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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b | CCRS BUSINESS RULES SPECIFICATION 2018-03-29.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 | CCRS BUSINESS RULES SPECIFICATION 2018-03-29.docx | Fri Jun 15 14:47:45 2018 UTC |
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1 | Business R ule Engine Specifica tion | |
2 | Community Care Reimb ursement S ystem | |
3 | Rule Speci fication D ocument | |
4 | ||
5 | ||
6 | ||
7 | March 2018 | |
8 | Version 3. 4 | |
9 | ||
10 | Department of Vetera ns Affairs | |
11 | ||
12 | ||
13 | ||
14 | Revision H istory | |
15 | ||
16 | Date | |
17 | Version | |
18 | Descriptio n | |
19 | Author | |
20 | 10/12/2017 | |
21 | 1.0 | |
22 | Initial Dr aft | |
23 | K. Phaup ( FTC) | |
24 | 11/20/2017 | |
25 | 2.0 | |
26 | Updated Ta ble 1: Rul es Invento ry | |
27 | Section 2. 2 Rules De tails | |
28 | Rule 001 – Deactivat ed OHI con dition and rule acti ons; updat ed rule at tributes; added 30 d ay timely filing req uirement f or previou sly reject ed or deni ed claims; separated Outpatien t claims f rom Inpati ent claims by design ating Rule 001a and R ule001b | |
29 | Rule 002 – Added des cription, attributes and condi tions | |
30 | Rule 003 – updated d escription and rule attributes to captur e that ref erral must be active at date o f service and flu sh ot excepti ons | |
31 | Rule 004 – descripti on, rules attributes and | |
32 | Rule 005 – descripti on updated to captur e dates of service m ust be wit hin the da tes of ser vice speci fied in th e Referral ; updated to reflect that clai m lines mu st be matc hed agains t the refe rral activ e at the t ime of the initial r eferral | |
33 | Rule 008 – new rule, Payment A uthority | |
34 | J. Lucas ( GT) | |
35 | 12/28/17 | |
36 | 3.0 | |
37 | Section 2. 1 Rules In ventory, R ule 006, D uplicates – Separate d Professi onal, Dent al, and Ph armaceutic al Claims as 006a fr om Institu tional Cla ims as 006 b | |
38 | Section 2. 2 Rules De tails, Rul e 006a, Du plicates – Professio nal, Denta l, and Pha rmaceutica l: Updated rule to n ot use ren dering inf o to ident ify duplic ates | |
39 | Section 2. 2 Rules De tails, Rul e006b, Dup licates – Institutio nal: Upda ted rule t o check fo r duplicat es using i nstitution (billing) and elimi nate the r endering f ield | |
40 | J. Lucas ( GT) | |
41 | 1/3/18 | |
42 | 3.1 | |
43 | Section 2. 1 Rules In ventory, R ule 002, T hreshold – Separated Rule into 4 differe nt rules f or each in voice type | |
44 | J. Lucas ( GT) | |
45 | 1/24/18 | |
46 | 3.2 | |
47 | Section 2. 2 Rules De tails, Rul e 008 Paym ent Author ity – Elab orated rul e to match payment a uthority c ontained i n claim li ne with an obligatio n number | |
48 | Section 2. 2. Rules D etails, Ru le 009 | |
49 | J. Lucas ( GT) | |
50 | 3/22/2018 | |
51 | 3.3 | |
52 | Updated se ction 2.2. 7, and add ed 2.2.9 a nd 2.2.10 | |
53 | Imani Port er (GT) | |
54 | 3/26/2018 | |
55 | 3.4 | |
56 | Updated a few sectio ns and add ed 2.2.11 | |
57 | Imani Port er (GT) | |
58 | ||
59 | ||
60 | Table of C ontents | |
61 | ||
62 | ||
63 | 1.Introduc tion4 | |
64 | 2.Rule Det ail5 | |
65 | 2.1Rules I nventory5 | |
66 | 2.2Rules D etails5 | |
67 | 3.Rule Set s7 | |
68 | 3.1If-then Rule Sets 7 | |
69 | 3.2Decisio n Tables7 | |
70 | 3.3Decisio n Trees7 | |
71 | 3.4Rule Fl ows7 | |
72 | 4.Rules Im plementati on8 | |
73 | 4.1Develop ment of th e Rules Su bsystem8 | |
74 | 4.2Integra tion of th e Rules Su bsystem8 | |
75 | ||
76 | Introducti on | |
77 | ||
78 | CCRS is a payment pr ocessing s ystem, whi ch will ha ndle the a utomation of process ing invoic es from va lidation t o payment including the verifi cation of payment ac curacy of the invoic es submitt ed by the Contracted Community Care Netw orks (CCNS ). The Sy stem will generate a ccurate re imbursemen t payments according to the co ntract or appropriat e fee sche dule to th e contract ed entitie s, to auto mate and f acilitate post payme nt audit a ctivities for reimbu rsements a nd to auto mate and f acilitate revenue op eration ac tivities s uch as app licable da ta from ED I Transmis sion (837) Coordinat ion of Ben efits (COB ) informat ion for th ird party billing an d first pa rty copaym ent liabil ity determ ination. | |
79 | ||
80 | This docum ent identi fied the r ules, rule sets, rul e-flows, r ule constr aints, bus iness obje ct models, and all o ther attri butes rela ted to the CCRS Busi ness Rule Engine’s r ule design and imple mentation. | |
81 | ||
82 | ||
83 | Rule Detai l | |
84 | Rules Inve ntory | |
85 | This table is a cons olidated l ist of imp lemented r ules withi n the appl ication. C olumns ide ntify high -level rul e applicab ility to w hich categ ory of cla ims, the a ssociated BOM entry associatio ns, as wel l as a des cription o f what the rule will accomplis h. | |
86 | ||
87 | RULE # | |
88 | RULE | |
89 | RULE DESCR IPTION | |
90 | CATEGORY | |
91 | BUSINESS O BJECTS | |
92 | 001a | |
93 | Timely Fil ing Outpat ient | |
94 | Outpatient claims ar e submitte d within a llowed tim eframe fro m date of service | |
95 | Profession al, Instit utional Ou tpatient, | |
96 | Dental | |
