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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\testing\Test Cases | Tester worksheet Sprint 5 New.xlsx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\testing\Test Cases | Tester worksheet Sprint 5 New.xlsx | Fri Jun 15 15:33:14 2018 UTC |
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1 | SHEET: Pay ment Autho rit y | ||
2 | Notes,Give n the syst em automat ically ide ntifies th e payment authority associate to the rei mbursement invoice | ||
3 | When invoi ces are pa id | ||
4 | Then I exp ect CCRS w ill be abl e to valid ate that t he payment authority is correc t or other wise deny the paymen t, | ||
5 | >>>>>,Iden tify that payment au thority is correct, | ||
6 | TC4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et, | ||
7 | Acceptance criteria, >>>> 1,W hen the cl aim invoic e is for a uthority 1 703 and 17 28, it sho uld be val idated und er contrac t 8153 – T itle 38 an d show pay ment appro ved, | ||
8 | Test objec tive:,Veri fy the Sys tem automa tically ev aluate lin e items on the invoi ce to ensu re the pay ment autho rity for r eferral ma tches paym ent author ity in the 837COB. Obligation Number an d Payment Authority are equiva lent.,2, W hen the va lidated cl aim invoic e is under contract 8153 – Tit le 38, it should not display p ayment aut hority Mil l Bill (17 25) and it should sh ow payment denied, | ||
9 | Roles impa cted:,3,Wh en the cla im invoice includes the CLIN n umber, it should dis play Mill Bill (1725 ) payment authority | ||
10 | , | ||
11 | Test setup /Precondit ions:,Paym ent author ity SPECS are comple ted. Payme nt Authori ty tables, columns, data are a vailable ,>>>>>,cla im invoice is for au thority 17 03 ----> validate u nder contr act 8153 - Title 38, | ||
12 | Requiremen t or Chang e,-------> Shows pay ment APPRO VED, | ||
13 | Acceptance criteria, >When the claim invo ice is for authority 1703 and 1728, it s hould be v alidated u nder contr act 8153 – Title 38 and show p ayment app roved | ||
14 | >When the validated claim invo ice is und er contrac t 8153 – T itle 38, i t should n ot display payment a uthority M ill Bill ( 1725) and it should show payme nt denied | ||
15 | >When the claim invo ice includ es the CLI N number, it should display Mi ll Bill (1 725) payme nt authori ty,>>>>>,c laim invoi ce is for authority 1728 ---- > validate under con tract 8153 -Title 38 , | ||
16 | -------> S hows payme nt APPROVE D, | ||
17 | Assumption s:,>>>>>,c laim invoi ce validat ed under c ontract 81 53 - Title 38 ----> should not display p ayment aut hority Mil l Bill (17 25), | ||
18 | Test Case #,>>>>>,cl aim invoic e validate d under co ntract 815 3 - Title 38 ----> s hould be D ENIED, | ||
19 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et,>>>>>,c laim invoi ce include s the CLIN number--- --> displ ay Mill Bi ll (1725) payment au thority, | ||
20 | Step numbe r,Descript ion,Expect ed results , | ||
21 | 1,Use a qu ery to ide ntify clai ms, claim line and , only diffe rent payme nt authori ty is Mill Bill (172 5). Other s are 1703 and 1728, | ||
22 | 2,authorit y would be under con tract 8153 – Title 3 8, | ||
23 | 3,If payme nt authori ty for ref erral in a n invoice line item does not m atch the p ayment aut hority in the 837COB ---> anno tate datab ase record for the i nvoice lin e as denie d includin g CARC/RAR C code for denial , | ||
24 | 4,• If the payment a uthority i n the 837C OB does no t match th e payment authority in the ref erral, it will be de nied.,cont ract 8153, simplified acquisiti on procedu res set fo rth in thi s part app ly to the acquisitio n of healt h-care res ources con sisting of commercia l services or the us e of medic al equipme nt or spac e, | ||
