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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\pmpm | PMPM_Invoicing_File_Format.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\pmpm | PMPM_Invoicing_File_Format.docx | Fri Jun 15 14:54:02 2018 UTC |
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1 | Community Care Netwo rk | |
2 | Administra tive Invoi ce | |
3 | Format Do cumentatio n | |
4 | ||
5 | Department of Vetera ns Affairs | |
6 | January 2 017 | |
7 | Version 1. 0 | |
8 | ||
9 | Revision H istory | |
10 | ||
11 | Date | |
12 | Version | |
13 | Descriptio n | |
14 | Author | |
15 | 1/31/2017 | |
16 | 1.02 | |
17 | Updated bo th reports to contai n CLINs | |
18 | Richard Mu ller | |
19 | 1/30/2017 | |
20 | 1.01 | |
21 | Updated to include A nnual Reco nciliation Report se ction | |
22 | Richard Mu ller | |
23 | 8/30/2016 | |
24 | 1.0 | |
25 | Initial do cumentatio n | |
26 | Richard Mu ller | |
27 | ||
28 | Table of C ontents | |
29 | 1.Introduc tion4 | |
30 | 1.1.Scope4 | |
31 | 1.2.Admini strative F ee Invoice (Monthly) Formattin g5 | |
32 | 1.2.1.File Name Form at5 | |
33 | 1.2.2.Per Member Per Month Rec ord Format 5 | |
34 | 1.2.3.File Header Fo rmat6 | |
35 | 1.2.4.File Footer Fo rmat6 | |
36 | 1.3.Admini strative F ee (Annual ) Recap Re port Forma tting7 | |
37 | 1.3.1.Annu al Recap R eport File Name Form at7 | |
38 | 1.3.2.Annu al Recap R eport Reco rd Format7 | |
39 | 1.3.3.Annu al Recap R eport File Header Fo rmat8 | |
40 | 1.3.4.Annu al Recap R eport File Footer Fo rmat8 | |
41 | ||
42 | Introducti on | |
43 | ||
44 | The Commun ity Care N etwork ven dors will submit ele ctronic co pies of th e monthly administra tive fee ( PMPM) invo ices to th e CO / COR (in appro ved Micros oft Office format) a nd the Tun gsten Netw ork and in accordanc e with the instructi ons provid ed in FAR 52.212-4(g ). | |
45 | ||
46 | Scope | |
47 | ||
48 | Invoicing for PMPM m ust includ e a supple mental dat a file of elements t aken from VA Approve d Referral s and VA P rior Autho rization n umbers and EDI 837 C oordinatio n of Benef its (COB) transactio ns to CCN providers including the follow ing inform ation at t he claim l evel: | |
49 | ||
50 | 1.VA provi ded referr al number (Approved Referral) | |
51 | 2.VA Prior Authoriza tion numbe r | |
52 | 3.Internal Claim Num ber (ICN) and (Patie nt Control Number) | |
53 | 4.Date (s) of servic e for each Veteran i ncluded in the PMPM invoice mo nth | |
54 | 5.VA provi ded EDIPI for each V eteran inc luded in t he PMPM | |
55 | 6.Date Pai d to CCN p rovider | |
56 | 7.Amount P aid | |
57 | 8.Billed A mount | |
58 | 9.Name of CCN Provid er paid | |
59 | 10.CCN Pro vider NPI number | |
60 | 11. PMPM C LIN (XX11A A, XX11AB, XX11AC) | |
61 | ||
62 | The annual reconcili ation repo rt of all unpaid PMP M fees wil l be used resolve an y potentia l outstand ing PMPM f ees and VA adjustmen ts to fund ing. The a nnual reco nciliation report is submitted in accord ance with the contra ct deliver able secti on of the contract. At the end of the op tion year / contract year, the contracto r must alw ays submit any souts tanding PM PM invoice s within 2 70 days. | |
63 | ||
64 | VA provide d EDIPI fo r each Vet eran inclu ded in the monthly i nvoice | |
65 | Internal C laim Numbe r (ICN) a nd (Patien t Control Number) | |
