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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Questions | CCRS Requirements Elaboration - Master File - Teams 1-8.docx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Questions | CCRS Requirements Elaboration - Master File - Teams 1-8.docx | Fri Jun 15 14:49:31 2018 UTC |
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1 | CCRS Requi rements El aboration Document – Master Fi le | |
2 | CCRS Requi rements El aboration Document – Master Fi le | |
3 | Teams 1-8 | |
4 | CCRS | |
5 | Teams 1-8 | |
6 | CCRS | |
7 | 2018 | |
8 | 2018 | |
9 | Contents | |
10 | Team 1 Ope n Question s2 | |
11 | Team 1 Ref erences2 | |
12 | Team 2 Ope n Question s2 | |
13 | Team 2 Ref erences3 | |
14 | Team 3 Ope n Question s3 | |
15 | Team 3 Ref erences3 | |
16 | Team 4 Ope n Question s4 | |
17 | Team 4 Ref erences6 | |
18 | Team 5 Ope n Question s6 | |
19 | Team 5 Ref erences7 | |
20 | Team 6 Ope n Question s7 | |
21 | Team 6 Ref erences:8 | |
22 | Team 7 Ope n Question s8 | |
23 | Team 7 Ref erences9 | |
24 | Team 8 Ope n Question s9 | |
25 | Team 8 Ref erences9 | |
26 | Appendix – Closed Qu estions10 | |
27 | Team 110 | |
28 | Team 210 | |
29 | Team 311 | |
30 | Team 411 | |
31 | Team 512 | |
32 | Team 612 | |
33 | Team 712 | |
34 | Team 813 | |
35 | ||
36 | Team 1 Ope n Question s | |
37 | ||
38 | Business U ser Story | |
39 | Question/A nswer | |
40 | Notes | |
41 | ClaimsStor y039 | |
42 | The team c urrently d oes not ha ve clear r equirement s regardin g resubmis sion, and it might d epend on r eal data b efore we c an create a rule for timely fi ling. Team 1 will ne ed to cont inue the c onversatio n regardin g how to m anage resu bmission. | |
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53 | ||
54 | Team 1 Ref erences | |
55 | Team 2 Ope n Question s | |
56 | Business U ser Story | |
57 | Question/A nswer | |
58 | Notes | |
59 | ||
60 | ||
61 | ||
62 | ||
63 | ||
64 | ||
65 | ||
66 | ||
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71 | ||
72 | Team 2 Ref erences | |
73 | Team 3 Ope n Question s | |
74 | ||
75 | Business U ser Story | |
76 | Question/A nswer | |
77 | Notes | |
78 | ||
79 | ||
80 | ||
81 | ||
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91 | Team 3 Ref erences | |
92 | ||
93 | ||
94 | ||
95 | ||
96 | Team 4 Ope n Question s | |
97 | ||
98 | Business U ser Story | |
99 | Question/A nswer | |
100 | Notes | |
101 | ClaimsStor y039 | |
102 | Date of Se rvice | |
103 | Several ru les depend on the no tion of a date of se rvice (tim ely filing , LEIE, va lid referr al). | |
104 | Currently, the follo wing dates are used as the dat e of servi ce: See ta ble 1 belo w | |
105 | Is the adm ission dat e the righ t date for instituti onal inpat ient? Arle en to foll ow up with Program I ntegrity C an a start date for a service be before the admiss ion date, esp. if a patient wa s admitted around mi dnight? | |
106 | What to us e as the d ate of ser vice for i nstitution al outpati ent? Line level serv ice date i s not requ ired for o utpatient. Use date of service – require d that bot h dates (s tatement t o and stat ement from ) be prese nt. Shadi proposed t he followi ng: | |
107 | If (Statem ent Date T o - Statem ent Date F rom >= 1), line leve l service_ date is re quired in source and will be p opulated a t F_INSTIT UTIONAL_ME DICAL_CLAI M_DETAILS. service_da te | |
108 | Else if (S tatement D ate To - S tatement D ate From = 0), line level serv ice_date i s not requ ired to be populated ....so an alternativ e field wo uld need t o be used here. | |
109 | What is th is other f ield? What about usi ng stateme nt dates f or all ins titutional as descri bed below? | |
110 | Instead of dealing w ith the he adache to discern wh ich field to use for each of t he differe nt Institu tional cla im sub-typ es, I reco mmend we p ropose to VA that we use eithe r the Stat ement From Date or S tatement T o Date for all Insti tutional c laims acro ss the boa rd. These are the re asons: 1) Statement From/To ar e required for all I nstitution al claims, 2) both d ates are s ufficientl y close to the Admit /Discharge /Line Leve l Service Date irres pective of which are populated , and 3) P rogram Int egrity has leaned on the State ment Date fields in Institutio nal duplic ate rule c hecks on P IT instead of servic e dates. | |
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112 | ||
113 | Arleen wil l follow u p with OPI regarding definitiv e service date to us e for inst itutional inpatient /outpatien t | |
114 | ||
115 | ClaimsStor y010 | |
116 | Claim Amou nt Thresho ld Rule | |
117 | ||