97 | ClaimLine | |
98 | Claim | |
99 | 001b | |
100 | Timely Fil ing Inpati ent | |
101 | Inpatient claims are submitted within th e allowed time frame from date of discha rge | |
102 | Institutio nal Inpati ent | |
103 | ClaimLine, Claim | |
104 | 002a | |
105 | Claim Amou nt Thresho ld - Profe ssional | |
106 | Claims tha t exceed a customiza ble thresh old are fl agged for audit and held for 2 4 hours | |
107 | Profession al | |
108 | ||
109 | Claim | |
110 | 002b | |
111 | Claim Amou nt Thresho ld - Insti tutional | |
112 | Claims tha t exceed a customiza ble thresh old are fl agged for audit and held for 2 4 hours | |
113 | Institutio nal | |
114 | ||
115 | Claim | |
116 | 002c | |
117 | Claim Amou nt Thresho ld – Denta l | |
118 | Claims tha t exceed a customiza ble thresh old are fl agged for audit and held for 2 4 hours | |
119 | Dental | |
120 | Claim | |
121 | 003 | |
122 | Referrals | |
123 | Claim line s have a m atching re ferral | |
124 | Profession al, Instit utional, | |
125 | Dental | |
126 | ClaimLine | |
127 | 004 | |
128 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE) | |
129 | Claim line CCN provi ders were not in the LEIE duri ng the dat e of servi ce | |
130 | Profession al, Instit utional, | |
131 | Dental | |
132 | ClaimLine | |
133 | Claim | |
134 | 005 | |
135 | Dates of S ervice | |
136 | Claim line service w as provide d within t he dates o f service specified by the ref erral | |
137 | Profession al, Instit utional, | |
138 | Dental | |
139 | ClaimLine, | |
140 | Claim | |
141 | 006a | |
142 | Duplicates – Profess ional and Dental | |
143 | Claim line is not a duplicate of another claim lin e submitte d within t he claim o r within a previous claim that was not s et to reje cted or de nied | |
144 | Profession al, | |
145 | Dental | |
146 | ClaimLine, Claim | |
147 | ||
148 | 006b | |
149 | Duplicates - Institu tional | |
150 | Claim line is not a duplicate of another claim lin e submitte d within t he claim o r within a previous claim that was not s et to reje cted or de nied | |
151 | Institutio nal | |
152 | ClaimLine, Claim | |
153 | 007a | |
154 | Standardiz ed Episode of Care ( SEOC) | |
155 | Service pr ovided wit hin the cl aim line i s included within th e SEOC | |
156 | Profession al, Instit utional, D ental | |
157 | ClaimLine | |
158 | 007b | |
159 | Standardiz ed Episode of Care ( SEOC) | |
160 | CCRS must validate q uantity an d threshol d in 837CO B match CC RA | |
161 | Profession al, Instit utional, D ental | |
162 | ClaimLine | |
163 | 008a | |
164 | Payment Au thority | |
165 | CCRS must validate p ayment aut hority for referral to payment authority in the 83 7COB | |
166 | Profession al, Instit utional, D ental | |
167 | ClaimLine, Claim | |
168 | 008b | |
169 | Payment Au thority | |
170 | CCRS must validate p ayment aut hority for 837COB to CCRS refe rence tabl e. | |
171 | Profession al, Instit utional, D ental | |
172 | ClaimLine, Claim | |
173 | 009 | |
174 | Provider | |
175 | CCRS must validate s ervices pr ovided by the provid er via PPM S feed mat ch the 837 invoice c laims | |
176 | Profession al, Instit utional, D ental | |
177 | ClaimLine | |
178 | 010 | |
179 | Billed Adm inistrativ e Charge | |
180 | CCRS must the activi ty, sorted by CLIN o n the PMPM report, m atches the line item s in our d atabases | |
181 | Profession al, Instit utional, D ental | |
182 | ClaimLine | |
183 | 011 | |
184 | ICN | |
185 | CCRS must validate t he ICN in CCRA refer ral to ICN in 837 in voice clai ms. | |
186 | Profession al, Instit utional, D ental | |
187 | ClaimLine | |
188 | Rules Inve ntory | |
189 | ||
190 | ||
191 | The corres ponding ru le details are captu red in the next sect ion. | |
192 | ||
193 | Rules Deta ils | |
194 | This secti on provide s all the details re quired for implement ation of t he rules f unctionali ty. These details he lp define the rule p arameters and rule m eta-data w hich is us ed to defi ne the imp lementatio n logic in the secti ons below. | |
195 | ||
196 | The follow ing table describes the variou s rule pro perties su ch as cond itions, ac tions, att ributes, e tc. that a re require d to imple ment the r ule. | |
197 | ||
198 | Timely Fil ing | |
199 | RULE # | |
200 | RULE NAME | |
201 | DATE LAST MODIFIED | |
202 | 001a | |
203 | Timely Fil ing Outpat ient | |
204 | 11/20/2017 | |
205 | Rule Descr iption | |
206 | Verify the invoice c laim is re ceived wit hin the ti mely filin g period, so that th e claim is accepted if the dat e of servi ce is with in the pre -defined p eriod of t ime and de nied if it is not wi thin the p re-defined period of time. | |
207 | Rule Attri butes | |
208 | IF the inv oice claim line “Dat e of servi ce” is ove r 180 days over the “Claim Rec eived Date ” | |
209 | THEN claim line reco rd is anno tated as D enied incl uding the appropriat e CARC/RAR C reason | |
210 | Rule Condi tions | |
211 | Always den y claims n ot submitt ed within one hundre d eighty ( 180) days from the d ate of ser vice for p assing the timely fi ling deadl ine. | |
