... .......... .......... ........ 9 | |||||
98 | 2.6.1.12.F unctional Requiremen t FRPRE 1. 1.1.1 – 11 .......... .......... .......... .......... ........ 9 | |||||
99 | 2.6.2.Modi fication o f the exis ting PCRR to include the data elements n eeded to s ubmit time ly third p arty Fee B asis care related bi lls....... .......... ..... 9 | |||||
100 | 2.6.2.1.Fu nctional R equirement FRPRE 2.1 .1 – 01 .. .......... .......... .......... .......... ......... 9 | |||||
101 | 2.6.2.2.Fu nctional R equirement FRPRE 2.1 .1 – 02 .. .......... .......... .......... .......... ......... 9 | |||||
102 | 2.6.2.3.Fu nctional R equirement FRPRE 2.1 .1 – 03 .. .......... .......... .......... .......... ........10 | |||||
103 | 2.6.2.4.Fu nctional R equirement FRPRE 2.1 .1 – 04 .. .......... .......... .......... .......... ........10 | |||||
104 | 2.6.2.5.Fu nctional R equirement FRPRE 2.1 .1 – 05 .. .......... .......... .......... .......... ........10 | |||||
105 | 2.6.2.6.Fu nctional R equirement FRPRE 2.1 .1 – 06 .. .......... .......... .......... .......... ........10 | |||||
106 | 2.6.2.7.Fu nctional R equirement FRPRE 2.1 .1 – 07 .. .......... .......... .......... .......... ........10 | |||||
107 | 2.6.2.8.Fu nctional R equirement FRPRE 2.1 .1 – 08 .. .......... .......... .......... .......... ........10 | |||||
108 | 2.6.2.9.Fu nctional R equirement FRPRE 2.1 .1 – 09 .. .......... .......... .......... .......... ........10 | |||||
109 | 2.6.2.10.F unctional Requiremen t FRPRE 2. 1.1 – 10.. .......... .......... .......... .......... ........10 | |||||
110 | 2.6.2.11.F unctional Requiremen t FRPRE 2. 1.1 – 11.. .......... .......... .......... .......... ........10 | |||||
111 | 2.6.2.12.F unctional Requiremen t FRPRE 2. 1.1 – 12.. .......... .......... .......... .......... ........11 | |||||
112 | 2.6.2.13.F unctional Requiremen t FRPRE 2. 1.1 – 13.. .......... .......... .......... .......... ........11 | |||||
113 | 2.6.2.14.F unctional Requiremen t FRPRE 2. 1.1 – 13.1 .......... .......... .......... .......... .......11 | |||||
114 | 2.6.2.15.F unctional Requiremen t FRPRE 2. 1.1 – 14.. .......... .......... .......... .......... ........11 | |||||
115 | 2.6.2.16.F unctional Requiremen t FRPRE 2. 1.2 ...... .......... .......... .......... .......... .......... .11 | |||||
116 | 2.6.2.17.F unctional Requiremen t FRPRE 2. 2.1 – 01.. .......... .......... .......... .......... ........11 | |||||
117 | ||||||
118 | 2.6.2.18.F unctional Requiremen t FRPRE 2. 2.1 – 02.. .......... .......... .......... .......... ........11 | |||||
119 | 2.6.2.19.F unctional Requiremen t FRPRE 2. 2.1 – 03.. .......... .......... .......... .......... ........11 | |||||
120 | 2.6.2.20.F unctional Requiremen t FRPRE 2. 2.1 – 04.. .......... .......... .......... .......... ........11 | |||||
121 | 2.6.2.21.F unctional Requiremen t FRPRE 2. 2.1 – 05.. .......... .......... .......... .......... ........12 | |||||
122 | 2.7. Grap hical User Interface (GUI) Spe cification s ........ .......... .......... .......... ...... 12 | |||||
123 | 2.8. Mult i-division al Specifi cations... .......... .......... .......... .......... .......... .......... ....... 12 | |||||
124 | 2.9. Perf ormance Sp ecificatio ns........ .......... .......... .......... .......... .......... .......... ...... 12 | |||||
125 | 2.10.Quali ty Attribu tes Specif ication .. .......... .......... .......... .......... .......... .......... ..... 12 | |||||
126 | 2.11.Relia bility Spe cification s......... .......... .......... .......... .......... .......... .......... .......... 12 | |||||
127 | 2.12.Scope Integrati on........ .......... .......... .......... .......... .......... .......... .......... .......... ... 12 | |||||
128 | 2.13.Secur ity Specif ications . .......... .......... .......... .......... .......... .......... .......... .......... 12 | |||||
129 | 2.14.Syste m Features ......... .......... .......... .......... .......... .......... .......... .......... .......... ... 12 | |||||
130 | 2.15.Usabi lity Speci fications. .......... .......... .......... .......... .......... .......... .......... .......... 13 | |||||
131 | 3.Applicab le Standar ds ....... .......... .......... .......... .......... .......... .......... ... 13 | |||||
132 | 4.Interfac es ....... .......... .......... .......... .......... .......... .......... .......... .......... ... 14 | |||||
133 | 4.1. Comm unications Interface s ........ .......... .......... .......... .......... .......... .......... ...... 14 | |||||
134 | 4.2. Hard ware Inter faces..... .......... .......... .......... .......... .......... .......... .......... .......... .. 14 | |||||
135 | 4.3. Soft ware Inter faces..... .......... .......... .......... .......... .......... .......... .......... .......... ... 14 | |||||
136 | 4.4. User Interface s ........ .......... .......... .......... .......... .......... .......... .......... .......... ....... 14 | |||||
137 | 5.Legal, C opyright, and Other Notices .. .......... .......... .......... .......... .... 15 | |||||
138 | 6.Purchase d Componen ts ....... .......... .......... .......... .......... .......... ......... 15 | |||||
139 | 6.1. Defe ct Source (TOP 5) .. .......... .......... .......... .......... .......... .......... .......... .......... . 15 | |||||
140 | 7.User Cla ss Charact eristics.. .......... .......... .......... .......... .......... .......... 15 | |||||
141 | 8.Estimati on ....... .......... .......... .......... .......... .......... .......... .......... .......... . 15 | |||||
142 | Attachment A – Appro val Signat ures ..... .......... .......... .......... .......... ....... 17 | |||||
143 | Attachment B – Acron ym List an d Glossary ......... .......... .......... .......... . 18 | |||||
144 | Attachment C – Enter prise Requ irements . .......... .......... .......... .......... ... 20 | |||||
145 | Attachment D – Chang e Log .... .......... .......... .......... .......... .......... .......... .. 22 | |||||
146 | ||||||
147 | List of Ta bles | |||||
148 | ||||||
149 | Table 1: G oals and I mpacts ... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... ......... 1 | |||||
150 | Table 2: B illing Pre certificat ion for Fe e Care BNs /Owner Req uirements (OWNR) ... .......... .......... .......... ... 2 | |||||
151 | Table 3: A cronym Lis t......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... 18 | |||||
152 | Table 4: E nterprise Requiremen ts ....... .......... .......... .......... .......... .......... .......... .......... .......... .......... .......... ... 20 | |||||
153 | ||||||
154 | ||||||
155 | List of Fi gures | |||||
156 | ||||||
157 | Figure 1: Cumulative Probabili ty (“S-cur ve”) Chart ......... .......... .......... .......... .......... .......... .......... .......... . 16 | |||||
158 | ||||||