118 | We want to use servi ce date an d the effe ctive date of the th reshold am ount for t he rule? I .e., the t hreshold c heck would be based on the ser vice date. This will be consis tent with the LIEIE rule. Need clarifica tion from Sasha on t his questi on | |
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129 | ||
130 | Team 4 Ref erences | |
131 | ||
132 | Table 1: | |
133 | Type | |
134 | Line/claim Level? | |
135 | CCRSDB | |
136 | 837i/p/d | |
137 | Profession al | |
138 | Line | |
139 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS.ser vice_date_ from | |
140 | Date of Se rvice (Fro m) | |
141 | (Loop: 240 0, DTP03) | |
142 | Institutio nal inpati ent | |
143 | Claim | |
144 | DIM_INSTIT UTIONAL_CL AIM.admiss ion_date | |
145 | ||
146 | Admission Date | |
147 | (Loop: 230 0, DTP02) | |
148 | Institutio nal outpat ient | |
149 | Line | |
150 | F_INSTITUT IONAL_MEDI CAL_CLAIM_ DETAILS.se rvice_date | |
151 | ? | |
152 | Dental | |
153 | Claim | |
154 | F_DENTAL_C LAIM_DETAI LS.date_of _service | |
155 | ||
156 | ||
157 | ||
158 | Team 5 Ope n Question s | |
159 | ||
160 | Business U ser Story | |
161 | Question/A nswer | |
162 | Notes | |
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176 | Team 5 Ref erences | |
177 | Team 6 Ope n Question s | |
178 | ||
179 | Business U ser Story | |
180 | Question/A nswer | |
181 | Notes | |
182 | ClaimStory 027 | |
183 | [IPPS Invo ice, Fig 1 ] Addition ally on th e UI, the Date of Se rvice fiel d is requi red. The m ost recent version o f the IPPS Invoice d oes not in clude this field to collect da ta against this. Do we need t o add the Date of Se rvice fiel d back int o the IPPS Invoice? Justine to follow up with Kell ey Coleman – verify with Kelle y if invoi ce date an d date of service is the same | |
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195 | Team 6 Ref erences: | |
196 | ||
197 | Figure 1: | |
198 | ||
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203 | ||
204 | ||
205 | Team 7 Ope n Question s | |
206 | Business U ser Story | |
207 | Question/A nswer | |
208 | Notes | |
209 | ||
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221 | ||
222 | Team 7 Ref erences | |
223 | Team 8 Ope n Question s | |
224 | Business U ser Story | |
225 | Question/A nswer | |
226 | Notes | |
227 | ||
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229 | ||
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231 | ||
232 | ||
233 | ||
234 | ||
235 | ||
236 | ||
237 | ||
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239 | ||
240 | Team 8 Ref erences | |
241 | ||
242 | Appendix – Closed Qu estions | |
243 | Team 1 | |
244 | Business U ser Story | |
245 | Question/A nswer | |
246 | Notes | |
247 | ||
248 | ||
249 | ||
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259 | ||
260 | Team 2 | |
261 | Business U ser Story | |
262 | Question/A nswer | |
263 | Notes | |
264 | ClaimsStor y016 | |
265 | 2/5/18: Si nce a refe rral will not be pro vided for flu shots, what adju stments sh ould the C CRS team m ake to ens ure that e ligibility data is a vailable f or these f lu shot cl aims to en able third party rev enue recov ery? We won’t have a referra l for a fl u shot– it will come in on an 837 COB so we will k now if the re is any OHI. Check with Shad i regardin g what typ es of elig ibility da ta we get. Plan B fo r flu shot s: Send al l flu shot s to CFM t ool – no b ill them i f there is no eligib ility stat us, no cop ay require d or no in surance | |
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277 | Team 3 | |
278 | Business U ser Story | |
279 | Question/A nswer | |
280 | Notes | |
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294 | ||
295 | Team 4 | |
296 | Business U ser Story | |
297 | Question/A nswer | |
298 | Notes | |
299 | ClaimStory 039 | |
300 | Date of Se rvice | |
301 | 2/5/18: No te that Me dicare som etimes use s the "to" date: | |
302 | Medicare u ses the li ne item ‘F rom’ date to determi ne the dat e of servi ce for cla ims filing timelines s for clai ms submitt ed by heal th care pr ofessional s and supp liers that include s pan dates of service . (This in cludes Dur able Medic al Equipme nt (DME) s upplies an d rental i tems.) If a line ite m ‘From’ d ate is not timely bu t the ‘To’ date is t imely, con tractors m ust split the line i tem and de ny the unt imely serv ices as no t timely f iled. Perh aps we sho uld implem ent the sa me rule if it's cons idered ind ustry stan dard? DME should be using the date of s ervice the same inst itutional outpatient | |
303 | ||
304 | ClaimsStor y010 | |
305 | Claim Amou nt Thresho ld Rule | |
306 | ||