25 | 5,If Invoi ces that d o not matc h a referr al should be annotat ed as deni ed.,Health -care prov iders incl ude health -care plan s and insu rers and a ny organiz ations, in stitutions , or other entities or individ uals who f urnish hea lth-care r esources. (38 U.S.C . 8153), | ||
26 | 6,If • Inv oices that do not ma tch a refe rral shoul d include a reason f or denial from a sta ndard list (CARC/RAR C).,Health -care reso urce inclu des hospit al care an d medical services ( as those t erms are d efined in section 17 01 of titl e 38 Unite d States C ode (U.S.C .)), any o ther healt h-care ser vice, and any health -care supp ort or adm inistrativ e resource , includin g the use of medical equipment or space. (38 U.S. C. 8153), | ||
27 | 7,• The va lidated in voice will only show evaluated line item , it shoul d display line item Payment Au thority in cluded in the referr al, | ||
28 | 8,• Line i tems match ing the re ferral, sh ould displ ay status as approve d, | ||
29 | 9,• Line i tems with a Payment Authority that does not match the referr al, should display s tatus as d enied, | ||
30 | 10, | ||
31 | 11, | ||
32 | 12, | ||
33 | 13, | ||
34 | 14, | ||
35 | 15, | ||
36 | |||
37 | Test Case# ,Test Ca se # T est Script s# , | ||
38 | |||
39 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et - Insti tutional , | ||
40 | Step numbe r,Descript ion,Expect ed results , | ||
41 | 1, | ||
42 | 2, | ||
43 | 3, | ||
44 | 4, | ||
45 | 5, | ||
46 | 6, | ||
47 | 7, | ||
48 | 8, | ||
49 | 9, | ||
50 | 10, | ||
51 | 11, | ||
52 | 12, | ||
53 | 13, | ||
54 | 14, | ||
55 | 15, | ||
56 | |||
57 | Test Case# ,Test Ca se # T est Script s# Re quirement, | ||
58 | |||
59 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et -Pharma cy Claims, | ||
60 | Step numbe r,Descript ion,Expect ed results , | ||
61 | 1, | ||
62 | 2, | ||
63 | 3, | ||
64 | 4, | ||
65 | 5, | ||
66 | 6, | ||
67 | 7, | ||
68 | 8, | ||
69 | 9, | ||
70 | 10, | ||
71 | 11, | ||
72 | 12, | ||
73 | 13, | ||
74 | 14, | ||
75 | 15, | ||
76 | |||
77 | |||
78 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
79 | |||
80 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et-Dental Claims, | ||
81 | Step numbe r,Descript ion,Expect ed results , | ||
82 | 1, | ||
83 | 2, | ||
84 | 3, | ||
85 | 4, | ||
86 | 5, | ||
87 | 6, | ||
88 | 7, | ||
89 | 8, | ||
90 | 9, | ||
91 | 10, | ||
92 | 11, | ||
93 | 12, | ||
94 | 13, | ||
95 | 14, | ||
96 | 15, | ||
97 | |||
98 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
99 | |||
100 | |||
101 | SHEET: Sta nd. Episod e of Care | ||
102 | CS034, | ||
103 | |||
104 | TC4-CS034- 632370 De velop base line code set for St andardized Episode o f Care, | ||
105 | Note:, | ||
106 | Test objec tive:,Veri fy 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., 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., | ||
107 | Roles impa cted:, | ||
108 | Test setup /Precondit ions:,User has acces to (SEOC) informati on in the database. ,• The val idated inv oice will only show evaluated line item, it should display l ine item d ate of ser vice (DOS) are withi n the SEOC | ||
109 | • Line ite ms within the SEOC, should dis play statu s as appro ved | ||
110 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied | ||
111 | , | ||
112 | Requiremen t or Chang e,Given th e system c an automat ically eva luate invo ice line i tems | ||
113 | When invoi ces are re ceived | ||
114 | 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. , | ||
115 | Acceptance criteria, • 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 | ||