159 | 1.Introduc tion | |||||
160 | ||||||
161 | The Chief Business O ffice (CBO ), Purchas ed Care Pr ogram Offi ce is requ esting enh ancements to assist the Depart ment of Ve terans Aff airs Medic al Centers (VAMCs) i n obtainin g timely p recertific ation from third par ty payers before car e is rende red by not ifying the appropria te staff a s soon as Department of Vetera ns Affairs (VA) prov ided outpa tient serv ices requi ring prece rtificatio n are sche duled and authorizat ions are c reated in the Vetera ns Health Informatio n Systems and Techno logy Archi tecture (V istA) Fee Package fo r inpatien t or outpa tient care . | |||||
162 | ||||||
163 | 1.1.Purpos e | |||||
164 | ||||||
165 | This Requi rements Sp ecificatio n Document (RSD) spe cifies the requireme nts for th e 3rd Part y Billing Integrated Billing ( IB) Precer tification Enhanceme nts of the Electroni c Data Int erchange ( EDI) Conso lidated Pa tient Acco unt Center (CPAC) Re venue Enha ncements P rogram. Th e intended audience is the CBO Purchased Care Prog ram Office , CPAC key stakehold ers includ ing the CP AC Revenue Systems M anagement (RSM) orga nization, and the CP AC EDI Rev enue Enhan cements de velopment team. | |||||
166 | ||||||
167 | 1.2.Scope | |||||
168 | ||||||
169 | This docum ent addres ses the Bu siness Nee d (BN) and requireme nts propos ed in the 3rd Party Billing IB Precertif ication En hancements Business Requiremen ts Documen t (BRD) da ted Januar y 2011, wh ich outlin es recomme nded chang es to the VistA Fee Basis and IB applica tions. | |||||
170 | ||||||
171 | The goals/ impacts of the enhan cements pr oposed in the BRD ar e shown in Table 1. | |||||
172 | ||||||
173 | Table 1: G oals and I mpacts | |||||
174 | ||||||
175 | Goal/Objec tive and D esired Out come | |||||
176 | Impact | |||||
177 | Appropria te Revenue Staff wou ld be noti fied when an authori zation is created in the VistA Fee Basis | |||||
178 | Package fo r inpatien t or outpa tient care . | |||||
179 | Appropria te Revenue Staff wou ld be noti fied when an outpati ent servic e requirin g precerti fication i s schedule d. | |||||
180 | The modif ied Potent ial Cost R ecovery Re port (PCRR ) would pr ovide the informatio n needed f or billing to submit third par ty bills i n | |||||
181 | a timely m anner. | |||||
182 | Revenue S taff has t he opportu nity to co ntact thir d party ca rriers reg arding fut ure Fee Ba sis appoin tments bef ore treatm ent is ren dered 100% of the ti me. | |||||
183 | Revenue S taff has t he opportu nity to co ntact thir d party ca rriers reg arding fut ure qualif ying outpa tient appo intments b efore trea tment is r endered 10 0% of the time. | |||||
184 | Billing S taff would be able t o use the modified P CRR to sub mit third party Fee Basis care related b ills witho ut having to complet e addition al researc h 100% of the time. | |||||
185 | This docum ent addres ses only t he 3rd Par ty Billing IB Precer tification Enhanceme nts, one o f five enh ancements comprising the EDI C PAC Revenu e Enhancem ents Progr am. Detail s regardin g other en hancements in the pr ogram are described in separat e RSDs. | |||||
186 | ||||||
187 | During req uirements elaboratio n for this enhanceme nt, the BN s and requ irements w ere discus sed from t he perspec tive of th e BRD, inc luding the changes r ecommended in the BR D to addre ss the BN. | |||||
188 | ||||||
189 | The revise d understa nding of t he BNs and goals has revealed that BN 3 is no long er a need since it h as been ad dressed on other Pro jects and doesn’t ne ed to be i mplemented . Addition ally, BN | |||||
190 | 2.2 (while the solut ion will b e develope d within t he VistA I B software , the nece ssary info rmation fr om the Vis tA Surgery Package w ill need t o be pulle d onto the report) i s not requ ired. Thes e revised BNs will b e reflecte d in this RSD. | |||||
191 | ||||||
192 | The BNs/re quirements are shown in Table 2. Table 2 also refl ects the o bsolescenc e on BN 3. | |||||
193 | ||||||
194 | Table 2: B illing Pre certificat ion for Fe e Care BNs /Owner Req uirements (OWNR) | |||||
195 | ||||||
196 | BN | |||||
197 | Feature | |||||
198 | Number | |||||
199 | Functional Capabilit ies / Feat ure | |||||
200 | Descriptio n | |||||
201 | Ranking R= Required O =Optional | |||||
202 | BN 1: Appr opriate st aff would be notifie d of autho rized Fee Basis care upon entr y and/or u pdate into the VistA Fee Basis Package. | |||||
203 | F 1.1 | |||||
204 | Create a m echanism t hat would notify Uti lization R eview (UR) Nurses an d Insuranc e Verifica tion Clerk s when an authorizat ion is cre ated and/o r updated in the Vis tA Fee Bas is package for Veter ans with a ctive, bil lable insu rance (exc luding Med icare only and Medic are supple mental pol icies). | |||||
205 | R | |||||
206 | BN 1: Appr opriate st aff would be notifie d of autho rized Fee Basis care upon entr y and/or u pdate into the VistA Fee Basis Package. | |||||
207 | F 1.1.1 | |||||
208 | With the a bility to generate a report of the same, as needed . | |||||
209 | R | |||||
210 | ||||||
211 | ||||||
212 | BN | |||||
213 | Feature | |||||
214 | Number | |||||
215 | Functional Capabilit ies / Feat ure | |||||
216 | Descriptio n | |||||
217 | Ranking R= Required O =Optional | |||||
218 | BN 1: Appr opriate st aff would be notifie d of autho rized Fee Basis care upon entr y and/or u pdate into the VistA Fee Basis Package. | |||||
219 | F 1.1.1.1 | |||||
220 | Data eleme nts commun icated wil l include | |||||
221 | Name of o rdering ph ysician | |||||
222 | Diagnosis /Procedure (includin g Internat ional Clas sification of Diseas es – Ninth Revision/ Tenth Revi sion – Cli nical Modi fication [ ICD-9/10-C M]/Current Procedura l Terminol ogy [CPT] codes if p rovided) f or service s authoriz ed | |||||
223 | Scheduled date of s ervice (St art | |||||
224 | & End Date s) | |||||
225 | Name of N on-VA loca tion | |||||
226 | (Vendor) | |||||
227 | Insurance informati on on file | |||||
228 | Last date insurance verified | |||||
229 | Type of s ervice | |||||
230 | (inpatient /outpatien t) | |||||
231 | Existing service re lated cond itions (if applicabl e) | |||||
232 | Outpatien t Copaymen t Status | |||||
233 | Medicatio n Copaymen t | |||||
234 | Exemption Status | |||||
235 | R | |||||
236 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
237 | F 2.1 | |||||
238 | Ability to generate the existi ng PCRR wi th additio nal data e lements ne eded to su bmit a thi rd party b ill. | |||||
239 | R | |||||
240 | ||||||
241 | ||||||
242 | BN | |||||
243 | Feature | |||||
244 | Number | |||||
245 | Functional Capabilit ies / Feat ure | |||||
246 | Descriptio n | |||||
247 | Ranking R= Required O =Optional | |||||
248 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
249 | F 2.1.1 | |||||
