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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | CCRS BUSINESS RULES 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 | CCRS BUSINESS RULES SPECIFICATION.docx | Fri Jun 15 14:48:30 2018 UTC |
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1 | Business R ule Engine Specifica tion | ||
2 | Community Care Reimb ursement S ystem | ||
3 | Rule Speci fication D ocument | ||
4 | |||
5 | |||
6 | |||
7 | October 20 17 | ||
8 | Version 1. 0 | ||
9 | |||
10 | Department of Vetera ns Affairs | ||
11 | |||
12 | |||
13 | |||
14 | Revision H istory | ||
15 | |||
16 | Date | ||
17 | Version | ||
18 | Descriptio n | ||
19 | Author | ||
20 | 10/12/2017 | ||
21 | 1.0 | ||
22 | Initial Dr aft | ||
23 | K. Phaup ( FTC) | ||
24 | 11/20/2017 | ||
25 | 2.0 | ||
26 | Updated Ta ble 1: Rul es Invento ry | ||
27 | Section 2. 2 Rules De tails | ||
28 | Rule 001 – Deactivat ed OHI con dition and rule acti ons; updat ed rule at tributes; added 30 d ay timely filing req uirement f or previou sly reject ed or deni ed claims; separated Outpatien t claims f rom Inpati ent claims by design ating Rule 001a and R ule001b | ||
29 | Rule 002 – Added des cription, attributes and condi tions | ||
30 | Rule 003 – updated d escription and rule attributes to captur e that ref erral must be active at date o f service and flu sh ot excepti ons | ||
31 | Rule 004 – descripti on, rules attributes and | ||
32 | Rule 005 – descripti on updated to captur e dates of service m ust be wit hin the da tes of ser vice speci fied in th e Referral ; updated to reflect that clai m lines mu st be matc hed agains t the refe rral activ e at the t ime of the initial r eferral | ||
33 | Rule 008 – new rule, Payment A uthority | ||
34 | J. Lucas ( GT) | ||
35 | |||
36 | |||
37 | |||
38 | |||
39 | |||
40 | |||
41 | Table of C ontents | ||
42 | |||
43 | |||
44 | 1.Introduc tion4 | ||
45 | 2.Rule Det ail5 | ||
46 | 2.1Rules I nventory5 | ||
47 | 2.2Rules D etails5 | ||
48 | 3.Rule Set s7 | ||
49 | 3.1If-then Rule Sets 7 | ||
50 | 3.2Decisio n Tables7 | ||
51 | 3.3Decisio n Trees7 | ||
52 | 3.4Rule Fl ows7 | ||
53 | 4.Rules Im plementati on8 | ||
54 | 4.1Develop ment of th e Rules Su bsystem8 | ||
55 | 4.2Integra tion of th e Rules Su bsystem8 | ||
56 | |||
57 | Introducti on | ||
58 | |||
59 | CCRS is a payment pr ocessing s ystem whic h will han dle the au tomation o f processi ng invoice s from val idation to payment i ncluding t he verific ation of p ayment acc uracy of t he invoice s submitte d by the C ontracted Community Care Netwo rks (CCNS) . The Sys tem will g enerate ac curate rei mbursement payments according to the con tract or a ppropriate fee sched ule to the contracte d entities , to autom ate and fa cilitate p ost paymen t audit ac tivities f or reimbur sements an d to autom ate and fa cilitate r evenue ope ration act ivities su ch as appl icable dat a from EDI Transmiss ion (837) Coordinati on of Bene fits (COB) informati on for 3rd party bil ling and 1 st party c opayment l iability d eterminati on. | ||
60 | |||
61 | This docum ent identi fied the r ules, rule sets, rul e-flows, r ule constr aints, bus iness obje ct models, and all o ther attri butes rela ted to the CCRS Busi ness Rule Engine’s r ule design and imple mentation. | ||
62 | |||
63 | |||
64 | Rule Detai l | ||
65 | General Re quirements for All R ules | ||
66 | If at leas t one rule fails, a claim line is denied (decision =DENIED) o r submitte d for manu al review (decision= PENDING_RE VIEW) | ||