212 | Condition Deactivate d: Always grant add itional ti me to the claims fil ing deadli ne require ments for Veterans w ith OHI wh en the pro vider firs t submitte d the clai m to the p rimary pay er, and th e adjudica tion occur red past t he VA fili ng deadlin e. The Con tractor mu st always ensure cla ims for se rvices den ied by ano ther insur er include the Expla nation of Benefits ( EOB) or re mittance a dvice (RA) statement indicatin g the date s of servi ce, amount of the cl aim, and r eason(s) f or denial. The Contr actor must always de ny all OHI claims su bmitted be yond ninet y (90) day s from the date of t he other i nsurer’s a djudicatio n. | |
213 | If an invo ice or cla im line is denied or rejected, the CCN h as 30 days from the date of re jection or denial to resubmit the correc ted invoic e | |
214 | Rule Actio ns | |
215 | When the c laim is re ceived it will show the claime d service was perfor med within the autho rized epis ode of car e | |
216 | If the “Da te of serv ice” is 18 0 DAYS ON OR BEFORE the "Claim Received Date", THE N status o f the clai m is set t o ACCEPT. | |
217 | If the “Cl aim Receiv ed Date” i s 30 days ON OR BEFO RE CCN not ification of a rejec ted or den ied invoic e or claim , THEN sta tus of the claim is set to ACC EPT. | |
218 | Deactivate d: If the “Admit Dat e” or “Fir st date of service” is 90 DAYS ON OR BEF ORE the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to AC CEPT. | |
219 | If the “da te of serv ice” is 18 1 DAYS ON OR AFTER t he "Claim Received D ate", THEN status of the claim is set to DENIED fo r Timely F iling (TF) . | |
220 | Deactivate d: If the “Admit Dat e” OR “Fir st date of service” is 91 DAYS ON AFTER the "Claim Received Date from VA COB", T HEN status of the cl aim is set to DENIED for Timel y Filing ( TF). | |
221 | When DENYI NG a claim the syste m will rec ord a reas on code wi thin indus try standa rds with t he denial descriptio n on the c ommunicati on transmi tted back to the con tractor fo r correcti on and res ubmittal. | |
222 | ||
223 | RULE # | |
224 | RULE NAME | |
225 | DATE LAST MODIFIED | |
226 | 001b | |
227 | Timely Fil ing Inpati ent | |
228 | 11/20/2017 | |
229 | Rule Descr iption | |
230 | Verify the invoice c laim is re ceived wit hin the ti mely filin g period, so that th e claim is accepted if the dat e of servi ce is with in the pre -defined p eriod of t ime and de nied if it is not wi thin the p re-defined period of time. | |
231 | Rule Attri butes | |
232 | IF the inv oice claim line “Dat e of Disch arge” is o ver 180 da ys over th e “Claim R eceived Da te” | |
233 | THEN claim line reco rd is anno tated as D enied incl uding the appropriat e CARC/RAR C reason | |
234 | Rule Condi tions | |
235 | Always den y claims n ot submitt ed within one hundre d eighty ( 180) days from the d ate of dis charge for passing t he timely filing dea dline. | |
236 | Condition Deactivate d: Always grant add itional ti me to the claims fil ing deadli ne require ments for Veterans w ith OHI wh en the pro vider firs t submitte d the clai m to the p rimary pay er, and th e adjudica tion occur red past t he VA fili ng deadlin e. The Con tractor mu st always ensure cla ims for se rvices den ied by ano ther insur er include the Expla nation of Benefits ( EOB) or re mittance a dvice (RA) statement indicatin g the date s of servi ce, amount of the cl aim, and r eason(s) f or denial. The Contr actor must always de ny all OHI claims su bmitted be yond ninet y (90) day s from the date of t he other i nsurer’s a djudicatio n. | |
237 | If an invo ice or cla im line is denied or rejected, the CCN h as 30 days from the date of re jection or denial to resubmit the correc ted invoic e | |
238 | Rule Actio ns | |
239 | When the c laim is re ceived it will show the claime d service was perfor med within the autho rized epis ode of car e | |
240 | If the “Da te of Disc harge” is 180 DAYS O N OR BEFOR E the "Cla im Receive d Date", T HEN status of the cl aim is set to ACCEPT . | |
241 | If the “Cl aim Receiv ed Date” i s 30 days ON OR BEFO RE CCN not ification of a rejec ted or den ied invoic e or claim , THEN sta tus of the claim is set to ACC EPT. | |
242 | Deactivate d: If the “Admit Dat e” or “Fir st date of service” is 90 DAYS ON OR BEF ORE the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to AC CEPT. | |
243 | If the “Di scharge Da te” is 181 DAYS ON O R AFTER th e "Claim R eceived Da te", THEN status of the claim is set to DENIED for Timely Fi ling (TF). | |
244 | Deactivate d: If the “Admit Dat e” OR “Fir st date of service” is 91 DAYS ON AFTER the "Claim Received Date from VA COB", T HEN status of the cl aim is set to DENIED for Timel y Filing ( TF). | |
245 | When DENYI NG a claim the syste m will rec ord a reas on code wi thin indus try standa rds with t he denial descriptio n on the c ommunicati on transmi tted back to the con tractor fo r correcti on and res ubmittal. | |
246 | ||
247 | Claim Amou nt Thresho ld | |
248 | RULE # | |
249 | RULE NAME | |
250 | DATE LAST MODIFIED | |
251 | 002a | |
252 | Claim Amou nt Thresho ld -Profes sional | |
253 | 01/03/2018 | |
254 | Rule Descr iption | |