250 | Data eleme nts commun icated wil l include: | |||||
251 | Station/F acility/Di vision Num ber | |||||
252 | Type of s ervice | |||||
253 | (inpatient /outpatien t/prescrip tion) | |||||
254 | Name of r endering p hysician | |||||
255 | Name of o rdering ph ysician | |||||
256 | Diagnosis /Procedure (includin g all appl icable ICD -9/10-CM/C PT codes i f provided ) for serv ices autho rized | |||||
257 | Dates of service (S tart & End dates) | |||||
258 | Name of N on-VA loca tion | |||||
259 | (Vendor) | |||||
260 | All appli cable prov ider/facil ity Nation al Provide r Identifi er (NPI) a nd taxonom y codes. | |||||
261 | Insurance informati on on file | |||||
262 | Last date insurance verified | |||||
263 | Existing service co nnected co nditions ( if applica ble) and s pecial tre atment aut horities | |||||
264 | Outpatien t Copaymen t Status | |||||
265 | Medicatio n Copaymen t | |||||
266 | Exemption Status | |||||
267 | Indicator signifyin g whether or not the Fee Basis care rela ted episod e of care has been p reviously billed to a third pa rty carrie r | |||||
268 | If it has been bill ed previou sly, indic ate date b illed and the associ ated bill number(s) | |||||
269 | Display t he authori zation num ber or pre certificat ion number UR receiv ed from th e insuranc e carrier | |||||
270 | R | |||||
271 | ||||||
272 | ||||||
273 | BN | |||||
274 | Feature | |||||
275 | Number | |||||
276 | Functional Capabilit ies / Feat ure | |||||
277 | Descriptio n | |||||
278 | Ranking R= Required O =Optional | |||||
279 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
280 | F 2.1.2 | |||||
281 | Ability to different iate and s ort the da ta on this report by 5 digit s tation num ber | |||||
282 | R | |||||
283 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
284 | F 2.2 | |||||
285 | The episod es of care displayed on this m odified re port would be based on the fol lowing cri teria: | |||||
286 | R | |||||
287 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
288 | F 2.2.1 | |||||
289 | Veteran h as active, billable insurance (similar t o the curr ent Re-Gen erate Unbi lled Amoun ts Report [IBT RE-GE N UNBILLED REPORT]), include o nly Fee Ba sis care r elated epi sodes of c are that h ave not be en billed to a third party car rier previ ously | |||||
290 | Insurance effective date | |||||
291 | Insurance expiratio n date | |||||
292 | Treatment date fall s within e ffective/e xpiration dates | |||||
293 | Display t he authori zation num ber or pre certificat ion number UR receiv ed from th e insuranc e carrier | |||||
294 | R | |||||
295 | BN 2: Modi fy the exi sting PCRR to includ e the data elements needed to submit tim ely third party Fee Basis care related b ills. | |||||
296 | F 2.2 | |||||
297 | While the solution will be de veloped wi thin the V istA IB so ftware, th e necessar y informat ion from t he VistA S urgery Pac kage will need to be pulled on to the rep ort. | |||||
298 | Not | |||||
299 | Required | |||||
300 | ||||||
301 | ||||||
302 | BN | |||||
303 | Feature | |||||
304 | Number | |||||
305 | Functional Capabilit ies / Feat ure | |||||
306 | Descriptio n | |||||
307 | Ranking R= Required O =Optional | |||||
308 | BN 3: Appr opriate st aff would be notifie d of futur e VA provi ded outpat ient appoi ntments th at meet ce rtain | |||||
309 | criteria. (Obsolete) | |||||
310 | F 3.1 | |||||
311 | Create a m echanism t hat would notify UR Nurses whe n a future appointme nt that me ets the fo llowing cr iteria is scheduled: | |||||
312 | Not | |||||
313 | Required | |||||
314 | BN 3: Appr opriate st aff would be notifie d of futur e VA provi ded outpat ient appoi ntments th at meet ce rtain | |||||
315 | criteria. (Obsolete) | |||||
316 | F 3.1.1 | |||||
317 | Veteran w ith active , billable insurance (excludin g Medicare only and Medicare s upplementa l policies ). | |||||
318 | Not | |||||
319 | Required | |||||
320 | BN 3: Appr opriate st aff would be notifie d of futur e VA provi ded outpat ient appoi ntments th at meet ce rtain | |||||
321 | criteria. (Obsolete) | |||||
322 | F 3.1.2 | |||||
323 | Provide f unctionali ty/option that gives certain u sers the a bility to add or del ete specif ic clinic names need ed for the precertif ication pr ocess at t he local l evel for o ptimal use . (Note: S imilar fun ctionality has previ ously been written f or | |||||
324 | CPAC use a nd coding can be pro vided to t he Office of | |||||
325 | Informatio n and Tech nology | |||||
326 | [OI&T] whe n needed). | |||||
327 | Not | |||||
328 | Required | |||||
329 | BN 3: Appr opriate st aff would be notifie d of futur e VA provi ded outpat ient appoi ntments th at meet ce rtain | |||||
330 | criteria. | |||||
331 | (Obsolete) | |||||
332 | F 3.2 | |||||
333 | Ability to generate an on dema nd report listing qu alifying p atients/ap pointments . | |||||
334 | Not | |||||
335 | Required | |||||
336 | ||||||
337 | 1.3.Refere nces | |||||
338 | ||||||
339 | The follow ing docume ntation/hy perlinks c ontain inf ormation r elated to this RSD: | |||||
340 | ||||||
341 | 3rd Party Billing P recertific ation Enha ncements B RD, Januar y 2011 | |||||
342 | Please re fer to App endix A of the BRD f or additio nal refere nces relev ant to thi s enhancem ent | |||||
343 | ||||||
344 | 2.Overall Descriptio n | |||||
345 | ||||||
346 | 2.1.Access ibility Sp ecificatio ns | |||||
347 | ||||||
348 | This proje ct will ad here to al l applicab le require ments of S ection 508 of the Re habilitati on Act of | |||||
349 | 1973, as a mended (29 U.S.C. 79 4d). A 508 complianc e review w ill be con ducted in accordance with Prog ram Manage ment Accou ntability System (PM AS) standa rds. | |||||
350 | ||||||
351 | 2.2.Busine ss Rules S pecificati on | |||||
352 | ||||||
353 | There are no specifi c new busi ness rules applicabl e to this enhancemen t. | |||||
354 | ||||||
355 | A high-lev el view of the curre nt (as-is) and futur e (to-be) billing pr ecertifica tion for f ee care pr ocesses/wo rkflows ar e availabl e via Tech nical Serv ices Proje ct Reposit ory (TSPR) here: htt p:// DNS | |||||
356 | ||||||
357 | 2.3.Design Constrain ts Specifi cation | |||||
358 | VA Standa rds and Co nventions for Massac husetts Ge neral Hosp ital Utili ty Multi- Programmin g System ( MUMPS) dev elopment | |||||
359 | VA Techni cal Refere nce Model (TRM) | |||||
360 | ||||||
361 | 2.4.Disast er Recover y Specific ation | |||||
362 | ||||||
363 | There are no new or specific d isaster re covery spe cification s for this project. The disast er recover y specific ations per taining to any VistA system ar e applicab le to this project. | |||||
364 | ||||||
365 | 2.5.Docume ntation Sp ecificatio ns | |||||
366 | ||||||
367 | System doc umentation to be del ivered wil l be in ac cordance w ith PMAS a nd ProPath System | |||||
368 | Developmen t Processe s. | |||||
369 | ||||||