116 | • Line ite ms within the SEOC, should dis play statu s as appro ved | ||
117 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied, | ||
118 | 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 denied sta tus. , | ||
119 | Assumption s:, | ||
120 | Test Case #,query fo r claim /c laim line and their episode of care, CPT code, ref erral , Da te of serv ice, frequ ency of se rvice,• Th e validate d invoice will only show evalu ated line item, it s hould disp lay line i tem date o f service (DOS) are within the SEOC | ||
121 | • Line ite ms within the SEOC, should dis play statu s as appro ved | ||
122 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied | ||
123 | , | ||
124 | TS4- CS034 - 632370 D evelop bas eline code set for S tandardize d Episode of Care - Profession al, | ||
125 | Step numbe r,Descript ion,Expect ed results , | ||
126 | 1,Using a query ide ntify clai ms, claim lines,Clai m and clai m lines ar e identifi ed, | ||
127 | 2,• If a l ine item d oes not fa ll within the Standa rdized Epi sode of Ca re (SEOC) it will be denied., | ||
128 | 3,• Invoic es that do not match a referra l should b e annotate d as denie d, | ||
129 | 4,• Invoic es that do not match a referra l should i nclude a r eason for denial fro m a standa rd list (C ARC/RARC). , | ||
130 | 5,• The va lidated in voice will only show evaluated line item , it shoul d display line item date of se rvice (DOS ) are with in the SEO C, | ||
131 | 6,• Line i tems withi n the SEOC , should d isplay sta tus as app roved, | ||
132 | 7,• Line i tems with DOS outsid e of the S EOC, shoul d display status as denied, | ||
133 | 8, | ||
134 | 9, | ||
135 | 10, | ||
136 | 11, | ||
137 | 12, | ||
138 | 13, | ||
139 | 14, | ||
140 | 15, | ||
141 | |||
142 | Test Case# ,Test Ca se # T est Script s# , | ||
143 | |||
144 | TS4- CS034 - 632370 D evelop bas eline code set for S tandardize d Episode of Care- I nstitution al , | ||
145 | Step numbe r,Descript ion,Expect ed results , | ||
146 | 1, | ||
147 | 2, | ||
148 | 3, | ||
149 | 4, | ||
150 | 5, | ||
151 | 6, | ||
152 | 7, | ||
153 | 8, | ||
154 | 9, | ||
155 | 10, | ||
156 | 11, | ||
157 | 12, | ||
158 | 13, | ||
159 | 14, | ||
160 | 15, | ||
161 | |||
162 | Test Case# ,Test Ca se # T est Script s# Re quirement, | ||
163 | |||
164 | TS4- CS034 - 632370 D evelop bas eline code set for S tandardize d Episode of Care-Ph armacy Cla ims, | ||
165 | Step numbe r,Descript ion,Expect ed results , | ||
166 | 1, | ||
167 | 2, | ||
168 | 3, | ||
169 | 4, | ||
170 | 5, | ||
171 | 6, | ||
172 | 7, | ||
173 | 8, | ||
174 | 9, | ||
175 | 10, | ||
176 | 11, | ||
177 | 12, | ||
178 | 13, | ||
179 | 14, | ||
180 | 15, | ||
181 | |||
182 | |||
183 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
184 | |||
185 | TS4- CS034 - 632370 D evelop bas eline code set for S tandardize d Episode of Care-De ntal Claim s, | ||
186 | Step numbe r,Descript ion,Expect ed results , | ||
187 | 1, | ||
188 | 2, | ||
189 | 3, | ||
190 | 4, | ||
191 | 5, | ||
192 | 6, | ||
193 | 7, | ||
194 | 8, | ||
195 | 9, | ||
196 | 10, | ||
197 | 11, | ||
198 | 12, | ||
199 | 13, | ||
200 | 14, | ||
201 | 15, | ||
202 | |||
203 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
204 | |||
205 | |||
206 | SHEET: Sco pe Of Epis ode | ||
207 | CS014, | ||
208 | |||
209 | TC4- CS, | ||
210 | |||
211 | Test objec tive:, | ||
212 | Roles impa cted:, | ||
213 | Test setup /Precondit ions:,The invoice mu st include the rende ring provi der’s NPI, the rende ring servi ce facilit y and the service fa cility zip code to e nsure accu rate payme nts., | ||
214 | Requiremen t or Chang e,The rend ering prov ider must be within the CCN Ne twork., | ||
