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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 | Initial ICD - SEOC Repository.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 | Initial ICD - SEOC Repository.docx | Fri Jun 15 14:51:34 2018 UTC |
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1 | Department of Vetera ns Affairs | |
2 | ||
3 | VHA Office of Commun ity Care | |
4 | ||
5 | Community Care Reimb ursement S ystem (CCR S) | |
6 | Standardiz ed Episode s of Care (SEOC) | |
7 | ||
8 | Interface Control Do cument (IC D) | |
9 | CLIN 0007A B - SAP | |
10 | ||
11 | ||
12 | ||
13 | ||
14 | February 2 018 | |
15 | Version 1. 0 | |
16 | ||
17 | ||
18 | ||
19 | Revision H istory | |
20 | Date | |
21 | Version | |
22 | Descriptio n | |
23 | Author | |
24 | 02/26/2018 | |
25 | 0.1 | |
26 | Initial Dr aft | |
27 | Imani Port er | |
28 | ||
29 | ||
30 | Background | |
31 | The Depart ment of Ve terans Aff airs Commu nity Care (VACC) req uested the creation of a highl y automate d system t o be used to validat e claims s ubmitted b y contract ed entitie s within t he newly e stablished Community Care Netw ork, gener ate reimbu rsement pa yments to the contra cted entit ies, to au tomate and facilitat e post pay ment audit activitie s for reim bursements and to au tomate and facilitat e revenue operation activities such as i dentifying care that requires pre-certif ication wi th Other H ealth Insu rance (OHI ) agencies , capturin g applicab le paid cl aim data a nd coordin ation of b enefit (CO B) informa tion for t hird party billing a nd first p arty copay ment liabi lity deter mination. The object ives of th e CCRS are : | |
32 | Implement modernized data inte gration an d validati on of 837 coordinati on of bene fits (COB) claims to maximize processing efficienc y and accu racy of re ferral, au thorizatio n, and rei mbursement | |
33 | Accelerate claim rei mbursement using an efficient combinatio n of busin ess rules and workfl ow managem ent capabi lities to intake ref errals and authoriza tions and eligibilit y Enrollme nt & Eligi bility (E& E) data an d apply de cision-mak ing rules for fast, accurate, automated processing | |
34 | Use analyt ics to mon itor perfo rmance and accountab ility to i ncentivize payment t imeliness and accura cy while e nabling re venue oper ations to initiate p rocesses t o recoup f unds via c o-pays/thi rd party b illing | |
35 | Align OCC objectives with Offi ce of Info rmation & Technology (OI&T) sy stems conv erging int erests and accountab ility to m itigate ri sks and ma ximize CCR S success | |
36 | Apply less ons learne d and best practices operation alizing VA ’s Program Integrity Tools (PI T) and fra ud prevent ion heuris tics throu gh past in tegrations with Fee Basis Clai ms Softwar e (FBCS), Veterans H ealth Info rmation Sy stems and Technology Architect ure (VistA ), and Cla ims Proces sing & Eli gibility | |
37 | Deploy a t eam with k nowledge o f existing data sour ces for Re ferral and Authoriza tion (FBCS /CCR&A), F inancial M anagement Systems (C entral Fee /FMS), Cor porate Dat a Warehous e (CDW), a nd Health Eligibilit y Center A dministrat ive Data R epository (HEC ADR) to standar dize and i ntegrate d ata points | |
38 | Design a s olution th at self-an alyzes tre nds while leveraging PIT and O CC experti se to prov ide busine ss specifi c heuristi cs, analyz e transact ional data , recogniz e patterns , and crea te enriche d informat ion | |
39 | Leverage p re-integra ted soluti ons, inclu ding JRule s, Websphe re Operati onal Decis ion Manage ment (WODM ) rules, t o reduce t otal cost of ownersh ip, with b uilt in da ta and mod ernized ca pabilities to meet i ncreasing transactio nal demand s for ALL Veteran cl aims, whil e enabling decision support ne cessary fo r oversigh t and mana gement of community care claim s | |
40 | ** | |
41 | Interface Design | |