370 | Documentat ion to be delivered includes b ut is not limited to : | |||||
371 | ||||||
372 | Installat ion Guide | |||||
373 | User Guid e | |||||
374 | Technical Manual | |||||
375 | Security Guide | |||||
376 | Contingen cy Plan | |||||
377 | Disaster Recovery P lan | |||||
378 | Deploymen t Plan | |||||
379 | Release N otes | |||||
380 | ||||||
381 | 2.6.Functi onal Speci fications | |||||
382 | ||||||
383 | This enhan cement see ks to assi st the VAM Cs in obta ining time ly precert ification from third party pay ers before care is r endered by notifying the appro priate sta ff as soon as VA-pro vided outp atient ser vices requ iring prec ertificati on are sch eduled and authoriza tions are created in the VistA Fee Packa ge for inp atient or outpatient care. Thi s would al so provide an opport unity for | |||||
384 | ||||||
385 | insurance identifica tion/verif ication pr ocesses (e ither inte rnally or externally /outsource d) to be c ompleted p rior to tr eatment. | |||||
386 | ||||||
387 | An additio nal compon ent of thi s change w ill modify the exist ing PCRR t o include data eleme nts that w ould give the Billin g Staff th e informat ion needed to submit third par ty bills r elated to | |||||
388 | Non-VA car e in a mor e efficien t and time ly manner. The expec tation is that VA ca n reduce o r eliminat e these mi ssed oppor tunities a nd increas e its thir d party co llections by timely identifica tion and p recertific ation of c are. These enhanceme nts would not affect Veterans’ wait time s for trea tment at t he VA or N on-VA faci lities. Th e business processes benefitin g from the se tools w ould occur behind th e scenes a nd would n ot delay p atient car e. | |||||
389 | ||||||
390 | 2.6.1.Noti fication o f authoriz ed Fee Bas is care up on entry i nto | |||||
391 | VistA Fee Basis Pack age | |||||
392 | ||||||
393 | 2.6.1.1.Fu nctional r equirement FRPRE – 1 .1 | |||||
394 | ||||||
395 | The system shall not ify UR Nur ses and In surance Ve rification Clerks, v ia a workl ist when a n authoriz ation is c reated in the VistA Fee Basis package fo r Veterans with acti ve, billab le insuran ce (exclud ing Medica re only an d Medicare supplemen tal polici es). | |||||
396 | ||||||
397 | 2.6.1.2.Fu nctional R equirement FRPRE 1.1 .1.1 – 01 | |||||
398 | ||||||
399 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e name of the orderi ng physici an (NPI #, Taxonomy Code, Last Name, Fir st Name MI ). | |||||
400 | ||||||
401 | 2.6.1.3.Fu nctional R equirement FRPRE 1.1 .1.1 – 02 | |||||
402 | ||||||
403 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e Diagnosi s/Procedur e for serv ices autho rized in f ree text w ith unlimi ted charac ters. | |||||
404 | ||||||
405 | 2.6.1.4.Fu nctional R equirement FRPRE 1.1 .1.1 – 03 | |||||
406 | ||||||
407 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e schedule d date of service wh ich includ es date ra nges (MM/D D/YY). | |||||
408 | ||||||
409 | 2.6.1.5.Fu nctional R equirement FRPRE 1.1 .1.1 – 04 | |||||
410 | ||||||
411 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e name of Non-VA loc ation (may not be po pulated). | |||||
412 | ||||||
413 | 2.6.1.6.Fu nctional R equirement FRPRE 1.1 .1.1 – 05 | |||||
414 | ||||||
415 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes al l active i nsurance i nformation on file ( may includ e multiple insurance plans). | |||||
416 | ||||||
417 | 2.6.1.7.Fu nctional R equirement FRPRE 1.1 .1.1 – 06 | |||||
418 | ||||||
419 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e last dat e the insu rance was verified ( MM/DD/YY). | |||||
420 | ||||||
421 | 2.6.1.8.Fu nctional R equirement FRPRE 1.1 .1.1 – 07 | |||||
422 | ||||||
423 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or | |||||
424 | Veterans w ith active , billable insurance that incl udes the t ype of ser vice (inpa tient/outp atient). | |||||
425 | ||||||
426 | 2.6.1.9.Fu nctional R equirement FRPRE 1.1 .1.1 – 08 | |||||
427 | ||||||
428 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or Veteran s with act ive, billa ble insura nce that i ncludes th e existing service c onnected c onditions and specia l treatmen t authorit ies in fre e text (ma y be multi ple servic e connecte d conditio ns, must i nclude all ). | |||||
429 | ||||||
430 | 2.6.1.10. Functiona l Requirem ent FRPRE 1.1.1.1 – 09 | |||||
431 | ||||||
432 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or | |||||
433 | Veterans w ith active , billable insurance that incl udes outpa tient copa yment stat us. | |||||
434 | ||||||
435 | 2.6.1.11. Functiona l Requirem ent FRPRE 1.1.1.1 – 10 | |||||
436 | ||||||
437 | The system shall pro vide the a bility to generate a report in the VistA Fee Basis package f or | |||||
438 | Veterans w ith active , billable insurance that incl udes medic ation copa yment exem ption stat us. | |||||
439 | ||||||
440 | 2.6.1.12. Functiona l Requirem ent FRPRE 1.1.1.1 – 11 | |||||
441 | ||||||
442 | The system shall be able to us e contract numbers a s a parame ter when g enerating the pre- c ertificati on worklis t to filte r Choice P rogram con tract numb ers from t he worklis t. | |||||
443 | ||||||
444 | 2.6.2.Modi fication o f the exis ting PCRR to include the data elements n eeded to s ubmit time ly third p arty Fee B asis care related bi lls | |||||
445 | ||||||
446 | Ability to generate the existi ng PCRR wi th additio nal data e lements (F ee Basis C laims Syst em | |||||
447 | [FBCS] dat a elements available in VistA Fee) neede d to submi t a third party bill . | |||||
448 | ||||||
449 | 2.6.2.1.Fu nctional R equirement FRPRE 2.1 .1 – 01 | |||||
450 | ||||||
451 | The system shall pro vide the a bility to generate t he existin g PCRR wit h Station/ Facility/D ivision nu mber to su pport subm ission of a third pa rty bill. | |||||
452 | ||||||
453 | 2.6.2.2.Fu nctional R equirement FRPRE 2.1 .1 – 02 | |||||
454 | ||||||
455 | The system shall pro vide the a bility to generate t he existin g PCRR wit h type of service | |||||
456 | (inpatient /outpatien t/pharmacy ) to suppo rt submiss ion of a t hird party bill. | |||||
457 | ||||||
458 | 2.6.2.3.Fu nctional R equirement FRPRE 2.1 .1 – 03 | |||||
459 | ||||||
460 | The system shall pro vide the a bility to generate t he existin g PCRR wit h name of rendering physician to support submissio n of a thi rd party b ill (NPI # , Taxonomy Code, Las t Name, Fi rst Name M I). | |||||
461 | ||||||
462 | 2.6.2.4.Fu nctional R equirement FRPRE 2.1 .1 – 04 | |||||
463 | ||||||
464 | The system shall pro vide the a bility to generate t he existin g PCRR wit h name of ordering p hysician t o support submission of a thir d party bi ll (NPI #, Taxonomy Code, Last Name, Fir st Name MI ). | |||||
465 | ||||||
466 | 2.6.2.5.Fu nctional R equirement FRPRE 2.1 .1 – 05 | |||||
467 | ||||||
