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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Questions | CCRS_Rules_Questions.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\Questions | CCRS_Rules_Questions.docx | Fri Jun 15 14:41:02 2018 UTC |
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1 | CCRS Rules Questions | |
2 | General | |
3 | Date of Se rvice | |
4 | Several ru les depend on the no tion of a date of se rvice (tim ely filing , LEIE, va lid referr al). | |
5 | Currently, the follo wing dates are used as the dat e of servi ce: | |
6 | Type | |
7 | Line/claim Level? | |
8 | CCRSDB | |
9 | 837i/p/d | |
10 | Profession al | |
11 | Line | |
12 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS.ser vice_date_ from | |
13 | Date of Se rvice (Fro m) | |
14 | (Loop: 240 0, DTP03) | |
15 | Institutio nal inpati ent | |
16 | Claim | |
17 | DIM_INSTIT UTIONAL_CL AIM.admiss ion_date | |
18 | ||
19 | Admission Date | |
20 | (Loop: 230 0, DTP02) | |
21 | Institutio nal outpat ient | |
22 | Line | |
23 | F_INSTITUT IONAL_MEDI CAL_CLAIM_ DETAILS.se rvice_date | |
24 | ? | |
25 | Dental | |
26 | Claim | |
27 | F_DENTAL_C LAIM_DETAI LS.date_of _service | |
28 | ||
29 | ||
30 | Questions: | |
31 | Is the adm ission dat e the righ t date for instituti onal inpat ient? Can a start da te for a s ervice be before the admission date, esp if a pati ent was ad mitted aro und midnig ht? | |
32 | What to us e as the d ate of ser vice for i nstitution al outpati ent? line level serv ice date i s not requ ired for o utpatient. Shadi pro posed the following: | |
33 | 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 | |
34 | 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. | |
35 | What is th is other f ield? | |
36 | What about using sta tement dat es for all instituti onal as de scribed be low? | |
37 | Instead of dealing w ith the he adache to discern wh ich field to use for each of t he differe nt Institu tional cla im sub-typ es, I reco mmend we p ropose to VA that we use eithe r the Stat ement From Date or S tatement T o Date for all Insti tutional c laims acro ss the boa rd. These are the re asons: 1) Statement From/To ar e required for all I nstitution al claims, 2) both d ates are s ufficientl y close to the Admit /Discharge /Line Leve l Service Date irres pective of which are populated , and 3) P rogram Int egrity has leaned on the State ment Date fields in Institutio nal duplic ate rule c hecks on P IT instead of servic e dates. | |
38 | ||
39 | Note that Medicare s ometimes u ses the "t o" date: | |
40 | Medicare u ses the li ne item ‘F rom’ date to determi ne the dat e of servi ce for cla ims filing timelines s for clai ms | |
41 | submitted by health care profe ssionals a nd supplie rs that in clude span dates of service. ( This inclu des Durabl e | |
42 | Medical Eq uipment (D ME) suppli es and ren tal items. ) If a lin e item ‘Fr om’ date i s not time ly but the ‘To’ date is timely , | |
43 | contractor s must spl it the lin e item and deny the untimely s ervices as not timel y filed. | |
44 | Perhaps we should im plement th e same rul e if it's considered industry standard? | |
45 | How to Det ermine Ins titutional Outpatien t Claims? | |
46 | CCRS curre ntly uses admission date (dim_ institutio nal_claim. admission_ date) as t he indicat or of an o utpatient claim. Is this the b est approa ch? | |
47 | Timely Fil ing Rule | |
48 | One of the validatio ns is to c heck for t ime since the last s ubmission. Currently , we assum e that res ubmitted c laims will have IDs in the for mat <claim ID>-<resu bmission n umber>. So we check for the nu mber after the last dash. If i t exists, we assume that the i nvoice is a re-submi ssion. Is this the r ight logic ? This ass umes that the networ ks cannot use dashes in their invoice ID s except w hen resubm itting. | |
49 | Claim Amou nt Thresho ld Rule | |
50 | Do we want to use se rvice date and the e ffective d ate of the threshold amount fo r the rule ? I.e., th e threshol d check wo uld be bas ed on the service da te. This w ill be con sistent wi th the LIE IE rule. | |
51 | We current ly set the status to "approved " automati cally afte r the 24-h our period . Is it un conditiona l? What if VA needs more time to review? Shouldn't it be int egrated wi th the cas e manageme nt tool? | |
52 | Referral R ules | |
53 | How do we want to tr eat flu sh ots that h ave a refe rral? Shou ld we igno re the ref erral date s if the r eferral ex ists? | |
54 | Payment Au thority | |
55 | Flu shot d oes not re quire a re ferral. Bu t if it co mes with a referral, should we check the PA agains t the refe rral or ag ainst the PA obligat ion table? | |
56 | ||
57 | ||
58 |
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