42 | Given the system can automatic ally evalu ate invoic e line ite ms, when i nvoices ar e received , then CCR S will be able to va lidate the line item s are with in the epi sode of ca re. It is validated by confirm ing that w hen an inv oice is pr ocessed us ing all th e required data elem ents and i s within t he episode of care, the invoic e is valid ated. If i t is not w ithin the episode of care, the invoice w ill displa y a denied status us ing a CARC /RARC code . An invoi ce has a p rocedure c ode and a referral. The referr al contain s a SEOC, and the SE OC has CPT code(s). Our interf ace will p ull SEOC d ata from a n external SEOC repo sitory. Th e SEOC dat a will be stored in the lookup table in our databa se. Based on the loo kup table, we shall make assoc iations be tween the SEOCs and the CPT co des. The r ules engin e will loo k up the C PT codes b ased on th e SEOC in the claim’ s referral . A high l evel proce ss flow ou tlining th e integrat ion work w ith EDI is outlined: | |
43 | ||
44 | ||
45 | Business R ules | |
46 | The CCRS D evelopment team will deliver t he Communi ty Care Re imbursemen t System ( CCRS) that will addr ess the re quirement, necessita ted by the Community Care Netw ork, to va lidate cla ims for re imbursemen t rather t han adjudi cate claim s for paym ent. Furt her this s ystem will address p ost paymen t requirem ents such as auditin g and reve nue operat ions or ac counting. | |
47 | At the hig hest level , we need the system to be abl e to recei ve all con tracted en tity submi tted 837I, P, D, (In stitutiona l, Profess ional, Den tal, Medic al Equipme nt, etc.) reimbursem ent claims directly from the c learinghou se so that the CCRS receives a ll claims that pass front end edits. The following high leve l validati ons will b e applied | |
48 | If an 837 does not i nclude a r eferral nu mber, it w ill be rej ected. | |
49 | If an 837 does not i nclude coo rdination of benefit s (COB) in formation it will be rejected. | |
50 | Invoice mu st include rendering provider NPI and se rvice faci lity NPI a nd full ad dress. | |
51 | Claims tha t failed d ata comple teness edi ts should be annotat ed as reje cted inclu ding a rea son for re jection fr om a stand ard list ( CARC/RARC) . | |
52 | Invoices t hat do not match a r eferral sh ould be an notated as denied. | |
53 | The date o f service must fall within the matching referral. | |
54 | 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. | |
55 | Invoices t hat are du plicates s hould be a nnotated a s denied. | |
56 | ||
57 | As it rela tes to vet erans refe rrals, we will: | |
58 | ||
59 | Accept inv oices that fall with in episode s of care | |
60 | Accept inv oices whos e date of service ar e within t he SEOC | |
61 | ||
62 | Out of Sco pe | |
63 | N/A | |
64 | SEOC | |
65 | The Standa rdized Epi sodes of C are (SEOC) is a stan dard set o f services /procedure s bundled together t hat relate to a spec ific categ ory of car e or sub-s pecialty. It’s usefu l because services a nd procedu res for ma ny conditi ons are fa irly stand ardized. S EOCs allow s the VA t o authoriz e all the standard s ervices an d procedur es at once , instead of separat ely as tre atment occ urs. They also reduc e need for secondary authoriza tions. For the follo wing categ ories of c are, TPA w ill defaul t to addin g a SEOC t o a referr al even if not speci fically re quested by the VA fa cility. If the facil ity uses a local epi sode of ca re for any of these categories of care, the TPA wi ll still a ssign the appropriat e national ly-establi shed SEOC: | |
66 | Chiropract ic | |
67 | Mammograph y | |
68 | Maternity | |
69 | Ophthalmol ogy | |
70 | Optometry | |
71 | Occupation al therapy | |
72 | Occupation al therapy functiona l or drive r evaluati on | |
73 | Physical t herapy | |
74 | Radiology MRI-MRA | |
75 | For the fo llowing ca tegories o f care, SE OCs can on ly be assi gned by TP As when th e VA facil ity specif ically req uests the SEOC on Fo rm 10-0386 . This set of SEOCs is optiona l but high ly recomme nded: | |
76 | Orthopedic | |
77 | Chronic pa in managem ent interv entional r adiology i njections | |