468 | The system shall pro vide the a bility to generate t he existin g PCRR wit h all avai lable | |||||
469 | Diagnosis/ Procedure data to su pport subm ission of a third pa rty bill. | |||||
470 | ||||||
471 | 2.6.2.6.Fu nctional R equirement FRPRE 2.1 .1 – 06 | |||||
472 | ||||||
473 | The system shall pro vide the a bility to generate t he existin g PCRR wit h dates of service ( start and end dates) to suppor t submissi on of a th ird party bill (MM/D D/YY). | |||||
474 | ||||||
475 | 2.6.2.7.Fu nctional R equirement FRPRE 2.1 .1 – 07 | |||||
476 | ||||||
477 | The system shall pro vide the a bility to generate t he existin g PCRR wit h name of Non-VA | |||||
478 | location t o support submission of a thir d party bi ll. | |||||
479 | ||||||
480 | 2.6.2.8.Fu nctional R equirement FRPRE 2.1 .1 – 08 | |||||
481 | ||||||
482 | The system shall pro vide the a bility to generate t he existin g PCRR wit h active/e ffective i nsurance i nformation on file a s of the d ate of ser vice to su pport subm ission of a third pa rty bill. | |||||
483 | ||||||
484 | 2.6.2.9.Fu nctional R equirement FRPRE 2.1 .1 – 09 | |||||
485 | ||||||
486 | The system shall pro vide the a bility to generate t he existin g PCRR wit h last dat e insuranc e was veri fied to su pport subm ission of a third pa rty bill ( MM/DD/YY). | |||||
487 | ||||||
488 | 2.6.2.10. Functiona l Requirem ent FRPRE 2.1.1 – 10 | |||||
489 | ||||||
490 | The system shall pro vide the a bility to generate t he existin g PCRR wit h existing service c onnected c onditions (if applic able), inc luding Spe cial Treat ment Autho rities, to support s ubmission of a third party bil l. | |||||
491 | ||||||
492 | 2.6.2.11. Functiona l Requirem ent FRPRE 2.1.1 – 11 | |||||
493 | ||||||
494 | The system shall pro vide the a bility to generate t he existin g PCRR wit h outpatie nt copayme nt status from the m ost recent Means Tes t adjudica tion resul ts (MT COP AY EXEMPT or MT COPA Y REQUIRED ) to suppo rt submiss ion of a t hird party bill. | |||||
495 | ||||||
496 | 2.6.2.12. Functiona l Requirem ent FRPRE 2.1.1 – 12 | |||||
497 | ||||||
498 | The system shall pro vide the a bility to generate t he existin g PCRR wit h medicati on copayme nt exempti on status (Medicatio n Copaymen t Exemptio n Status: EXEMPT or Medication Copayment Exemption Status: N ON-EXEMPT) to suppor t submissi on of a th ird party bill. | |||||
499 | ||||||
500 | 2.6.2.13. Functiona l Requirem ent FRPRE 2.1.1 – 13 | |||||
501 | ||||||
502 | The system shall pro vide the a bility to generate t he existin g PCRR wit h Indicato r signifyi ng whether or not th e Fee Basi s care rel ated episo de of care has been previously billed to a third p arty carri er, utiliz ing the ne w VistA Fe e Basis / IB / Claim s Tracking Interface File (to be develop ed as part of concur rent Fee R evenue Enh ancements project). Current cl aim data ( including corrected claims) wo uld be acc essed and reported, utilizing the new in terface fi le. | |||||
503 | ||||||
504 | 2.6.2.14. Functiona l Requirem ent FRPRE 2.1.1 – 13 .1 | |||||
505 | ||||||
506 | The system shall pro vide the a bility to indicate d ate billed and the a ssociated bill numbe r(s) if it has been billed pre viously ut ilizing th e new Vist A Fee Basi s / IB / C laims Trac king Inter face File (to be dev eloped as part of co ncurrent F ee Revenue Enhanceme nts projec t). | |||||
507 | ||||||
508 | 2.6.2.15. Functiona l Requirem ent FRPRE 2.1.1 – 14 | |||||
509 | ||||||
510 | The system shall pro vide the a bility to generate t he existin g PCRR wit h the abil ity to dis play the a uthorizati on number or precert ification number UR received f rom the in surance ca rrier. | |||||
511 | ||||||
512 | 2.6.2.16. Functiona l Requirem ent FRPRE 2.1.2 | |||||
513 | ||||||
514 | The system shall pro vide the a bility to generate t he existin g PCRR wit h ability to differe ntiate and sort the data on th is report by the 3 o r 5 digit station nu mber (tied to obliga tion numbe r) utilizi ng a quest ion/answer prompt at runtime. | |||||
515 | ||||||
516 | 2.6.2.17. Functiona l Requirem ent FRPRE 2.2.1 – 01 | |||||
517 | ||||||
518 | The system shall be able to di splay if t he Veteran has activ e, billabl e insuranc e (similar to the cu rrent Re-G enerate Un billed Amo unts Repor t [IBT RE- GEN UNBILL ED REPORT] ), include only Fee Basis care related e pisodes of care that have not been bille d to a thi rd party c arrier pre viously. | |||||
519 | ||||||
520 | 2.6.2.18. Functiona l Requirem ent FRPRE 2.2.1 – 02 | |||||
521 | ||||||
522 | The system shall be able to di splay the insurance effective date (MM/D D/YY). | |||||
523 | ||||||
524 | 2.6.2.19. Functiona l Requirem ent FRPRE 2.2.1 – 03 | |||||
525 | ||||||
526 | The system shall be able to di splay insu rance expi ration dat e (MM/DD/Y Y). | |||||
527 | ||||||
528 | 2.6.2.20. Functiona l Requirem ent FRPRE 2.2.1 – 04 | |||||
529 | ||||||
530 | The system shall be able to di splay if t reatment d ate falls within ins urance eff ective/exp iration da tes (MM/DD /YY). | |||||
531 | ||||||
532 | 2.6.2.21. Functiona l Requirem ent FRPRE 2.2.1 – 05 | |||||
533 | ||||||
534 | The system shall be able to di splay the authorizat ion number or precer tification number UR | |||||
535 | received f rom the in surance ca rrier. | |||||
536 | ||||||
537 | 2.7.Graphi cal User I nterface ( GUI) Speci fications | |||||
538 | ||||||
539 | This enhan cement doe s not invo lve a GUI. | |||||
540 | ||||||
541 | 2.8.Multi- divisional Specifica tions | |||||
542 | ||||||
543 | No new mul ti-divisio nal requir ements are being int roduced as part of t his enhanc ement. Thi s enhancem ent will u se existin g multi-di visional f unctionali ty and wil l continue to operat e in a mul ti-divisio n and/or m ulti-site environmen t. | |||||
544 | ||||||
545 | 2.9.Perfor mance Spec ifications | |||||
546 | ||||||
547 | No perform ance speci fications have been identified . | |||||
548 | ||||||
549 | It is impl ied that t his enhanc ement will not intro duce perfo rmance deg radation t o the exis ting syste m. | |||||
550 | ||||||
551 | 2.10. Qua lity Attri butes Spec ification | |||||
552 | ||||||
553 | The softwa re associa ted with t his enhanc ement shal l be relea sed with z ero high o r medium i mpact defe cts. Test defect log s will be submitted after inte rnal Quali ty Assuran ce (QA) an d site tes ting for V A review. | |||||
554 | ||||||
555 | MUMPS code developed for this project wi ll be comp liant to a ll VA MUMP S Coding S tandards a nd Convent ions. | |||||
556 | ||||||
557 | 2.11. Rel iability S pecificati ons | |||||
558 | ||||||
559 | As specifi ed in the BRD, syste m availabi lity shoul d be 24 ho urs per da y, 365 day s per year except du ring perio ds of sche duled main tenance. | |||||
560 | ||||||
561 | 2.12. Sco pe Integra tion | |||||
562 | ||||||