307 | 2/5/18: We currently set the s tatus to " approved" automatica lly after the 24-hou r period. Is it unco nditional? Yes What if VA need s more tim e to revie w? No - VA is not ge tting more time for review Sho uldn't it be integra ted with t he case ma nagement t ool? Send claims to CFM Tool f or 24 hour review, a nd if no a ction is t aken, clai m will aut omatically be paid, but record needs to be updated in workfl ow tool | |
308 | 2/5/18: Sh ould there be a sepa rate statu s for a de cision of the dollar threshold rule? Yes , status = under rev iew | |
309 | 2/5/18: If a claim e xceeds the threshold and is ac tively rej ected, wha t is the C ARC/RARC t hat we wou ld need to communica te back to the CCN? There is n o CARC/RAR C specific to exceed ing a high dollar am ount (thre shold) | |
310 | ||
311 | ||
312 | Initially, the thres hold rule to send cl aims to CF M is for r eview purp oses – a u ser has th e ability to reject it based o n some cri teria, but cannot be rejected for exceed ing the th reshold (i nitially) | |
313 | ||
314 | Determinin g Institut ional Outp atient Cla ims | |
315 | 2/5/18: CC RS current ly uses ad mission da te (dim_in stitutiona l_claim.ad mission_da te) as the indicator of an out patient cl aim. Is th is the bes t approach ? Yes | |
316 | ||
317 | ||
318 | ClaimsStor y039 | |
319 | Timely Fil ing | |
320 | 2/5/18: On e of the v alidations is to che ck for tim e since th e last sub mission. C urrently, we assume that resub mitted cla ims will h ave IDs in the forma t <claim I D>-<resubm ission num ber>. So w e check fo r the numb er after t he last da sh. If it exists, we assume th at the inv oice is a re-submiss ion. Is th is the rig ht logic? This assum es that th e networks cannot us e dashes i n their in voice IDs except whe n resubmit ting. Clai m frequenc y code wil l indicate a resubmi ssion. | |
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324 | “The Contr actor must always su bmit a cor rected inv oice that is identif ied by usi ng the pri or invoice number as the origi nal invoic e but cont ains a suf fix (e.g., Original Invoice Nu mber "-01" ) as the c orrected i nvoice.” | |
325 | ||
326 | ClaimsStor y030 | |
327 | Referral R ules | |
328 | 2/5/18: Ho w do we wa nt to trea t flu shot s that hav e a referr al? Use re ferral Sho uld we ign ore the re ferral dat es if the referral e xists? No – trust th e data on the referr al | |
329 | ||
330 | ||
331 | ClaimsStor y038 | |
332 | Payment Au thority | |
333 | 2/5/18: Fl u shot doe s not requ ire a refe rral. But if it come s with a r eferral, s hould we c heck the P A against the referr al or agai nst the PA obligatio n table? I f a flu sh ot is part of the re ferral, us e the paym ent author ity from t he referra l, for any thing else we will h ave a defa ult obliga tion numbe r for it. | |
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336 | ||
337 | Team 5 | |
338 | Business U ser Story | |
339 | Question/A nswer | |
340 | Notes | |
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354 | Team 6 | |
355 | Business U ser Story | |
356 | Question/A nswer | |
357 | Notes | |
358 | ClaimStory 027 | |
359 | 2.5.18: [I PPS Invoic e, Fig 1] Richard co nfirmed th at the Pur chase Orde r number i s the same as the Ob ligation N umber. How ever, the FMS OFS UI where Kel ley will b e uploadin g the IPPS Invoice i ndicates a Purchase Order numb er with 9 alpha-nume ric. Can w e confirm that we ca n use the Obligation Number of 6 alpha-n umeric cha racters in the PO Nu mber field of the UI ? No – The first 3 d igits (741 ) of the P O obligati on number are statio n ID. Obli gation num ber will b e specific to the CC N, but sta tion ID wi ll be the same | |
360 | ||
361 | ||
362 | ClaimStory 027 | |
363 | 2.5.18: [I PPS Invoic e] Can we confirm a schedule f or report generation such as d aily and i f there is a prefere nce for a time of re port gener ation? Pic k whatever works bes t for CCRS as long a s Kelley i s aware | |
364 | ||
365 | ClaimStory 027 | |
366 | 2.5.18: [I PPS Invoic e] Is ther e a prefer ence for a shared ac cess point where IPP S/CAR will access th e PDF IPPS Invoice? Possible s olution: F STP (sp?) drop zone – Kelley w ould be gi ven access to the sp ecific fol der she ne eds. | |
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369 | Team 7 | |
370 | Business U ser Story | |
371 | Question/A nswer | |
372 | Notes | |
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388 | Team 8 | |
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390 | Business U ser Story | |
391 | Question/A nswer | |
392 | Notes | |
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