66 | VA provide d referral number (A pproved Re ferral) | |
67 | Referral S ubmitted f or PMPM (Y /N) | |
68 | For vetera ns include d in a mon thly invoi ce (Referr al Submitt ed for PMP M - Y): | |
69 | Original I nvoice Num ber | |
70 | If the Ori ginal Invo ice was re jected (Ac cepted - N ): | |
71 | Prior Invo ice Number (Multiple s possible ) | |
72 | Reason for Rejection | |
73 | For vetera ns not inc luded in a monthly i nvoice (Re ferral Sub mitted for PMPM - N) : | |
74 | Reason for Delay | |
75 | Potential Claim amou nt (Cost E stimate) | |
76 | Estimated Claim paym ent date | |
77 | PMPM CLIN (XX11AA, X X11AB, XX1 1AC) | |
78 | ||
79 | Administra tive Fee I nvoice (Mo nthly) For matting | |
80 | ||
81 | The Contra ctor must always sub mit Admini strative F ee invoice s in the a pproved fo rmat as fo llows: | |
82 | ||
83 | File Name Format | |
84 | ||
85 | File Name Definition | |
86 | Field Name | |
87 | Field Form at | |
88 | Sample Dat a | |
89 | CCN | |
90 | Text | |
91 | CCN | |
92 | PMPM Regio n Designat ion | |
93 | Text | |
94 | Region1 | |
95 | Invoice St art Date | |
96 | Date | |
97 | 20170801 | |
98 | Invoice En d Date | |
99 | Date | |
100 | 20170831 | |
101 | File Exten sion | |
102 | Text | |
103 | .TXT | |
104 | ||
105 | Example Fi le Name fo rmat: | |
106 | CCN-Region 1-20170801 -20170831. txt | |
107 | ||
108 | Per Member Per Month Record Fo rmat | |
109 | ||
110 | Record Def inition | |
111 | Field Name | |
112 | Reference Designatio n | |
113 | Field Form at | |
114 | Field Cont ents | |
115 | Sample Dat a | |
116 | Notes: | |
117 | Referral n umber | |
118 | REF01, REF 02 | |
119 | Data field s separate d by "*" | |
120 | Up to 50 c haracter A lpha Numer ic | |
121 | 9F*______ | |
122 | 9F - Autho rization N umber | |
123 | Prior Auth orization number | |
124 | REF01, REF 02 | |
125 | Data field s separate d by "*" | |
126 | Up to 50 c haracter A lpha Numer ic | |
127 | G1*______ | |
128 | G1 - Prior Authoriza tion Numbe r | |
129 | ICN & Pati ent Contro l Number | |
130 | CLM | |
131 | Numeric | |
132 | ||
133 | 261515 | |
134 | ||
135 | Date of se rvice | |
136 | DTM - SERV ICE DATE | |
137 | Date | |
138 | CCYYMMDD | |
139 | 20160810 | |
140 | ||
141 | EDIPI | |
142 | REF*F8 | |
143 | Alpha Nume ric | |
144 | Up to 50 c haracter A lpha Numer ic | |
145 | EP03251577 7007230 | |
146 | Original R eference N umber | |
147 | Date Paid | |
148 | DTM - SERV ICE DATE | |
149 | Date | |
150 | CCYYMMDD | |
151 | 20160810 | |
152 | ||
153 | Amount Pai d | |
154 | CLP04 (Cla imPaymentA mount) | |
155 | Accounting | |
156 | Numeric w/ 2 digit de cimal | |
157 | 751.50 | |
158 | ||
159 | Billed Amo unt | |
160 | CLP03 (Tot alClaimCha rgeAmount) | |
161 | Accounting | |
162 | Numeric w/ 2 digit de cimal | |
163 | 1323.64 | |
164 | ||
165 | CCN Provid er Name | |
166 | NM103, NM1 04, NM105, NM106 | |
167 | Last, Firs t, MI, Pre fix | |
168 | Data field s separate d by "*" | |
169 | TOWNSEND*W ILLIAM*P* | |
170 | ||
171 | CCN Provid er NPI num ber | |
172 | PLB01 (Pro viderIdent ifier) | |
173 | Numeric | |
174 | ||
175 | 6543210903 | |
176 | ||
177 | PMPM CLIN | |
178 | REF02 | |
179 | Alpha Nume ric | |
180 | XX011AA | |
181 | 1011AA | |
182 | Region ID, three num eric and t wo alpha c haracters | |