78 | Chronic pa in managem ent spinal cord stim ulator | |
79 | Sleep stud y | |
80 | Upper/lowe r gastroin testinal | |
81 | Wound care | |
82 | SEOC Taxon omy: | |
83 | Attribute | |
84 | Data Type | |
85 | Data Defin ition | |
86 | Example | |
87 | SEOC ID Nu mber | |
88 | String | |
89 | Service Li ne Abbrevi ation_SEOC Name_Vers ion Number _PAL (if a PAL SEOC) _PCRT (if need pre-c ert) | |
90 | PMR_CHIROP RACTIC_1.0 .1 | |
91 | Service Li ne (associ ated with the specia lty) | |
92 | String | |
93 | Service Li ne for eac h SEOC | |
94 | Rehabilita tive Servi ces | |
95 | Category o f Care (CO C) | |
96 | String | |
97 | Category o f Care ass ociated wi th SEOC | |
98 | Chiropract ic | |
99 | SEOC Name | |
100 | String | |
101 | Name of th e SEOC | |
102 | Chiropract ic | |
103 | Clinical S ervice | |
104 | String | |
105 | The clinic al service associate d with the SEOC | |
106 | N/AContinu ed Pain Ma nagement | |
107 | Version | |
108 | String | |
109 | Version nu mber if th e SEOC | |
110 | 1.0.1 | |
111 | Version Ef fective St art Date[M onth/Day/Y ear] | |
112 | Date | |
113 | The effect ive start date for t his versio n of the S EOC | |
114 | January 1, 2018 | |
115 | Version Ef fective En d Date[Mon th/Day/Yea r] | |
116 | Date | |
117 | The effect ive end da te for thi s version of the SEO C | |
118 | June 1, 20 18 | |
119 | No. of Ser vice/Proce dure withi n SEOC | |
120 | Number | |
121 | The number of servic es associa ted with t he SEOC | |
122 | 123 | |
123 | Service/Ca re Request ed | |
124 | String | |
125 | One or mor e services associate d with the SEOC | |
126 | Breast MRI including CHEM pane l, as clin ically ind icated | |
127 | Duration ( days) | |
128 | Number | |
129 | The window of time a pproved to provide t his servic e | |
130 | 90 | |
131 | Authorized No. of V isit(s) - by Service | |
132 | Number | |
133 | The numeri cal amount of approv ed visits for a part icular ser vice | |
134 | 4 | |
135 | CPT Codes | |
136 | Number | |
137 | The CPT co de set des cribes med ical, surg ical, and diagnostic services and is des igned to c ommunicate uniform i nformation about med ical servi ces and pr ocedures a mong physi cians, cod ers, patie nts, accre ditation o rganizatio ns, and pa yers for a dministrat ive, finan cial, and analytical purposes. | |
138 | 99201 | |
139 | CPT Descri ption | |
140 | String | |
141 | Provides a short, pl ain langua ge descrip tion of th e service/ procedure each indiv idual CPT code repre sents | |
142 | Office or other outp atient vis it for the evaluatio n and mana gement of an establi shed patie nt | |
143 | Disclaimer | |
144 | String | |
145 | Community provider n eeds to se e this as it identif ies certai n details exclusive to VA that they woul d not enco unter with any other insurer | |
146 | ** All req uests for additional therapeut ic modalit ies, inclu ding heat/ cold modal ities and massage th erapy requ ire VA rev iew. | |
147 | Pre-Cert s ervices | |
148 | Number | |
149 | Identifies individua l CPT code s that req uire insur ance pre-c ertificati on for Vet erans who have Other Health In surance. | |
150 | 77077, 205 26, 20527, 23020 | |
151 | PAL SEOC | |
152 | Boolean | |
153 | A yes/no i ndicator t hat define s the SEOC is a serv ice listed on the Pr ior Author ization Li st (PAL) | |
154 | Yes | |
155 | DRG | |
156 | String | |
157 | An inpatie nt code fo r the Diag nostic Rel ated Group (DRG) tha t defines the cost, complexity and lengt h of stay for inpati ent servic es | |
158 | D12.56 | |
159 | QASP categ ory | |
160 | String | |
161 | Is a singl e selectio n at the S EOC level of five ca tegories u nder the Q uality Ass urance Sur veillance Plan (QASP ). Those c ategories are: Gener al Care, P rimary Car e, General Dentistry , Specialt y Dentistr y, Complim entary & I ntegrative Health Ca re | |
162 | General Ca re | |
163 | ||
164 | Requiremen ts Affecte d by this ICD | |
165 | The alignm ent of req uirements that are a ffected by this ICD are listed : | |