255 | Verify the invoice t otal does not exceed a customi zable thre shold, so that the c laim is ac cepted if the invoic e total do es not exc eed the th reshold an d suspende d for manu al review if it exce eds the th reshold fo r 24 hours . If no a ction is t aken withi n 24 hours , then acc ept invoic e. If an invoice ex aminer rev iews and d etermines the invoic e should n ot be paid , then pro cess the i nvoice as denied. | |
256 | Rule Attri butes | |
257 | IF the inv oice claim total exc eeds custo mizable th reshold | |
258 | THEN the c laim line record is annotated as ‘Pendin g Review’ | |
259 | IF no furt her action is taken within 24 hours | |
260 | THEN accep t invoice for reimbu rsement | |
261 | OR | |
262 | IF an invo ice examin er reviews the invoi ce and det ermines th e invoice should not be paid | |
263 | THEN all c laim line records ar e annotate d as ‘Deni ed’ includ ing the ap propriate CARC/RARC reason | |
264 | Rule Condi tions | |
265 | Invoices t hat total exceeds th e customiz able thres hold are a nnotated a s ‘Pending Review’ a nd held fo r 24 hours | |
266 | If no furt her action is taken after a 24 hour hold , the clai m lines ar e approved for reimb ursement | |
267 | Invoices t hat are de termined b y an invoi ce examine r during t he 24-hour hold to n ot be paid should be annotated as denied . | |
268 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
269 | Rule Actio ns | |
270 | Invoices t hat total exceeds th e customiz able thres hold are a nnotated a s ‘Pending Review’ a nd held fo r 24 hours | |
271 | If no furt her action is taken after a 24 hour hold , the clai m lines ar e approved for reimb ursement | |
272 | Invoices t hat are de termined b y an invoi ce examine r during t he 24-hour hold to n ot be paid should be annotated as denied . | |
273 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
274 | ||
275 | RULE # | |
276 | RULE NAME | |
277 | DATE LAST MODIFIED | |
278 | 002b | |
279 | Claim Amou nt Thresho ld - Insti tutional | |
280 | 01/03/2018 | |
281 | Rule Descr iption | |
282 | Verify the invoice t otal does not exceed a customi zable thre shold, so that the c laim is ac cepted if the invoic e total do es not exc eed the th reshold an d suspende d for manu al review if it exce eds the th reshold fo r 24 hours . If no a ction is t aken withi n 24 hours , then acc ept invoic e. If an invoice ex aminer rev iews and d etermines the invoic e should n ot be paid , then pro cess the i nvoice as denied. | |
283 | Rule Attri butes | |
284 | IF the inv oice claim total exc eeds custo mizable th reshold | |
285 | THEN the c laim line record is annotated as ‘Pendin g Review’ | |
286 | IF no furt her action is taken within 24 hours | |
287 | THEN accep t invoice for reimbu rsement | |
288 | OR | |
289 | IF an invo ice examin er reviews the invoi ce and det ermines th e invoice should not be paid | |
290 | THEN all c laim line records ar e annotate d as ‘Deni ed’ includ ing the ap propriate CARC/RARC reason | |
291 | Rule Condi tions | |
292 | Invoices t hat total exceeds th e customiz able thres hold are a nnotated a s ‘Pending Review’ a nd held fo r 24 hours | |
293 | If no furt her action is taken after a 24 hour hold , the clai m lines ar e approved for reimb ursement | |
294 | Invoices t hat are de termined b y an invoi ce examine r during t he 24-hour hold to n ot be paid should be annotated as denied . | |
295 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
296 | Rule Actio ns | |
297 | ||
298 | ||
299 | RULE # | |
300 | RULE NAME | |
301 | DATE LAST MODIFIED | |
302 | 002c | |
303 | Claim Amou nt Thresho ld - Denta l | |
304 | 01/03/2018 | |
305 | Rule Descr iption | |
306 | Verify the invoice t otal does not exceed a customi zable thre shold, so that the c laim is ac cepted if the invoic e total do es not exc eed the th reshold an d suspende d for manu al review if it exce eds the th reshold fo r 24 hours . If no a ction is t aken withi n 24 hours , then acc ept invoic e. If an invoice ex aminer rev iews and d etermines the invoic e should n ot be paid , then pro cess the i nvoice as denied. | |
307 | Rule Attri butes | |
308 | IF the inv oice claim total exc eeds custo mizable th reshold | |
309 | THEN the c laim line record is annotated as ‘Pendin g Review’ | |
310 | IF no furt her action is taken within 24 hours | |
311 | THEN accep t invoice for reimbu rsement | |
312 | OR | |
313 | IF an invo ice examin er reviews the invoi ce and det ermines th e invoice should not be paid | |
314 | THEN all c laim line records ar e annotate d as ‘Deni ed’ includ ing the ap propriate CARC/RARC reason | |
315 | Rule Condi tions | |
316 | Invoices t hat total exceeds th e customiz able thres hold are a nnotated a s ‘Pending Review’ a nd held fo r 24 hours | |
317 | If no furt her action is taken after a 24 hour hold , the clai m lines ar e approved for reimb ursement | |
318 | Invoices t hat are de termined b y an invoi ce examine r during t he 24-hour hold to n ot be paid should be annotated as denied . | |
319 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
320 | Rule Actio ns | |
321 | Invoices t hat total exceeds th e customiz able thres hold are a nnotated a s ‘Pending Review’ a nd held fo r 24 hours | |
322 | If no furt her action is taken after a 24 hour hold , the clai m lines ar e approved for reimb ursement | |