563 | This enhan cement wil l be limit ed to chan ges to the VistA Fee Basis and IB applic ations. Th is enhance ment will also provi de modific ations to the PCRR. | |||||
564 | ||||||
565 | 2.13. Sec urity Spec ifications | |||||
566 | ||||||
567 | There are no explici t security specifica tions stat ed for thi s enhancem ent. | |||||
568 | ||||||
569 | All VA and Veterans Health Adm inistratio n (VHA) se curity req uirements will be ad hered to. Cross-cutt ing securi ty require ments are contained in the VA Enterprise Requireme nts Reposi tory (ERR) . Efforts that invol ve the col lection an d maintena nce of ind ividually identifiab le informa tion must be covered by a Priv acy Act sy stem of re cords noti ce. | |||||
570 | ||||||
571 | 2.14. Sys tem Featur es | |||||
572 | ||||||
573 | This enhan cement mod ifies an e xisting Vi stA applic ation. | |||||
574 | ||||||
575 | The System Features introduced by this p roject are detailed in Section 2.6. | |||||
576 | ||||||
577 | 2.15. Usa bility Spe cification s | |||||
578 | ||||||
579 | The existi ng Fee Bas is interfa ce will be used for this enhan cement, in cluding ex isting usa bility spe cification s. The use r interfac e features of the ex isting Vis tA Fee Bas is Applica tion will not be mod ified, and therefore no perfor mance degr adation wi ll be intr oduced. | |||||
580 | ||||||
581 | Additional functiona lity will be describ ed from a user stand point in t he user gu ide. Train ing needed to begin using the new functi onality is expected to be mini mal. | |||||
582 | ||||||
583 | 3.Applicab le Standar ds | |||||
584 | ||||||
585 | Configurat ion Manage ment (CM) processes provide th e release and contro l of the s ystem, har dware, and software to which t his docume nt applies , includin g identifi cation num ber(s), ti tle(s), ab breviation (s), versi on number( s), and re lease numb er(s). | |||||
586 | ||||||
587 | Listed bel ow are VA reference and guidan ce documen tation and standards applicabl e to or ta ilored for the EDI P C Project. This guid ance is us ed to fulf ill the pe rformance requiremen ts of this contract. | |||||
588 | ||||||
589 | 44 U.S.C. § 3541, “ Federal In formation Security M anagement Act (FISMA ) of 2002” | |||||
590 | Federal I nformation Processin g Standard s (FIPS) P ublication 140-2, “S ecurity | |||||
591 | Requiremen ts For Cry ptographic Modules” | |||||
592 | Software Engineerin g Institut e, Softwar e Acquisit ion-Capabi lity Matur ity Modeli ng (SA- CM M) Level 3 procedure s and proc esses | |||||
593 | VA Direct ive 6102, “Internet/ Intranet S ervices,” July 15, 2 008 | |||||
594 | 36 C.F.R. Part 1194 “Electron ic and Inf ormation T echnology (IT) Acces sibility | |||||
595 | Standards, ” July 1, 2003 | |||||
596 | Office of Managemen t and Budg et (OMB) C ircular A- 130, “Mana gement of Federal | |||||
597 | Informatio n Resource s,” Novemb er 28, 200 0 | |||||
598 | 32 C.F.R. Part 199, “Civilian Health an d Medical Program of the Unifo rmed Servi ces | |||||
599 | (CHAMPUS)” | |||||
600 | An Introd uctory Res ource Guid e for Impl ementing t he Health Insurance Portabilit y and | |||||
601 | Accountabi lity Act ( HIPAA) Sec urity Rule , March 20 05 | |||||
602 | Sections 504 and 50 8 of the R ehabilitat ion Act (2 9 U.S.C. § 794d), as amended b y the | |||||
603 | Workforce Investment Act of 19 98 (P.L. 1 05-220), A ugust 7, 1 998 | |||||
604 | Homeland Security P residentia l Directiv e (12) (HS PD-12) | |||||
605 | VA Direct ive 6500, “Informati on Securit y Program, ” August 4 , 2006 | |||||
606 | VA Handbo ok 6500, “ Informatio n Security Program,” September 18, 2007 | |||||
607 | VA Handbo ok, 6500.5 , Incorpor ating Secu rity and P rivacy in System Dev elopment | |||||
608 | Lifecycle. | |||||
609 | VA Handbo ok 6500.6, “Contract Security, ” March 12 , 2010 | |||||
610 | PMAS port al (refere nce Perfor mance Work Statement [PWS] Ref erences – Technical | |||||
611 | Library) | |||||
612 | ||||||
613 | Office of Enterpris e Developm ent (OED) ProPath Pr ocess Meth odology (r eference P WS Referen ces) – Tec hnical Lib rary and P roPath Lib rary. Note : In the e vent of a conflict, OED ProPat h takes pr ecedence o ver other processes or methodo logies. | |||||
614 | TRM | |||||
615 | National Institute Standards and Techno logy (NIST ) Special Publicatio ns (SP) 80 0-60 and 8 00-53 | |||||
616 | IT Asset Management (ITAM) an d Enterpri se Managem ent Founda tion (EMF) BR-0006, version 00 2.1-140520 08, dated 10/30/2007 [Note inf ormational , Context, and ITAM- EMF Conce ptual link ] | |||||
617 | HIPAA of 1996; Pub. L 104-191. | |||||
618 | Patient P rotection and Afford able Care Act (PPACA ), Pub. L. 111-148, 124 Stat. 119, H.R. 3590, enac ted March 23, 2010 | |||||
619 | Prompt Pa yment Act | |||||
620 | The aim o f this pro ject is to make cert ain that t he EDI PC systems ar e complian t with the Committee on Operat ing Rules for Inform ation Exch ange (CORE ) Rules as published by Counci l for Affo rdable Qua lity Healt hcare (CAQ H) | |||||
621 | VA Sectio n 508 poli cies and p rocedures 6221 Acces sible Elec tronic and IT, Direc tive/Handb ook, publi shed by VA ’s Section 508 Produ ct Develop ment Produ ct Assessm ent Compet ency Divis ion | |||||
622 | VA MUMPS Programmin g Standard s and Conv entions. R evised 04/ 03/2007 | |||||
623 | VA Sectio n 508 poli cies and p rocedures 6221 Acces sible Elec tronic and IT, Direc tive/Handb ook, publi shed by VA ’s Section 508 Produ ct Develop ment Produ ct Assessm ent Compet ency Divis ion (refer ence at ht tp:// DNS /viewPubli cation.asp ?Pub_ID=43 5&FType=2) | |||||
624 | ||||||
625 | 4.Interfac es | |||||
626 | ||||||
627 | 4.1.Commun ications I nterfaces | |||||
628 | ||||||
629 | No new com munication s interfac es are req uired for this enhan cement. | |||||
630 | ||||||
631 | 4.2.Hardwa re Interfa ces | |||||
632 | ||||||
633 | No new com munication s interfac es are req uired for this enhan cement. | |||||
634 | ||||||
635 | 4.3.Softwa re Interfa ces | |||||
636 | ||||||
637 | No new sof tware inte rfaces are required for this e nhancement . | |||||
638 | ||||||
639 | These enha ncements w ill be mod ifications to the Vi sta Fee Ba sis and IB applicati ons but do n’t | |||||
640 | affect the Software Interfaces . | |||||
641 | ||||||
642 | 4.4.User I nterfaces | |||||
643 | ||||||
644 | This enhan cement wil l use the existing V istA Fee B asis roll and scroll user inte rface. No modificati ons are sp ecified to the user interface. | |||||
645 | ||||||
646 | 5.Legal, C opyright, and Other Notices | |||||
647 | ||||||