166 | Rational I D | |
167 | Requiremen t | |
168 | Business S tory | |
169 | Acceptance Criteria | |
170 | ||
171 | ClaimsStor y033 | |
172 | As a CCRS User, I ne ed the Sys tem to aut omatically evaluate invoice li ne items s o that I c an validat e the line items are within th e episode of care. | |
173 | • When the system re ceives the reimburse ment invoi ce with ma tching ref erral, it will disp lay as val idated if it is with in the sco pe of the referral | |
174 | • When the system re ceives the reimburse ment invoi ce with ma tching ref erral, if it is not within the scope of the referr al, valida tion will list a den ied status | |
175 | ||
176 | ClaimsStor y034 | |
177 | As a CCRS User, I ne ed the Sys tem to aut omatically evaluate line items on the in voice to e nsure they fall with in the Sta ndardized Episode of Care (SEO C) so that I can pro cess the l ine item. | |
178 | • The vali dated invo ice will o nly show e valuated l ine item, it should display li ne item da te of serv ice (DOS) are within the SEOC | |
179 | • Line ite ms within the SEOC, should dis play statu s as appro ved | |
180 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied | |
181 | ||
182 | Rejection Rules | |
183 | If the lin e item dat e of servi ce (DOS) i s outside of the SEO C, it will be reject ed | |
184 | ||
185 | Applicable Guideline s | |
186 | The follow ing regula tions and laws are a pplicable to identit y manageme nt applica tions: | |
187 | VA Identit y Manageme nt Policy, VAIQ 7011 145, June 28, 2010 | |
188 | VHA Direct ive 2009-0 21 Data En try Requir ements for Administr ative Data | |
189 | VHA Direct ive 2006-0 36 Data Qu ality Requ irements f or Identit y Manageme nt and the Master Pa tient Inde x Function s | |
190 | VHA Direct ive 2007-0 37 Identit y Authenti cation for Health Ca re Service s | |
191 | VHA Handbo ok 1050.01 National Patient Sa fety Impro vement Han dbook | |
192 | VHA Handbo ok 1907.1 Health Inf ormation M anagement and Health Records | |
193 | VHA Handbo ok 1907.05 Repair of Catastrop hic Edits to Patient Identity | |
194 | Joint Comm ission Nat ional Pati ent Safety Goals- Go al 1- Impr ove the ac curacy of patient id entificati on | |
195 | ||
196 | Testing | |
197 | Environmen t | |
198 | Test Cases /Operation s Performe d | |
199 | ||
200 | ||
201 | Testing No tes | |
202 | Rational I D | |
203 | Test Case | |
204 | Test Scrip t | |
205 | Expected R esults | |
206 | ||
207 | Given the system can automatic ally evalu ate invoic e line ite ms | |
208 | When invoi ces are re ceived | |
209 | Then I exp ect CCRS w ill be abl e to valid ate the li ne items a re within the episod e of care. | |
210 | We validat e by confi rming that when an i nvoice is processed using all of the req uired data elements and is wit hin the ep isode of c are, the i nvoice is validated. If it is not within the episo de of care , the invo ice will d isplay a d enied stat us. | |
211 | • The vali dated invo ice will o nly show e valuated l ine item, it should display li ne item da te of serv ice (DOS) are within the SEOC | |
212 | • Line ite ms within the SEOC, should dis play statu s as appro ved | |
213 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied | |
214 | ||
215 | Glossary T erms | |
216 | ||
217 | Term | |
218 | Meaning | |
219 | AD | |
220 | Active Dir ectory | |
221 | AERB | |
222 | Architectu re Enginee ring Revie w Board | |
223 | ANR | |
224 | Automated Notificati on Record | |
225 | API | |
226 | Applicatio n Programm ing Interf ace | |
227 | BHIE | |
228 | Bidirectio nal Health Informati on Exchang e | |
229 | BN | |
230 | Business N eed | |
231 | BRD | |
232 | Business R equirement s Document | |
233 | C&A | |
234 | Certificat ion & Accr editation | |
235 | C&P | |
236 | Compensati on & Pensi on | |
237 | CAPRI | |
238 | Compensati on and Pen sion Recor d Exchange | |
239 | CDM | |
240 | Continuous Diagnosti cs and Mit igation | |
241 | CFR | |
242 | Code of Fe deral Regu lations | |
243 | COTS | |