323 | Invoices t hat are de termined b y an invoi ce examine r during t he 24-hour hold to n ot be paid should be annotated as denied . | |
324 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
325 | ||
326 | Referrals | |
327 | RULE # | |
328 | RULE NAME | |
329 | DATE LAST MODIFIED | |
330 | 003 | |
331 | Referrals | |
332 | 11/20/2017 | |
333 | Rule Descr iption | |
334 | Automatica lly match invoices t o existing active re ferrals wi thin CCRS, so only m atched inv oices are processed. Deny inv oices that have no m atching re ferral or if the ref erral is n o longer a ctive, so that denia ls can be stored and communica ted. Appr ove invoic es that do not inclu de referra l numbers if the ser vice provi ded was a flu shot. | |
335 | Rule Attri butes | |
336 | IF a claim line is n ot for a f lu shot in dicated by a CPT cod e of ‘G000 8’, ‘90658 ’, ‘90656’ , or ‘9066 2’ | |
337 | AND referr al number of the cla im line do es not mat ch an exis ting activ e referral number du ring the d ate of ser vicef | |
338 | THEN annot ate databa se record as denied within app ropriate C ARC/RARC r eason | |
339 | Rule Condi tions | |
340 | Invoices t hat do not contain a flu shot CPT code a nd do not match an a ctive refe rral shoul d be annot ated as de nied. | |
341 | Invoices t hat do not contain a flu shot CPT code a nd do not match a re ferral sho uld includ e a reason for denia l from a s tandard li st (CARC/R ARC). | |
342 | Rule Actio ns | |
343 | When the s ystem rece ives the r eimburseme nt invoice it needs to be matc hed to exi sting refe rral unles s CPT code indicates a flu sho t | |
344 | When the s ystem rece ives a cla im line wi thout a re ferral wit h a CPT co de indicat ing a flu shot it is processed and the s ystems sho ws the pay ment appro ved | |
345 | When the s ystem matc hed the in voice with referral it is proc essed and the system shows the payment a pproved | |
346 | When the s ystem rece ives the r eimburseme nt invoice with no m atching ex isting ref erral, it will be re jected unl ess the CP T code ind icates a f lu shot | |
347 | When the s ystem does n't match the invoic e with ref erral it i s processe d with a r ejected st atus | |
348 | When the s ystem does n't match the invoic e with ref erral it i s added to exception s report | |
349 | When the r eimburseme nt invoice is reject ed it will list the rejections reason wi thin the e xception r eport | |
350 | Only valid ated claim invoices will be st ored in th e CCRS Rep ository | |
351 | ||
352 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE) | |
353 | RULE # | |
354 | RULE NAME | |
355 | DATE LAST MODIFIED | |
356 | 004 | |
357 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE) | |
358 | 11/20/17 | |
359 | Rule Descr iption | |
360 | Verify the provider is not on the LEIE, so that th e claim is accepted if the pro vider of s ervice is not includ ed in the LEIE and d enied if t he provide r of servi ce is incl uded in th e LEIE. | |
361 | In process of furthe r elaborat ion to ide ntify if t he LEIE ed iting rule will be v alidating if the pro vider was on the LEI E at the d ate of ref erral or i f the prov ider was o n the LEIE at the da te of serv ice | |
362 | Rule Attri butes | |
363 | CCR&A | |
364 | Rule Condi tions | |
365 | ||
366 | Rule Actio ns | |
367 | ||
368 | ||
369 | Dates of S ervice | |
370 | RULE # | |
371 | RULE NAME | |
372 | DATE LAST MODIFIED | |
373 | 005 | |
374 | Dates of S ervice | |
375 | 11/21/2017 | |
376 | Rule Descr iption | |
377 | Automatica lly proces s the invo ices using the requi red data e lements wi thin the m atching ac tive refer ral to val idate the invoice is within th e dates of service s pecified w ithin the current re ferral | |
378 | Rule Attri butes | |
379 | IF the inv oice claim line does not fall within the dates of service in dicated wi thin the m atching ac tive refer ral | |
380 | THEN annot ate databa se record as denied with appro priate CAR C/RARC rea son | |
381 | Rule Condi tions | |
382 | The date o f service must be ma tched with the refer ral active at the ti me of the initial re ferral | |
383 | The date o f service must fall within the matching referral. | |
384 | Invoices t hat are no t within t he dates o f service should be annotated as denied. | |
385 | Invoices t hat are no t within t he dates o f service should inc lude a rea son for de nial from a standard list (CAR C/RARC). | |
386 | Rule Actio ns | |
387 | When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, it w ill displa y as valid ated if it is within the dates of servic e | |
388 | When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, if it is not wi thin the d ates of se rvice of t he referra l, validat ion will l ist a deni ed status | |
389 | ||
390 | Duplicates | |
391 | RULE # | |
392 | RULE NAME | |
393 | DATE LAST MODIFIED | |
394 | 006a | |
395 | Duplicates – Profess ional, Den tal | |
396 | 03/26/2018 | |
397 | Rule Descr iption | |
398 | Automatica lly identi fy the dup licate lin e item sub mitted wit hin the co ntracted r eimburseme nt invoice using the unique co mbination of invoice line data so that i mproper pa yments can be preven ted. | |