183 | ||
184 | Example PM PM Record (fields se parated by "^"): | |
185 | 9F*1234567 89^G1*5737 59597429^2 61515^2016 0810^EP032 5157770072 30^2016081 0^751.50^1 312051^TOW NSEND*WILL IAM*P*^654 3210903^10 11AA | |
186 | ||
187 | File Heade r Format | |
188 | ||
189 | Header Def inition (M onthly Inv oice) | |
190 | Field Name | |
191 | Field Form at | |
192 | Field Cont ents | |
193 | Sample Dat a | |
194 | PMPM Regio n Designat ion | |
195 | Text | |
196 | Alpha Nume ric | |
197 | REG1 | |
198 | Invoice St art Date | |
199 | Date | |
200 | CCYYMMDD | |
201 | 20170801 | |
202 | Invoice En d Date | |
203 | Date | |
204 | CCYYMMDD | |
205 | 20170831 | |
206 | Number of Active Mem bers bille d this mon th | |
207 | Numeric | |
208 | Count of a ctive memb ers for th is month | |
209 | 12345 | |
210 | ||
211 | Example He ader forma t (first l ine in fil e): | |
212 | REG1^20170 801^201708 31^12345 | |
213 | ||
214 | File Foote r Format | |
215 | ||
216 | Footer Def inition (M onthly Inv oice) | |
217 | Field Name | |
218 | Field Form at | |
219 | Field Cont ents | |
220 | Sample Dat a | |
221 | PMPM Regio n Designat ion | |
222 | Text | |
223 | Alpha Nume ric | |
224 | REG1 | |
225 | Total Invo ice Amount Paid | |
226 | Accounting | |
227 | Numeric w/ 2 digit de cimal | |
228 | 25123.54 | |
229 | Total invo ice Amount Billed | |
230 | Accounting | |
231 | Numeric w/ 2 digit de cimal | |
232 | 259126.44 | |
233 | Total PMPM Record Co unt | |
234 | Numeric | |
235 | Count of r ecords in file (Shou ld match A ctive Memb er count i n Header) | |
236 | 12345 | |
237 | ||
238 | Example Fo oter forma t (last li ne in file ): | |
239 | REG1^25123 .54^259126 .55^12345 | |
240 | ||
241 | Administra tive Fee ( Annual) Re cap Report Formattin g | |
242 | ||
243 | The Contra ctor must always sub mit an Ann ual Recap Report in the approv ed format as follows : | |
244 | ||
245 | Annual Rec ap Report File Name Format | |
246 | ||
247 | Header Def inition (A nnual Reca p Report) | |
248 | Field Name | |
249 | Field Form at | |
250 | Field Cont ents | |
251 | Sample Dat a | |
252 | PMPM Regio n Designat ion | |
253 | Text | |
254 | Alpha Nume ric | |
255 | REG1 | |
256 | Reconcilia tion Perio d Start Da te | |
257 | Date | |
258 | CCYYMMDD | |
259 | 20170801 | |
260 | Reconcilia tion Perio d End Date | |
261 | Date | |
262 | CCYYMMDD | |
263 | 20170831 | |
264 | ||
265 | Example An nual Recap Report He ader forma t (first l ine in fil e): | |
266 | REG1^20170 801^201708 31 | |
267 | ||
268 | Annual Rec ap Report Record For mat | |
269 | ||
270 | Record Def inition | |
271 | Field Name | |
272 | Field Form at | |
273 | Field Cont ents | |
274 | Sample Dat a | |
275 | Notes: | |
276 | EDIPI | |
277 | Alpha Nume ric | |
278 | Up to 50 c haracter A lpha Numer ic | |
279 | EP03251577 7007230 | |
280 | Original R eference N umber | |
281 | ICN & Pati ent Contro l Number | |
282 | Numeric | |
283 | ||
284 | 261515001 | |
285 | ||
286 | VA provide d referral number (A pproved Re ferral) | |
287 | Data field s separate d by "*" | |
288 | Up to 50 c haracter A lpha Numer ic | |
289 | 9F*______ | |
290 | 9F - Autho rization N umber | |
291 | Referral S ubmitted f or PMPM | |
292 | "Y" or "N" | |
293 | Alpha char acter | |
294 | N | |
295 | ||