215 | Acceptance criteria, The render ing provid er must ha ve been ac tive withi n the CCN Network at the time that the s ervice was provided. , | ||
216 | |||
217 | Assumption s:, | ||
218 | Test Case #, | ||
219 | TS4- CS, | ||
220 | Step numbe r,Descript ion,Expect ed results , | ||
221 | 1, | ||
222 | 2,If an 83 7 does not include a referral number, it will be r ejected., | ||
223 | 3, | ||
224 | 4,If an 83 7 does not include c oordinatio n of benef its (COB) informatio n it will be rejecte d, | ||
225 | 5, | ||
226 | 6,The invo ice must i nclude the rendering provider’ s NPI, the rendering service f acility an d the serv ice facili ty zip cod e to ensur e accurate payments. , | ||
227 | 7,ETL is v alidating that refer ral number and COB i nformation fields ar e not null , | ||
228 | 8,The rend ering prov ider must be within the CCN Ne twork., | ||
229 | 9,The NPI number and date of s ervice mus t be made available when query ing the PP MS system to confirm if the pr ovider was within ne twork at t he time of the claim invoice s ervice., | ||
230 | 10,The ren dering pro vider must have been active wi thin the C CN Network at the ti me that th e service was provid ed, | ||
231 | 11,- Is th is a Team 4 responsi bility? Wh at is PPMS ? PPMS is one of our interface s (a diffe rent syste m). The i nterface i tself is t he respons ibility of the inter face team. SEOC inf ormation i s coming f rom CCRA. PPMS is w hat we che ck for LEI E, | ||
232 | 12,The NPI number an d date of service mu st be made available when quer ying the P PMS system to confir m if the p rovider wa s within n etwork at the time o f the clai m invoice service, | ||
233 | 13, | ||
234 | 14, | ||
235 | 15, | ||
236 | |||
237 | Test Case# ,Test Ca se # T est Script s# , | ||
238 | |||
239 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et - Insti tutional , | ||
240 | Step numbe r,Descript ion,Expect ed results , | ||
241 | 1, | ||
242 | 2, | ||
243 | 3, | ||
244 | 4, | ||
245 | 5, | ||
246 | 6, | ||
247 | 7, | ||
248 | 8, | ||
249 | 9, | ||
250 | 10, | ||
251 | 11, | ||
252 | 12, | ||
253 | 13, | ||
254 | 14, | ||
255 | 15, | ||
256 | |||
257 | Test Case# ,Test Ca se # T est Script s# Re quirement, | ||
258 | |||
259 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et -Pharma cy Claims, | ||
260 | Step numbe r,Descript ion,Expect ed results , | ||
261 | 1, | ||
262 | 2, | ||
263 | 3, | ||
264 | 4, | ||
265 | 5, | ||
266 | 6, | ||
267 | 7, | ||
268 | 8, | ||
269 | 9, | ||
270 | 10, | ||
271 | 11, | ||
272 | 12, | ||
273 | 13, | ||
274 | 14, | ||
275 | 15, | ||
276 | |||
277 | |||
278 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
279 | |||
280 | TS4- CS038 - 632371 CS038-Ref actor Paym ent Author ity rule s et-Dental Claims, | ||
281 | Step numbe r,Descript ion,Expect ed results , | ||
282 | 1, | ||
283 | 2, | ||
284 | 3, | ||
285 | 4, | ||
286 | 5, | ||
287 | 6, | ||
288 | 7, | ||
289 | 8, | ||
290 | 9, | ||
291 | 10, | ||
292 | 11, | ||
293 | 12, | ||
294 | 13, | ||
295 | 14, | ||
296 | 15, | ||
297 | |||
298 | Test Case# ,Test Ca se # T est Script s# Requireme nt, | ||
299 | |||
300 | |||
301 | SHEET: She et1 | ||
302 | |||
303 | |||
304 | SHEET: She et2 | ||
305 | [12/20/ 2017 4:13 PM] Mulla ney: , | ||
306 | Here are t he rules. The code c urrently o nly checks for admis sion date for instit utional, | ||
307 | |||
308 | Institutio nal Inpati ent (poten tially Cla im Level A dmission D ate), | ||
309 | DIM_INSTIT UTIONAL_CL AIM.admiss ion_date, | ||
310 | |||
311 | Institutio nal Outpat ient and O ther Non-I npatient, | ||
312 | 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, | ||
313 | 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., | ||
314 | |||
315 | |||
316 | |||