399 | Rule Attri butes | |
400 | IF claim l ine matche s any othe r claim li ne within the invoic e or withi n another invoice ba sed on uni que combin ation of | |
401 | Patient ID | |
402 | Service Da te From | |
403 | Place Of S ervice | |
404 | Procedure Code | |
405 | Procedure Modifier(s ) (optiona l) | |
406 | Billed Amo unt | |
407 | Status | |
408 | AND the ma tching cla im line is not annot ated as pr eviously r ejected or declined | |
409 | AND the ma tching cla im line is annotated as PAID | |
410 | THEN annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | |
411 | Rule Condi tions | |
412 | Deny any l ine item t hat was pr eviously r eimbursed by VA. | |
413 | Deny any l ine item d uplicates with a sta tus of BIL L_SENT and PAID | |
414 | Line items that are duplicates should be annotated as denied . | |
415 | Line items that are duplicates should in clude a re ason for d enial from a standar d list (CA RC/RARC). | |
416 | Identify u nique Vete rans that were reimb ursed in a month for PMPM paym ents. | |
417 | Deny any c laim that was previo usly submi tted by a provider f or the sam e service provided t o a partic ular indiv idual on a specified date of s ervice. | |
418 | Rule Actio ns | |
419 | The system will dete ct duplica te claims utilizing the claim unique ide ntifier an d prevent payment of duplicate s | |
420 | • When the system de termines t he reimbur sement cla im submiss ion claim line match es any oth er claim l ines based on unique combinati on of the following: | |
421 | - Patie nt Id | |
422 | - Servi ce Date Fr om | |
423 | - Place Of Servic e | |
424 | - Proce dure Code | |
425 | - Proce dure Modif ier(s) (op tional) | |
426 | - Bille d Amount | |
427 | - Statu s | |
428 | • When the matching related cl aim line(s ) has been paid and shows an a llowed amo unt >0, th en the cla im will be flagged a s a duplic ate • When ther e is more than one c laim modif ier, then it will be flagged a s a duplic ate when a ll modifie rs match | |
429 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} | |
430 | • When the matching claim line s are not part of th e same cla im, then i t will be flagged as a duplica te | |
431 | • When bot h the matc hing relat ed claim l ine(s) and the claim line(s) s how a prev ious Pay F lag set to 'Yes' | |
432 | ||
433 | RULE # | |
434 | RULE NAME | |
435 | DATE LAST MODIFIED | |
436 | 006b | |
437 | Duplicates – Institu tional | |
438 | 12/28/17 | |
439 | Rule Descr iption | |
440 | Automatica lly identi fy the dup licate lin e item sub mitted wit hin the co ntracted r eimburseme nt invoice using the unique co mbination of invoice line data so that i mproper pa yments can be preven ted. | |
441 | Rule Attri butes | |
442 | IF claim l ine matche s any othe r claim li ne within the invoic e or withi n another invoice ba sed on uni que combin ation of | |
443 | Patient ID | |
444 | Service Da te From | |
445 | Service Da te To (opt ional) | |
446 | Place Of S ervice | |
447 | Procedure Code | |
448 | Procedure Modifier(s ) (optiona l) | |
449 | Billed Amo unt | |
450 | Status | |
451 | AND the ma tching cla im line is not annot ated as pr eviously r ejected or declined | |
452 | AND the ma tching cla im line is annotated as PAID | |
453 | THEN annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | |
454 | Rule Condi tions | |
455 | Deny any l ine item t hat was pr eviously r eimbursed by VA. | |
456 | Deny any l ine item d uplicates with a sta tus of BIL L_SENT and PAID | |
457 | Line items that are duplicates should be annotated as denied . | |
458 | Line items that are duplicates should in clude a re ason for d enial from a standar d list (CA RC/RARC). | |
459 | Identify u nique Vete rans that were reimb ursed in a month for PMPM paym ents. | |
460 | Deny any c laim that was previo usly submi tted by a provider f or the sam e service provided t o a partic ular indiv idual on a specified date of s ervice. | |
461 | Rule Actio ns | |
462 | The system will dete ct duplica te claims utilizing the claim unique ide ntifier an d prevent payment of duplicate s | |
463 | • When the system de termines t he reimbur sement cla im submiss ion claim line match es any oth er claim l ines based on unique combinati on of the following: | |
464 | - Patie nt Id | |
465 | - Servi ce Date Fr om | |
466 | Service Da te To (inp atient onl y) | |
467 | - Place Of Servic e | |
468 | - Proce dure Code | |
469 | - Proce dure Modif ier(s) (op tional) | |
470 | - Bille d Amount | |
471 | - Statu s | |
472 | • When the matching related cl aim line(s ) has been paid and shows an a llowed amo unt >0, th en the cla im will be flagged a s a duplic ate • When ther e is more than one c laim modif ier, then it will be flagged a s a duplic ate when a ll modifie rs match | |
473 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} | |
474 | • When the matching claim line s are not part of th e same cla im, then i t will be flagged as a duplica te | |
475 | • When bot h the matc hing relat ed claim l ine(s) and the claim line(s) s how a prev ious Pay F lag set to 'Yes' | |
476 | ||
477 | Standardiz ed Episode of Care ( SEOC) | |
478 | RULE # | |