244 | Commercial -Off-the-S helf | |
245 | CPRS | |
246 | Computeriz ed Patient Record Sy stem | |
247 | CUI | |
248 | Clinician User Inter face | |
249 | DAS | |
250 | Data Acces s Service | |
251 | DBMS | |
252 | Database M anagement System | |
253 | DBQ | |
254 | Disability Benefits Questionna ire | |
255 | DD | |
256 | Data Dicti onary | |
257 | DEAP | |
258 | Disability Exam and Assessment Program | |
259 | DoD | |
260 | Department of Defens e | |
261 | EA | |
262 | Enterprise Architect ure | |
263 | EDIPI | |
264 | Electronic Data Inte rchange Pe rsonal Ide ntifier | |
265 | ELDM | |
266 | Enterprise Logical D ata Model | |
267 | FIPS | |
268 | Federal In formation Process St andards | |
269 | FISMA | |
270 | Federal In formation Security M anagement Act | |
271 | GUI | |
272 | Graphical User Inter face | |
273 | HIPAA | |
274 | Health Inf ormation P ortability and Accou ntability Act | |
275 | HL7 | |
276 | Health Lev el 7 | |
277 | HTML | |
278 | Hypertext Markup Lan guage | |
279 | HTTP | |
280 | Hypertext Transfer P rotocol | |
281 | IAM | |
282 | Identity a nd Access Management | |
283 | ICR | |
284 | Integratio n Control Registrati on | |
285 | ID | |
286 | Identifica tion | |
287 | IdP to SP | |
288 | Identity P rovider to Service P rovider | |
289 | iEHR | |
290 | Integrated Electroni c Health R ecord | |
291 | IPPS | |
292 | Invoice Pa yment Proc essing Sys tem | |
293 | IPT | |
294 | Integrated Project T eam | |
295 | LAN | |
296 | Local Area Network | |
297 | LDM | |
298 | Logical Da ta Model | |
299 | MVI | |
300 | Master Vet eran Index | |
301 | NIST | |
302 | National I nstitute o f Standard s and Tech nology | |
303 | OMB | |
304 | Office of Management and Budge t | |
305 | PIA | |
306 | Privacy Im pact Asses sment | |
307 | PIV | |
308 | Personal I dentify Ve rification | |
309 | PKI | |
310 | Public Key Infrastru cture | |
311 | PMAS | |
312 | Project Ma nagement A ccountabil ity System | |
313 | POST | |
314 | Power-On S elf-Test | |
315 | REST | |
316 | Representa tional Sta te Transfe r | |
317 | RPC | |
318 | Remote Pro cedure Cal l | |
319 | RPO | |
320 | Recovery P oint Objec tive | |
321 | RSD | |
322 | Requiremen ts Specifi cation Doc ument | |
323 | RTM | |
324 | Requiremen ts Traceab ility Matr ix | |
325 | RTO | |
326 | Recovery T ime Object ive | |
327 | SAML | |
328 | Security A ssertion M arkup Lang uage | |
329 | SDD | |
330 | System Des ign Docume nt | |
331 | SLD | |
332 | Service Le vel Defini tion | |
333 | SM | |
334 | Servicemem ber | |
335 | SOA | |
336 | Service-Or iented Arc hitecture | |
337 | SOAP | |
338 | Simple Obj ect Access Protocol | |
339 | SP | |
340 | Service Pr ovider | |
341 | SSO | |
342 | Single Sig n-on | |
343 | SSOe | |
344 | Single Sig n-on Exter nal | |
345 | SSOi | |
346 | Single Sig n-on Inter nal | |
347 | SSP | |
348 | System Sec urity Plan | |
349 | TCP | |
350 | Transactio n Control Protocol | |
351 | TLS | |
352 | Transport Layer Secu rity | |
353 | TRM/SP | |
354 | Technical Reference Manual / S tandards P rofile | |
355 | UML | |
356 | Unified Mo deling Lan guage | |
357 | UPN | |
358 | User Princ ipal Name | |
359 | U.S.C. | |
360 | United Sta tes Code | |
361 | VA | |
362 | Department of Vetera ns Affairs | |
363 | VAAFI | |
364 | VA Authent ication Fe deration I nfrastruct ure | |
365 | VAAR | |
366 | VA Acquisi tion Regul ation | |
367 | VBA | |
368 | Veterans B enefits Ad ministrati on | |
369 | VBMS | |
370 | Veterans B enefits Ma nagement S ystem | |
371 | VCA | |
372 | VLER Capab ility Area | |
373 | VHA | |
374 | Veterans H ealth Admi nistration | |
375 | VIC | |
376 | Veteran Id entificati on Card | |
377 | VIERS | |
378 | Veterans I nformation /Eligibili ty Reporti ng System | |
379 | VIP | |
380 | Veteran-fo cused Inte gration Pr ocess | |
381 | VistA | |
382 | Veterans H ealth Info rmation Sy stems and Technology Architect ure | |
383 | VLER | |
384 | Virtual Li fetime Ele ctronic Re cord | |
385 | ||
386 |
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