317 | |||
318 | SHEET: LEI E | ||
319 | TC4-632369 CS011-De velop code for List of Exclude d Individu als and En tities | ||
320 | ,To update in ration al , | ||
321 | Test objec tive:,Veri fy that cl aim /claim line is d enied whe n the prov ider is on LEIE list ,https://o ig.hhs.gov /exclusion s/exclusio ns_list.as p, | ||
322 | Roles impa cted:,List of Exclud ed Individ uals and E ntities (L EIE), | ||
323 | Test setup /Precondit ions:,Data base has p rovider ta bles and e xclusion l ist. | ||
324 | Provider N PI OR Prov ider TAX I D is on th e "LEIE Li st" AND | ||
325 | Provider e ntry exist with no R einstate D ate (i.e a n active e ntry) AND | ||
326 | Claim line Service D ate To >= the "LEI E List" ex clusion da te AND | ||
327 | Provider I D is not " 000000000" AND | ||
328 | TAX ID is not "00000 0000" | ||
329 | |||
330 | ,Add steps to verify for '0000 000000' va lues,need table and data, | ||
331 | Requiremen t or Chang e, | ||
332 | Acceptance criteria, | ||
333 | |||
334 | Assumption s:, | ||
335 | Test Case #,168263, | ||
336 | TS4- 63236 9 CS011-D evelop cod e for List of Exclud ed Individ uals and E ntities - Profession al - Claim line, | ||
337 | Step numbe r,Descript ion,Expect ed results , | ||
338 | 1, | ||
339 | Query Prov ider Look up table a nd select few provid ers that a re in the exclusion list and f ew that ar e not excl uded | ||
340 | |||
341 | ,Providers are selec ted _____ __________ __ | ||
342 | __________ _______ __ __________ ________,q uery table for NPI / Tax ID o n leie lis t and prov ider exist wit no re instate da te and cla im line se rvice sdat e >= exclu sion date and provid er ID or t ax id is n ot NULL or 0000000 , | ||
343 | 2,Select c laims / cl aim lines with exclu ded provid ers ( list ed in the LEIE list) ,Claims ar e selected ,date inst itution da tes , | ||
344 | 3,Select c laims / cl aim lines with non e xcluded pr oviders ( Providers are not in the LEIE list),Clai ms are sel ected, | ||
345 | 4,Run bat ch job usi ng the sam e batchID as the sel ected clai ms,Batch j ob is ran, | ||
346 | 5,Using De cision tab le query, validate t hat claims and claim lines wit h provider s in the L EIE list a re DENIED, Claims and claim lin es with pr oviders in the LEIE list are D ENIED, | ||
347 | 6,Using De cision tab le query, validate t hat claims and claim lines wit h provider s that are not iin t he listing are accep ted under this rule. This can be verifi ed using t he generat ed log, cl aims and c laim lines with prov iders that are not i in the lis ting are a ccepted un der this r ule, | ||
348 | Test Case# ,Test Ca se # T est Script # 15 8198, | ||
349 | |||
350 | TS4- 63236 9 CS011-D evelop cod e for List of Exclud ed Individ uals and E ntities- I nstitution al - Claim lines, | ||
351 | Step numbe r,Descript ion,Expect ed results , | ||
352 | 1, | ||
353 | Query Prov ider Look up table a nd select few provid ers that a re in the exclusion list and f ew that ar e not excl uded | ||
354 | |||
355 | ,Providers are selec ted _____ __________ __ | ||
356 | __________ _______ __ __________ ________,q uery table for NPI / Tax ID o n leie lis t and prov ider exist wit no re instate da te and cla im line se rvice sdat e >= exclu sion date and provid er ID or t ax id is n ot NULL or 0000000 | ||
357 | , | ||
358 | 2,Select c laims / cl aim lines with exclu ded provid ers ( list ed in the LEIE list) ,Claims ar e selected , | ||
359 | 3,Select c laims / cl aim lines with non e xcluded pr oviders ( Providers are not in the LEIE list),Clai ms are sel ected, | ||
360 | 4,Run bat ch job usi ng the sam e batchID as the sel ected clai ms,Batch j ob is ran, | ||