479 | RULE NAME | |
480 | DATE LAST MODIFIED | |
481 | 007 | |
482 | Standardiz ed Episode of Care | |
483 | 03/21/2018 | |
484 | Rule Descr iption | |
485 | Automatica lly evalua te line it ems on the invoice t o ensure t hey fall w ithin the Standardiz ed Episode of Care ( SEOC) so t he line it em can be processed. | |
486 | Rule Attri butes | |
487 | If procedu re code wi thin an in voice line item is n ot include d as a par t of the S EOC identi fied withi n the refe rral | |
488 | Or | |
489 | If procedu re code Da te of Serv ice within invoice l ine item d oes not fa ll within SEOC defin ed frequen cy of serv ice | |
490 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | |
491 | Rule Condi tions | |
492 | If a line item does not fall w ithin the Standardiz ed Episode of Care ( SEOC) it w ill be den ied. | |
493 | Validate b y making s ure valid procedural codes are matched b etween the referral and invoic e, make su re the dat e is withi n the refe rral, and the freque ncy | |
494 | SEOC will be based o n the date the refer ral is acc epted by t he provide r | |
495 | The durati on will be listed in the SEOC | |
496 | End date o f Referral = Start D ate + Dura tion | |
497 | Frequency will be li sted in th e SEOC | |
498 | Invoices t hat do not match a r eferral sh ould be an notated as denied. | |
499 | Invoices t hat do not match a r eferral sh ould inclu de a reaso n for deni al from a standard l ist (CARC/ RARC). | |
500 | Rule Actio ns | |
501 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item date of servic e (DOS) ar e within t he SEOC | |
502 | Line items within th e SEOC, sh ould displ ay status as approve d | |
503 | Line items with DOS outside of the SEOC, should di splay stat us as deni ed | |
504 | ||
505 | Payment Au thority | |
506 | RULE # | |
507 | RULE NAME | |
508 | DATE LAST MODIFIED | |
509 | 008a | |
510 | Payment Au thority | |
511 | 03/25/2018 | |
512 | Rule Descr iption | |
513 | Automatica lly evalua te line it ems on the invoice t o ensure t he payment authority in the 83 7COB has a matching obligation number in the Payme nt_Authori ty_Obligat ion Table. | |
514 | Rule Attri butes | |
515 | If payment authority in the 83 7COB does not have a matching obligation number in the Payme nt_Authori ty_Obligat ion Table; | |
516 | AND a clai m line is not for a flu shot i ndicated b y a CPT co de of ‘G00 08’, ‘9065 8’, ‘90656 ’, or ‘906 62’ | |
517 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | |
518 | Rule Condi tions | |
519 | If the pay ment autho rity in th e 837COB d oes not ha ve a match ing obliga tion numbe r, it will be denied . | |
520 | Invoices t hat do not match a r eferral sh ould be an notated as denied, u nless CPT indicates a flu shot . | |
521 | Invoices t hat do not have a ma tching obl igation nu mber, that are not f lu shots, should inc lude a rea son for de nial from a standard list (CAR C/RARC). | |
522 | Rule Actio ns | |
523 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item Paym ent Author ity includ ed in the referral | |
524 | Line items matching the referr al, should display s tatus as a pproved | |
525 | Line items with a Pa yment Auth ority that does not match an o bligation number, sh ould displ ay status as denied | |
526 | ||
527 | RULE # | |
528 | RULE NAME | |
529 | DATE LAST MODIFIED | |
530 | 008b | |
531 | Payment Au thority | |
532 | 03/26/2018 | |
533 | Rule Descr iption | |
534 | Automatica lly evalua te line it ems on the invoice t o ensure t he payment authority in the 83 7COB has a matching payment au thority in the CCRS reference table. | |
535 | Rule Attri butes | |
536 | If payment authority in the 83 7COB does not have a matching payment au thority in the Payme nt_Authori ty_Obligat ion table, as well a s a matchi ng | |
537 | Start date | |
538 | End date | |
539 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | |
540 | Rule Condi tions | |
541 | If the pay ment autho rity in th e 837COB d oes not ha ve a match ing paymen t authorit y in the C CRS refere nce table, it will b e denied. | |
542 | Invoices t hat do not have a ma tching pay ment autho rity shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
543 | Rule Actio ns | |
544 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item Paym ent Author ity includ ed in the referral | |
545 | Any referr al that co mes in sho uld have a matching Payment Au thority wi th start a nd end dat e, otherwi se display status as denied | |
546 | Basically making sur e Payment Authority is valid | |
547 | Line items with a Pa yment Auth ority that does not match a pa yment auth ority in t he CCRS re ference ta ble, shoul d display status as denied | |
548 | ||
549 | Scope of E pisode | |
550 | RULE # | |
551 | RULE NAME | |
552 | DATE LAST MODIFIED | |
553 | 009 | |
554 | Scope of E pisode | |
555 | 01/24/2018 | |
556 | Rule Descr iption | |
557 | Automatica lly evalua te line it ems on the invoice t o ensure t he service provided is authori zed throug h the refe rral so th e line ite m can be p rocessed. | |
558 | Rule Attri butes | |
559 | If procedu re code wi thin an in voice line item is n ot include d within t he referra l | |