648 | This effor t is spons ored by an agency of the Unite d States G overnment. Neither t he United States Gov ernment no r any agen cy thereof , nor any of its sub contractor s, nor any of their employees, makes any warranty, express o r implied, or assume s any lega l liabilit y or respo nsibility for the ac curacy, co mpleteness , or usefu lness of a ny informa tion, appa ratus, pro duct, or p rocess dis closed, or represent s that its use would not infri nge on pri vately own ed rights. Reference | |||||
649 | herein to any specif ic commerc ial produc t, process , or servi ce by trad e name, tr ademark, m anufacture r, or othe rwise does not neces sarily con stitute or imply its endorseme nt, recomm endation, or favorin g by the U nited Stat es Governm ent or any agency th ereof, or any of its subcontra ctors. The views and opinions of authors expressed herein do not neces sarily sta te or refl ect those of the Uni ted States Governmen t or any a gency ther eof. | |||||
650 | ||||||
651 | 6.Purchase d Componen ts | |||||
652 | ||||||
653 | Not applic able. | |||||
654 | ||||||
655 | 6.1.Defect Source (T OP 5) | |||||
656 | ||||||
657 | Not applic able. | |||||
658 | ||||||
659 | 7.User Cla ss Charact eristics | |||||
660 | ||||||
661 | The modifi cations id entified i n this enh ancement a re primari ly used by UR Nurses , Insuranc e Verifica tion Clerk s, Billers and secon dary users ; Accounts Receivabl e Technici ans, Reven ue Manager s, and CBO Revenue O perations Staff. | |||||
662 | ||||||
663 | 8.Estimati on | |||||
664 | ||||||
665 | TBD. | |||||
666 | ||||||
667 | Project So ftware Fun ctional Si ze and Siz e-Based | |||||
668 | Effort and Duration Estimate | |||||
669 | ||||||
670 | ||||||
671 | Applicatio n | |||||
672 | ||||||
673 | Item | |||||
674 | A | |||||
675 | B | |||||
676 | C | |||||
677 | D | |||||
678 | E | |||||
679 | Total | |||||
680 | Counted Fu nction | |||||
681 | Points | |||||
682 | ||||||
683 | ||||||
684 | ||||||
685 | ||||||
686 | ||||||
687 | TBD | |||||
688 | Estimated Scope | |||||
689 | Growth | |||||
690 | ||||||
691 | ||||||
692 | ||||||
693 | ||||||
694 | ||||||
695 | TBD | |||||
696 | Estimated Size at | |||||
697 | Release | |||||
698 | ||||||
699 | ||||||
700 | ||||||
701 | ||||||
702 | ||||||
703 | TBD | |||||
704 | ||||||
705 | Size-Based Effort Es timates | |||||
706 | Labor Hour s | |||||
707 | Probabilit y | |||||
708 | Low-Effort Estimate – With ind icated pro bability, project wi ll consume no more t han: | |||||
709 | TBD | |||||
710 | ||||||
711 | High-Effor t Estimate – With in dicated pr obability, project w ill consum e no more than: | |||||
712 | TBD | |||||
713 | ||||||
714 | ||||||
715 | Size-Based Duration Estimates | |||||
716 | Work Days | |||||
717 | Probabilit y | |||||
718 | Low-Durati on Estimat e – With i ndicated p robability , project will consu me no more than: | |||||
719 | TBD | |||||
720 | ||||||
721 | High-Durat ion Estima te -- With indicated probabili ty, projec t will con sume no mo re than: | |||||
722 | TBD | |||||
723 | ||||||
724 | ||||||
725 | ||||||
726 | ||||||
727 | ||||||
728 | ||||||
729 | ||||||
730 | TBD | |||||
731 | Figure 1: Cumulative Probabili ty (“S-cur ve”) Chart | |||||
732 | ||||||
733 | Attachment A – Appro val Signat ures | |||||
734 | ||||||
735 | ||||||
736 | ||||||
737 | ||||||
738 | ||||||
739 | ||||||
740 | Signed:Dat e: | |||||
741 | ||||||
742 | Greg Estes | |||||
743 | Business S ponsor | |||||
744 | ||||||
745 | ||||||
746 | ||||||
747 | ||||||
748 | ||||||
749 | ||||||
750 | Signed:Dat e: | |||||
751 | ||||||
752 | Charles Du nn | |||||
753 | CPAC Progr am Manager , Integrat ed Project Team (IPT ) Co-Chair | |||||
754 | ||||||
755 | ||||||
756 | ||||||
757 | ||||||
758 | ||||||
759 | ||||||
760 | Signed:Dat e: | |||||
761 | ||||||
762 | Ann Kliegl | |||||
763 | CPAC Proje ct Manager , IPT Co-C hair | |||||
764 | ||||||
765 | Attachment B – Acron ym List an d Glossary | |||||
766 | ||||||
767 | Table 3: A cronym Lis t | |||||
768 | ||||||
769 | Term | |||||
770 | Definition | |||||
771 | BN | |||||
772 | Business N eed | |||||
773 | BRD | |||||
774 | Business R equirement s Document | |||||
775 | CAQH | |||||
776 | Council fo r Affordab le Quality Healthcar e | |||||
777 | CBO | |||||
778 | Chief Busi ness Offic e | |||||
779 | CCD | |||||
780 | Continuity of Care D ocument | |||||
781 | CHAMPUS | |||||
782 | Civilian H ealth and Medical Pr ogram of t he Uniform ed Service s | |||||
783 | CM | |||||
784 | Configurat ion Manage ment | |||||
785 | CORE | |||||
786 | Committee on Operati ng Rules f or Informa tion Excha nge | |||||
787 | CPAC | |||||
788 | Consolidat ed Patient Account C enter | |||||
789 | CPT | |||||
790 | Current Pr ocedural T erminology | |||||
791 | EDES | |||||
792 | Emergency Department Encounter Summary | |||||
793 | EDI | |||||
794 | Electronic Data Inte rchange | |||||
795 | EMF | |||||
796 | Enterprise Managemen t Foundati on | |||||
797 | ERR | |||||
798 | Enterprise Requireme nts Reposi tory | |||||
799 | FBCS | |||||
800 | Fee Basis Claims Sys tem | |||||
801 | FIPS | |||||
802 | Federal In formation Processing Standards | |||||
803 | FISMA | |||||
804 | Federal In formation Security M anagement Act | |||||
805 | GUI | |||||
806 | Graphical User Inter face | |||||
807 | HIPAA | |||||
808 | Health Ins urance Por tability a nd Account ability Ac t | |||||
809 | HITSP | |||||
810 | Health IT Standards Panel | |||||
811 | HSPD-12 | |||||
812 | Homeland S ecurity Pr esidential Directive (12) | |||||
813 | IB | |||||
814 | Integrated Billing | |||||
815 | ICD-9/10-C M | |||||
816 | Internatio nal Classi fication o f Diseases – Ninth R evision/Te nth | |||||
817 | Revision – Clinical Modificati on | |||||
818 | IHE | |||||
819 | Integratin g the Heal thcare Ent erprise | |||||
820 | IPT | |||||
821 | Integrated Project T eam | |||||
822 | IT | |||||
823 | Informatio n Technolo gy | |||||
824 | ITAM | |||||
825 | IT Asset M anagement | |||||
826 | MUMPS | |||||
827 | Massachuse tts Genera l Hospital Utility M ulti-Progr amming Sys tem | |||||
828 | ||||||
829 | ||||||
830 | Term | |||||
831 | Definition | |||||
832 | NIST | |||||
833 | National I nstitute S tandards a nd Technol ogy | |||||
834 | NPI | |||||
835 | National P rovider Id entifier | |||||
836 | OED | |||||
837 | Office of Enterprise Developme nt | |||||
838 | OI&T | |||||
839 | Office of Informatio n and Tech nology | |||||
840 | OMB | |||||
841 | Office of Management and Budge t | |||||
842 | OWNR | |||||
843 | Owner Requ irements | |||||
844 | PCRR | |||||
845 | Potential Cost Recov ery Report | |||||
846 | PMAS | |||||
847 | Program Ma nagement A ccountabil ity System | |||||
848 | PPACA | |||||
849 | Patient Pr otection a nd Afforda ble Care A ct | |||||
850 | PWS | |||||
851 | Performanc e Work Sta tement | |||||
852 | QA | |||||
853 | Quality As surance | |||||
854 | RMR | |||||
855 | Requiremen ts Managem ent Reposi tory | |||||
856 | RSD | |||||
857 | Requiremen ts Specifi cation Doc ument | |||||
858 | RSM | |||||
859 | Revenue Sy stems Mana gement | |||||
860 | SA-CMM | |||||