361 | 5,Using De cision tab le query, validate t hat claims and claim lines wit h provider s in the L EIE list a re DENIED, Claims and claim lin es with pr oviders in the LEIE list are D ENIED, | ||
362 | 6,Using De cision tab le query, validate t hat claims and claim lines wit h provider s that are not iin t he listing are accep ted under this rule. This can be verifi ed using t he generat ed log, cl aims and c laim lines with prov iders that are not i in the lis ting are a ccepted un der this r ule, | ||
363 | Test Case# ,Test Ca se # T est Script # 158200 Requi rement, | ||
364 | |||
365 | TS4- 63236 9 CS011-D evelop cod e for List of Exclud ed Individ uals and E ntities - Dental, | ||
366 | Step numbe r,Descript ion,Expect ed results , | ||
367 | 1, | ||
368 | Query Prov ider Look up table a nd select few provid ers that a re in the exclusion list and f ew that ar e not excl uded | ||
369 | |||
370 | ,Providers are selec ted _____ __________ __ | ||
371 | __________ _______ __ __________ ________,q uery table for NPI / Tax ID o n leie lis t and prov ider exist wit no re instate da te and cla im line se rvice sdat e >= exclu sion date and provid er ID or t ax id is n ot NULL or 0000000 , | ||
372 | 2,Select c laims / cl aim lines with exclu ded provid ers ( list ed in the LEIE list) ,Claims ar e selected , | ||
373 | 3,Select c laims / cl aim lines with non e xcluded pr oviders ( Providers are not in the LEIE list),Clai ms are sel ected, | ||
374 | 4,Run bat ch job usi ng the sam e batchID as the sel ected clai ms,Batch j ob is ran, | ||
375 | 5,Using De cision tab le query, validate t hat claims and claim lines wit h provider s in the L EIE list a re DENIED, Claims and claim lin es with pr oviders in the LEIE list are D ENIED, | ||
376 | 6,Using De cision tab le query, validate t hat claims and claim lines wit h provider s that are not iin t he listing are accep ted under this rule. This can be verifi ed using t he generat ed log, cl aims and c laim lines with prov iders that are not i in the lis ting are a ccepted un der this r ule, | ||
377 | Test Case# ,Test Ca se # T est Script # 158201 Req uirement, | ||
378 | |||
379 | |||
380 | SHEET: Res ubmission | ||
381 | Update rat ional, | ||
382 | TC4-CS039- 632367 - Refactor T imely Fili ng Rule se t to inclu de 30-day resubmissi on require ment | ||
383 | ,Yes, | ||
384 | Test objec tive:,Veri fy that ti mely filin g rule inc ludes syst em is able to resubm it claims within 30 days after rejection ,report of f this tab le and sen d the prob lematic cl aim lines to the CCN s so they can correc t/re-submi t. | ||
385 | Denial - F or claim l ines that pass the 8 37 ETL val idations a nd get per sisted on CCRS claim tables, a Denial wo uld be sub ject to yo ur team's business r ules check s. We'll l ikely need a dedicat ed date fi eld in the database to capture if/when C CRS issues a denial. We have a due out q uestion to VA to con firm wheth er Rejects and Denia ls (or jus t Denials) need to b e accounte d for as p art of the 'Timely F iling' re- submission business rule condi tion. | ||
386 | |||
387 | For the 'T imely Fili ng' condit ion relate d to paid date, it r epresents the date t he CCN ini tially pai d the prov ider. This should co me to CCRS via the 8 37. Althou gh our cur rent F_DET AILS table s have a p aid_date f ield, we m ay want a separate p aid date f ield (e.g. , 'CCN_pai d_date') t o delineat e between the date t he CCN ini tially pai d the prov ider vs. t he date CC RS/VA paid the CCNs, | ||
388 | Roles impa cted:,We v alidate by confirmin g that whe n the corr ected clai m using th e EDIPI, t here is no duplicate payment. , | ||