296 | Vendor Ori ginal Invo ice Number | |
297 | Alpha Nume ric | |
298 | Alpha Nume ric | |
299 | PS-0005316 9-01 | |
300 | ||
301 | Original I nvoice Acc epted | |
302 | "Y" or "N" | |
303 | Alpha char acter | |
304 | Y | |
305 | ||
306 | Prior Invo ice Number (Multiple s possible ) | |
307 | Alpha Nume ric | |
308 | Alpha Nume ric | |
309 | PS-0005316 9-01 | |
310 | Only popul ated if Or iginal inv oice was r ejected | |
311 | Reason for Rejection | |
312 | Alpha Nume ric | |
313 | Up to 50 c haracter A lpha Numer ic | |
314 | Invoice di dn't match referral | |
315 | Cannot use delimiter in text ( "^") | |
316 | Referral S ubmitted f or PMPM (N ) | |
317 | "Y" or "N" | |
318 | Alpha char acter | |
319 | N | |
320 | ||
321 | Reason for Delay | |
322 | Alpha Nume ric | |
323 | Up to 50 c haracter A lpha Numer ic | |
324 | Claim didn 't match r eferral | |
325 | Cannot use delimiter in text ( "^") | |
326 | Potential Claim amou nt (Cost E stimate) | |
327 | Accounting | |
328 | Numeric w/ 2 digit de cimal | |
329 | 751.50 | |
330 | ||
331 | Estimated Claim paym ent date | |
332 | Date | |
333 | CCYYMMDD | |
334 | 20171210 | |
335 | ||
336 | PMPM CLIN | |
337 | Alpha Nume ric | |
338 | XX011AA | |
339 | 1011AA | |
340 | Region ID, three num eric and t wo alpha c haracters | |
341 | ||
342 | Referral S ubmitted f or PMPM an d accepted : | |
343 | EP03251577 7007230^26 1515001^9F *123456789 ^Y^PS-0005 3169-01^Y^ ^^^^1011AA | |
344 | ||
345 | Referral S ubmitted f or PMPM an d rejected : | |
346 | EP03251577 7007230^26 1515001^9F *123456789 ^Y^ PS-000 53169-01^N ^ PS-00050 534-01^Inv oice didn' t match re ferral^^10 11AA | |
347 | ||
348 | Referral n ot submitt ed: | |
349 | EP03251577 7007230^26 15150101^9 F*12345678 9^N^^^^^Cl aim didn't match ref erral^751. 50^2017121 0^1011AA | |
350 | ||
351 | Annual Rec ap Report File Heade r Format | |
352 | ||
353 | Header Def inition (A nnual Reca p Report) | |
354 | Field Name | |
355 | Field Form at | |
356 | Field Cont ents | |
357 | Sample Dat a | |
358 | PMPM Regio n Designat ion | |
359 | Text | |
360 | Alpha Nume ric | |
361 | REG1 | |
362 | Reconcilia tion Perio d Start Da te | |
363 | Date | |
364 | CCYYMMDD | |
365 | 20170801 | |
366 | Reconcilia tion Perio d End Date | |
367 | Date | |
368 | CCYYMMDD | |
369 | 20170831 | |
370 | ||
371 | Example An nual Recap Report He ader Forma t (first l ine in fil e): | |
372 | REG1^20170 801^201708 31 | |
373 | ||
374 | Annual Rec ap Report File Foote r Format | |
375 | ||
376 | Footer Def inition (A nnual Reca p Report) | |
377 | Field Name | |
378 | Field Form at | |
379 | Field Cont ents | |
380 | Sample Dat a | |
381 | PMPM Regio n Designat ion | |
382 | Text | |
383 | Alpha Nume ric | |
384 | REG1 | |
385 | Active Mem bership Ac cepted Cou nt | |
386 | Accounting | |
387 | Numeric | |
388 | 2415306 | |
389 | Active Mem bership Re jected Cou nt | |
390 | Accounting | |
391 | Numeric | |
392 | 2516 | |
393 | Active Mem bership De layed Coun t | |
394 | Accounting | |
395 | Numeric | |
396 | 1001 | |
397 | ||
398 | ||
399 | Example An nual Foote r format ( last line in file): | |
400 | REG1^24153 06^2516^10 01 | |
401 | ||
402 | Example An nual Foote r format ( last line in file): | |
403 | REG1^24153 06^2516^10 01 |
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