560 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | |
561 | Rule Condi tions | |
562 | If a line item does not fall w ithin the referral’s Scope of Episode, i t will be denied. | |
563 | Invoices t hat do not match a r eferral sh ould be an notated as denied. | |
564 | Invoices t hat do not match a r eferral sh ould inclu de a reaso n for deni al from a standard l ist (CARC/ RARC). | |
565 | An invoice can have the same r eferral be cause a re ferral can be update d with eac h visit | |
566 | Rule Actio ns | |
567 | Line items within th e referral , should d isplay sta tus as app roved | |
568 | Line items with DOS outside of the scope of episod e, should display st atus as de nied | |
569 | ||
570 | Provider | |
571 | RULE # | |
572 | RULE NAME | |
573 | DATE LAST MODIFIED | |
574 | 009 | |
575 | Provider | |
576 | 03/21/2018 | |
577 | Rule Descr iption | |
578 | Have the S ystem matc h the Serv ices provi ded by the Provider via PPMS f eed with 8 37 invoice claims. | |
579 | Rule Attri butes | |
580 | If the med ical servi ces by the Provider on the inv oice does not match the author ized servi ces by the Provider via the PP MS feed | |
581 | Then annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | |
582 | Rule Condi tion | |
583 | If the med ical servi ces provid ed by the Provider o n the 837- invoice cl aim does n ot match t he service s provided via PPMS feed, it w ill be den ied. | |
584 | Rule Actio ns | |
585 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item Prov ider Servi ce include d in PPMS feed | |
586 | Line items matching the PPMS f eed, shoul d display status as approved | |
587 | Line items with a Pr ovider Ser vice that does not m atch an Pr ovider Ser vice in th e PPMS fee d, should display st atus as de nied | |
588 | ||
589 | Billed Adm inistrativ e Charge | |
590 | RULE # | |
591 | RULE NAME | |
592 | DATE LAST MODIFIED | |
593 | 010 | |
594 | Billed Adm inistrativ e Charge | |
595 | 03/29/2018 | |
596 | Rule Descr iption | |
597 | Automatica lly valida te per mem ber per mo nth fee in voice matc hes 837 fo r the serv ices charg ed for the timeframe the admin istrative fee is bei ng charged . | |
598 | Rule Attri butes | |
599 | IF the per member pe r month fe e invoice does not h ave a corr esponding invoice an d referral | |
600 | THEN annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | |
601 | Rule Condi tions | |
602 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
603 | Will recei ve monthly per membe r per mont h fee invo ice | |
604 | Administra tive fee w ill not sh ow up on t he invoice ; Match th e referral to the in voice | |
605 | We will re ceive a pe r member p er month f ee invoice monthly | |
606 | Purpose of report is for audit ing purpos es at the time of pr ocessing p ayment for the PMPM | |
607 | Billed adm inistrativ e charges (not dolla r amount) are in PMP M | |
608 | Matching t hat there is a corre sponding i nvoice, al ong with t he same re ferral and invoice f or ID | |
609 | Rule Actio ns | |
610 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
611 | ||
612 | ICN | |
613 | RULE # | |
614 | RULE NAME | |
615 | DATE LAST MODIFIED | |
616 | 011 | |
617 | ICN | |
618 | 03/26/2018 | |
619 | Rule Descr iption | |
620 | Automatica lly valida te the ICN in CCRA r eferrals m atch the I CN in 837 invoice cl aims. | |
621 | Rule Attri butes | |
622 | IF the ICN in CCRA r eferrals d oes not ma tch the IC N in 837 i nvoice cla ims | |
623 | THEN annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | |
624 | Rule Condi tions | |
625 | ICN will b e provided in the Re ferral_Pat ient CCRA table | |
626 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
627 | ICN = varc har(29) | |
628 | ICN = Inte gration Co ntrol Numb er, Unique identifie r for Vete ran | |
629 | ICN is als o known as the Elect ronic Data Interchan ge Persona l Identifi er. It is assigned b y MVI to e ach patien t and prov ides the k ey to link ing the pa tient elec tronic hea lth record across th e enterpri se | |
630 | Rule Actio ns | |
631 | Invoices t hat are de nied shoul d include a reason f or denial from a sta ndard list (CARC/RAR C). | |
632 | ||
633 | Rule Sets | |
634 | This secti on defines the rule sets withi n the appl ication. | |
635 | If-then Ru le Sets | |
636 | Decision T ables | |
637 | Decision T rees | |
638 | Rule Flows | |
639 | ||
640 | The table below prov ides detai ls on the Rule Flows within th e applicat ion. | |
641 | Rule Flow# | |
642 | Rule Flow Name | |
643 | Rule Flow Descriptio n | |
644 | Rule Name | |
645 | Rule Evalu ation Resu lt | |
646 | ||
647 | ||
648 | ||
649 | ||
650 | ||
651 | Rule Flow Details | |
652 | ||
653 | ||
654 | Rules Impl ementation | |
655 | This secti on describ es the imp lementatio n and inte gration de tails for the rules into the a pplication . | |
656 | Developmen t of the R ules Subsy stem | |
657 | Descriptio n of how t he applica tion is in voking the rules (JR ules expor t methodol ogy, execu tion metho d?) | |
658 | Integratio n of the R ules Subsy stem | |
659 | Any interf aces the r ules subsy stem might need can be documen ted here ( ccrsdb?). |
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