389 | Test setup /Precondit ions:,Data base has R ejected cl aim that a re identif ied with a dash (-) and a suff ix like N | ||
390 | ex. 1353- N (nbr),Wh en the sys tem detect s correcte d claims u tilizing t he claim l ine item E DI unique identifier - annotat ed with su ffix and p revent pay ment of du plicates | ||
391 | • When pay ers accept s correcte d claims e lectronica lly, then we will re quire a on e-digit cl aim freque ncy or res ubmission code in th e loop 230 0 CLM segm ent (posit ion CLM05- 3), and a loop 2300 REF segmen t with an F8 qualifi er (positi on REF01) and an Int ernal Clai m Number ( ICN) (posi tion REF02 ), | ||
392 | Requiremen t or Chang e, | ||
393 | Acceptance criteria, | ||
394 | |||
395 | Assumption s:,Rejecte d claims a re availla ble in the CCRS DB. They are also resu bmitted cl aims in th e CCRS DB, | ||
396 | Test Case #,168260,S teps /quer ies, | ||
397 | TS4- CS039 -632367 -Refactor Timely Fil ing Rule s et to incl ude 30-day resubmiss ion requir ement - Pr ofessional , | ||
398 | Step numbe r,Descript ion,Expect ed results , | ||
399 | 1, | ||
400 | Query Deci sion table and selec t claims that has b een previo usly Rejec ted | ||
401 | |||
402 | , | ||
403 | Query resu lts are di splayed, | ||
404 | 2,Select c laims with Start_dat e minus Re jection de cision_dat e_time is < than 30 days,Claim s are sele cted, | ||
405 | 3,Select c laims with Start_dat e minus Re jection de cision_dat e_time is > than 30 days,Claim s are sele cted, | ||
406 | 4,Select c laims with Start_dat e minus Re jection de cision_dat e_time is = than 30 days,Claim s are sele cted, | ||
407 | 5,Run (Ti mely -Fili ng) batch job using the same b atchID as the select ed claims, Batch job is ran, | ||
408 | 6,Using De cision tab le query, validate that claim s that hav e Start_da te minus R ejection d ecision_da te_time < or = 30 ar e resubmit ted,Claims with < or = 30 days are resub mitted,sel ect * | ||
409 | from decis ion | ||
410 | --where de cision = ' rejected' | ||
411 | where etl_ batch_id = 'DL_837P_2 0171204_2' ,
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412 | 7,Query fo r the clai m lines as sociated t o the clai ms above a nd verify the outcom e In the d ecision ta ble for ea ch claim l ine,Claim lines outc ome displa ys in deci sion table , | ||
413 | 8,Verify D enied line s are for the Claims of more t han 30 day s and Appr oved line are for cl aims of le ss or equ al to 30 d ays,Denied and appro ved lines are verifi ed,If clai m is denie d what hap pens?, | ||
414 | Test Case# ,Test Ca se # T est Script s# 1 58194, | ||
415 | |||
416 | TS4- CS039 -632367 -Refactor Timely Fil ing Rule s et to incl ude 30-day resubmiss ion requir ement - In stitutiona l, | ||
417 | Step numbe r,Descript ion,Expect ed results , | ||
418 | 1, | ||
419 | Query Deci sion table and selec t claims that has b een previo usly Rejec ted | ||
420 | |||
421 | , | ||
422 | Query resu lts are di splayed, | ||
423 | 2,Select c laims with Start_dat e minus Re jection de cision_dat e_time is < than 30 days,Claim s are sele cted, | ||
424 | 3,Select c laims with Start_dat e minus Re jection de cision_dat e_time is > than 30 days,Claim s are sele cted, | ||
425 | 4,Select c laims with Start_dat e minus Re jection de cision_dat e_time is = than 30 days,Claim s are sele cted, | ||
426 | 5,Run (Ti mely -Fili ng) batch job using the same b atchID as the select ed claims, Batch job is ran, | ||
427 | 6,Using De cision tab le query, validate that claim s that hav e Start_da te minus R ejection d ecision_da te_time < or = 30 ar e resubmit ted,Claims with < or = 30 days are resub mitted,sel ect * from decision | ||
428 | where etl_ batch_id = 'EDI_837I_ 20171201', | ||