861 | Software A cquisition -Capabilit y Maturity Modeling | |||||
862 | SDS | |||||
863 | Standard D ata Servic es | |||||
864 | SP | |||||
865 | Special Pu blications | |||||
866 | TRM | |||||
867 | Technical Reference Model | |||||
868 | TSPR | |||||
869 | Technical Services P roject Rep ository | |||||
870 | UR | |||||
871 | Utilizatio n Review | |||||
872 | VA | |||||
873 | Department of Vetera ns Affairs | |||||
874 | VAMC | |||||
875 | Department of Vetera ns Affairs Medical C enter | |||||
876 | VETS | |||||
877 | VA Enterpr ise Termin ology Serv ices | |||||
878 | VHA | |||||
879 | Veterans H ealth Admi nistration | |||||
880 | VistA | |||||
881 | Veterans H ealth Info rmation Sy stems and Technology Architect ure | |||||
882 | ||||||
883 | Attachment C – Enter prise Requ irements | |||||
884 | ||||||
885 | Below is a subset of Enterpris e-level Re quirements that are of particu lar intere st to the business c ommunity. These requ irements M UST be add ressed wit hin each p roject res ulting fro m this wor k effort. If OI&T ca nnot addre ss these E nterprise- level requ irements, the Busine ss Owners responsibl e for each area MUST be engage d in any w aiver disc ussions pr ior to any decisions being mad e. This se ction is n ot meant t o be a com prehensive list of a ll Enterpr ise-level | |||||
886 | requiremen ts that ma y apply to this work effort an d should n ot preclud e the tech nical comm unity from reviewing all Enter prise-leve l requirem ents, and identifyin g others t hat should apply to this work effort as well. | |||||
887 | ||||||
888 | Enterprise -level req uirements are contai ned in the VA Requir ements Man agement Re pository ( RMR). Cont act the RM R Team to gain acces s to the R MR and to obtain the comprehen sive alloc ation of E nterprise- level requ irements f or the pro ject devel opment ite ration at PI I
|
|||||
889 | ||||||
890 | Table 4: E nterprise Requiremen ts | |||||
891 | ||||||
892 | ReqPro | |||||
893 | Tag | |||||
894 | Requiremen t | |||||
895 | Type | |||||
896 | Descriptio n | |||||
897 | ENTR99 | |||||
898 | Security | |||||
899 | All VA sec urity requ irements w ill be adh ered to. B ased on FI PS 199 and NIST SP 8 00-60, rec ommended S ecurity Ca tegorizati on is High . | |||||
900 | The Securi ty Categor ization wi ll drive t he initial set of mi nimal secu rity contr ols requir ed for the informati on system. Minimum s ecurity co ntrol requ irements a re address ed in NIST SP 800-53 and VA Ha ndbook 650 0, Appendi x D. | |||||
901 | ENTR10 | |||||
902 | Privacy | |||||
903 | All VA Pri vacy requi rements wi ll be adhe red to. Ef forts that involve t he collect ion and ma intenance of individ ually iden tifiable i nformation must be c overed by a Privacy Act system of record s notice. | |||||
904 | ENTR95 | |||||
905 | 508 Compli ance | |||||
906 | All Sectio n 508 requ irements w ill be adh ered to. C ompliance with Secti on 508 wil l be deter mined by f ully meeti ng the app licable re quirements as set fo rth in the VHA Secti on 508 che cklists (1 194.21, 11 94.22, 119 4.24, | |||||
907 | 1194.31 an d 1194.41) located a t: http:// DNS /508/resou rces_508.h tml
|
|||||
908 | ENTR7 | |||||
909 | Executive Order | |||||
910 | All execut ive order requiremen ts will be adhered t o. | |||||
911 | ENTR8 | |||||
912 | Identity | |||||
913 | Management | |||||
914 | All Enterp rise Ident ity Manage ment requi rements wi ll be adhe red to. Th ese requir ements are applicabl e to any a pplication that adds , updates, or perfor ms lookups on person s. | |||||
915 | ||||||
916 | ||||||
917 | ReqPro | |||||
918 | Tag | |||||
919 | Requiremen t | |||||
920 | Type | |||||
921 | Descriptio n | |||||
922 | ENTR103 | |||||
923 | Terminolog y | |||||
924 | Services | |||||
925 | Applicatio n/services shall ref erence the Standard Data Servi ces (SDS) as the aut horitative source to access no n- clinica l referenc e terminol ogy. | |||||
926 | ENTR104 | |||||
927 | Terminolog y | |||||
928 | Services | |||||
929 | Applicatio n/Services shall use the VA En terprise T erminology Services (VETS) as the author itative so urce to ac cess clini cal refere nce termin ology. | |||||
930 | ENTR105 | |||||
931 | Terminolog y | |||||
932 | Services | |||||
933 | Applicatio ns recordi ng the ass essments a nd care de livered in response to an Emer gency Depa rtment vis it shall c onform to standards defined by the VHA-e ndorsed ve rsion of C 28 – Heal th IT Stan dards Pane l (HITSP) Emergency Care Summa ry Documen t Using In tegrating the Health care Enter prise (IHE ) Emergenc y Departme nt Encount er Summary (EDES) Co mponent. | |||||
934 | ENTR106 | |||||
935 | Terminolog y | |||||
936 | Services | |||||
937 | Applicatio ns exchang ing data s ummarizing a patient ’s medical status sh all confor m to stand ards defin ed by the VHA-endors ed version of C 32 – HITSP Sum mary Docum ents Using Health Le vel Seven (HL7) Cont inuity of Care Docum ent (CCD) Component. | |||||
938 | ||||||
939 | Attachment D – Chang e Log | |||||
940 | ||||||
941 | Version | |||||
942 | Change | |||||
943 | Notes | |||||
944 | Status/Res olution | |||||
945 | 0.04 | |||||
946 | Modified f ormat and added requ irement. | |||||
947 | New Requir ement: 2.6 .1.12 – Ad d contract number pa rameter fo r Choice P rogram fil tering. | |||||
948 | ||||||
949 | ||||||
950 | 0.03 | |||||
951 | BN1 update d to read: “Appropri ate staff would be n otified of authorize d Fee Basi s care upo n entry an d/or updat e into the VistA Fee Basis Pac kage.” | |||||
952 | Accounts f or downstr eam depend encies wit h updates/ amendments to the in itial entr y. | |||||
953 | ||||||
954 | 0.03 | |||||
955 | BN1, F.1.1 . Updated to read: “ …when an a uthorizati on is crea ted and/or updated i n the Vist A Fee Basi s package… ” | |||||
956 | Accounts f or downstr eam depend encies wit h updates/ amendments to the in itial entr y. | |||||
957 | ||||||
958 | 0.03 | |||||
959 | BN1, F.1.1 .1.1 updat ed to incl ude: All a pplicable ICD-9/10 c odes | |||||
960 | Defining d ate of ser vice as el igibility range (Sta rt and End dates) | |||||
961 | Identifyin g Non-VA l ocation as | |||||
962 | ‘Vendor’ | |||||
963 | ||||||
964 | ||||||
965 | 0.03 | |||||
966 | BN2, F.2.1 .1: | |||||
967 | All data e lements in cluded in FBCS Requi red Field Listings f or VistA F ee_FBCS Ta ble Inclus ion.xlsx d ocument | |||||
968 | All applic able ICD-9 /10 codes | |||||
969 | Defining d ates of se rvice (Sta rt and End Dates) | |||||
970 | Identifyin g Non-VA l ocation as | |||||
971 | 'Vendor' | |||||
972 | Added in " All applic able provi der/facili ty NPI and taxonomy codes" | |||||
973 | ||||||
974 | ||||||
975 | 0.03 | |||||
976 | F2.1.2: “T ied to obl igation nu mber used to make th e payment” | |||||
977 | ||||||
978 |
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