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# | Location | File | Last Modified |
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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Rule_Specification\word_format | timely_filing_rule_specification.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\Rule_Specification\word_format | timely_filing_rule_specification.docx | Fri Jun 15 14:54:41 2018 UTC |
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1 | TimelyFili ng Rules | |
2 | Descriptio n | |
3 | 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. | |
4 | Validation Descripti on | |
5 | Timely Sub mission | |
6 | Claims mus t be submi tted withi n 180 days of the cl aim date o f service | |
7 | Timely Pro vider Paym ent | |
8 | Claims mus t be paid within 30 days of re ceiving th e claim | |
9 | Timely Res ubmission | |
10 | Rejected C laim Lines must be r esubmitted within 30 days of r ejection d ate | |
11 | Validation Logic | |
12 | Timely Sub mission - Applies to INST-IO: | |
13 | IF (the Cl aim.receiv edDate is 180 days G REATER tha n the Clai m.instClai m.admissio nDate) THE N { create Val idationFai lure: time lySubmissi on, CARC: 226 RARC: N385 for C laim} | |
14 | Timely Sub mission - Applies to PROF, DEN T: | |
15 | FOREACH Cl aimLine re lated to t he Claim { IF (th e Claim.re ceivedDate is 180 da ys GREATER than the ClaimLine. serviceDat e) THEN { cr eate Valid ationFailu re: timely Submission , CARC: 22 6 RARC: N3 85 for Cla imLine }} | |
16 | Timely Pro vider Paym ent Applie s to INST- IO, PROF, DENT: | |
17 | FOREACH Cl aimLine re lated to t he Claim { IF (th e Claim.re ceivedDate is 30 day s GREATER than the C laimLine.d ateProvide rPaid) THE N { create Validation Failure: t imelyProvi derPayment , CARC: 22 6 RARC: N3 85 for Cla imLine } } | |
18 | Timely Res ubmission Applies to INST-IO, PROF, DENT : | |
19 | IF (the Cl aim is a R esubmissio n) THEN { fetch the origi nal Claim FOREA CH ClaimLi ne related to the Re submission Claim { IF (the Resub missionCla imLine.lin eItemContr olNumber d oes NOT ma tch any Or iginalClai mLine.line ItemContro lNumber) T HEN { c reate Vali dationFail ure: timel yResubmiss ion, CARC: 226 RARC: N385 for Resubmissi onClaimLin e } OT HERWISE IF (the Resu bmissionCl aim.receiv eDate is 3 0 days GRE ATER than OriginalCl aim.decisi on.decisio nDate) THE N { crea te Validat ionFailure : timelyRe submission , CARC: 22 6 RARC: N3 85 for Res ubmissionC laimLine } }} | |
20 | Notes | |
21 | Data Eleme nts | |
22 | BRENGINE | |
23 | CCRSDB | |
24 | Claim.rece ivedDate | |
25 | DIM_VA_CLA IM.receive d_date | |
26 | Claim.inst Claim.admi ssionDate | |
27 | DIM_INSTIT UTIONAL_CL AIM.admiss ion_date | |
28 | Claim.sour ceSystem | |
29 | DIM_VA_CLA IM.source_ system | |
30 | Claim.clai mId | |
31 | DIM_VA_CLA IM.claim_i d | |
32 | Claim.deci sions** | |
33 | DECISION | |
34 | Claim.clai mLines** | |
35 | F_*_CLAIM_ DETAILS | |
36 | ClaimLine. key | |
37 | F_*_CLAIM_ DETAILS.cl aim_detail _key | |
38 | ClaimLine. lineItemCo ntrolNumbe r | |
39 | F_*_CLAIM_ DETAILS.li ne_item_co ntrol_numb er | |
40 | ClaimLine. serviceDat e | |
41 | F_*_CLAIM_ DETAILS.se rvice_date | |
42 | ClaimLine. dateProvid erPaid | |
43 | F_*_CLAIM_ DETAILS.da te_paid | |
44 | Decision.c laimLineKe y | |
45 | DECISION.c laim_detai l_key | |
46 | Decision.d escisionTy pe | |
47 | DECISION.d ecision | |
48 | Decision.d ecisionDat e | |
49 | DECISION.d ecision_da te_time |
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