429 | 7,Query fo r the clai m lines as sociated t o the clai ms above a nd verify the outcom e In the d ecision ta ble for ea ch claim l ine,Claim lines outc ome displa ys in deci sion table , | ||
430 | 8,Verify D enied line s are for the Claims of more t han 30 day s and Appr oved line are for cl aims of le ss or equ al to 30 d ays,Denied and appro ved lines are verifi ed,If clai m is denie d what hap pens?, | ||
431 | Test Case# ,Test Ca se # T est Script s# 158195 Requir ement, | ||
432 | |||
433 | TS4- CS039 -632367 -Refactor Timely Fil ing Rule s et to incl ude 30-day resubmiss ion requir ement - De ntal, | ||
434 | Step numbe r,Descript ion,Expect ed results , | ||
435 | 1, | ||
436 | Query Deci sion table and selec t claims that has b een previo usly Rejec ted | ||
437 | |||
438 | , | ||
439 | Query resu lts are di splayed, | ||
440 | 2,Select c laims with Start_dat e minus Re jection de cision_dat e_time is < than 30 days,Claim s are sele cted,Insti tutional: EDI_837I_2 0171201, | ||
441 | 3,Select c laims with Start_dat e minus Re jection de cision_dat e_time is > than 30 days,Claim s are sele cted,Profe ssional: D L_837P_201 71204_2, | ||
442 | 4,Select c laims with Start_dat e minus Re jection de cision_dat e_time is = than 30 days,Claim s are sele cted,Denta l: DL_837D _20171207_ 5, | ||
443 | 5,Run (Ti mely -Fili ng) batch job using the same b atchID as the select ed claims, Batch job is ran, | ||
444 | 6,Using De cision tab le query, validate that claim s that hav e Start_da te minus R ejection d ecision_da te_time < or = 30 ar e resubmit ted,Claims with < or = 30 days are resub mitted,sel ect * | ||
445 | from decis ion | ||
446 | --where de cision = ' rejected' | ||
447 | where etl_ batch_id = 'DL_837D_2 0171207_5' , | ||
448 | 7,Query fo r the clai m lines as sociated t o the clai ms above a nd verify the outcom e In the d ecision ta ble for ea ch claim l ine,Claim lines outc ome displa ys in deci sion table ,EDI_837I_ 20171201: | ||
449 | claim_key = 1663 | ||
450 | claim_line _key = 168 7, 1688 (T hese Shoul d Pass) | ||
451 | claim_key = 1666 | ||
452 | claim_line _key = 168 9 (These S hould Fail ) | ||
453 | ========== ========== ========== ========== ========== ===== | ||
454 | DL_837P_20 171204_2: | ||
455 | claim_key = 1664 | ||
456 | claim_line _key = 111 5 (These S hould Pass ) | ||
457 | claim_key = 1667 | ||
458 | claim_line _key = 111 6 (These S hould Fail ) | ||
459 | ========== ========== ========== ========== ========== ===== | ||
460 | DL_837D_20 171207_5: | ||
461 | claim_key = 1628 | ||
462 | claim_line _key = 602 , 603 (The se Should Pass) | ||
463 | claim_key = 1665 | ||
464 | claim_line _key = 605 , 606 (The se Should Fail), | ||
465 | 8,Verify D enied line s are for the Claims of more t han 30 day s and Appr oved line are for cl aims of le ss or equ al to 30 d ays,Denied and appro ved lines are verifi ed,If clai m is denie d what hap pens?, | ||
466 | Test Case# ,Test Ca se # T est Script s# 1581 96 Req uirement, | ||
467 | |||
468 | |||
469 | SHEET: Dat e of servi ce | ||
470 | Date , | ||
471 | |||
472 | |||
473 | SHEET: Ins titutional claims | ||
474 | [12/20/ 2017 4:13 PM] Mulla ney: , | ||
475 | Here are t he rules. The code c urrently o nly checks for admis sion date for instit utional, | ||
476 | |||
477 | Institutio nal Inpati ent (poten tially Cla im Level A dmission D ate), | ||
478 | DIM_INSTIT UTIONAL_CL AIM.admiss ion_date, | ||
479 | |||
480 | Institutio nal Outpat ient and O ther Non-I npatient, | ||
481 | 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, | ||
482 | 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., | ||
483 | |||
484 |
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