67 | PENDING_RE VIEW can b e set only if there are no DEN IED from o ther rules . If both denied and a rending _review ru les fail, the decisi on is DENI ED. | ||
68 | When all r ules succe ed, a clai m line is approved f or payment (decision =APPROVED) | ||
69 | When DENYI NG a claim the syste m will rec ord a reas on code wi thin indus try standa rds with t he denial descriptio n on the c ommunicati on transmi tted back to the con tractor fo r correcti on and res ubmittal ( http://www .wpc-edi.c om/referen ce/codelis ts/healthc are/claim- adjustment -reason-co des/ http: //www.wpc- edi.com/re ference/co delists/he althcare/r emittance- advice-rem ark-codes/ ) | ||
70 | Rules Inve ntory | ||
71 | This table is a cons olidated l ist of imp lemented r ules withi n the appl ication. C olumns ide ntify high -level rul e applicab ility to w hich categ ory of cla ims, the a ssociated BOM entry associatio ns, as wel l as a des cription o f what the rule will accomplis h. | ||
72 | |||
73 | RULE # | ||
74 | RULE | ||
75 | RULE DESCR IPTION | ||
76 | CATEGORY | ||
77 | BUSINESS O BJECTS | ||
78 | 001a | ||
79 | Timely Fil ing Outpat ient | ||
80 | Outpatient claims ar e submitte d within a llowed tim eframe fro m date of service | ||
81 | Profession al, Instit utional Ou tpatient, | ||
82 | Pharmacy, | ||
83 | Dental | ||
84 | ClaimLine | ||
85 | Claim | ||
86 | 001b | ||
87 | Timely Fil ing Inpati ent | ||
88 | Inpatient claims are submitted within th e allowed time frame from date of discha rge | ||
89 | Institutio nal Inpati ent | ||
90 | ClaimLine, Claim | ||
91 | 002 | ||
92 | Claim Amou nt Thresho ld | ||
93 | Claim line s that exc eed $30,00 0 are flag ged for au dit (PENDI NG_REVIEW) | ||
94 | Profession al, Instit utional, | ||
95 | Pharmacy, | ||
96 | Dental | ||
97 | Claim | ||
98 | ClaimLine | ||
99 | 003 | ||
100 | Referrals | ||
101 | Claim line s have a m atching re ferral | ||
102 | Profession al, Instit utional, | ||
103 | Pharmacy, | ||
104 | Dental | ||
105 | ClaimLine | ||
106 | 004 | ||
107 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE) | ||
108 | Claim line CCN provi ders were not in the LEIE duri ng the tim e of treat ment | ||
109 | Profession al, Instit utional, | ||
110 | Pharmacy, | ||
111 | Dental | ||
112 | ClaimLine | ||
113 | Claim | ||
114 | 005 | ||
115 | Dates of S ervice | ||
116 | |||
117 | Profession al, Instit utional, | ||
118 | Pharmacy, | ||
119 | Dental | ||
120 | ClaimLine | ||
121 | 006 | ||
122 | Duplicates | ||
123 | Claim line is not a duplicate of another claim lin e submitte d within t he claim o r within a previous claim that was not s et to reje cted or de nied | ||
124 | Profession al, Instit utional, | ||
125 | Pharmacy, | ||
126 | Dental | ||
127 | Claim Line , Claim | ||
128 | |||
129 | 007 | ||
130 | Standardiz ed Episode of Care ( SEOC) | ||
131 | Service pr ovided wit hin the cl aim line i s included within th e SEOC | ||
132 | Profession al, Instit utional, P harmacy, D ental | ||
133 | ClaimLine | ||
134 | |||
135 | 008 | ||
136 | Payment Au thority | ||
137 | CCRS must validate p ayment aut hority for referral to payment authority in the 83 7COB | ||
138 | Profession al, Instit utional, P harmacy, D ental | ||
139 | ClaimLine, Claim | ||
140 | Rules Inve ntory | ||
141 | |||
142 | |||
143 | The corres ponding ru le details are captu red in the next sect ion. | ||
144 | |||
145 | Rules Deta ils | ||
146 | This secti on provide s all the details re quired for implement ation of t he rules f unctionali ty. These details he lp define the rule p arameters and rule m eta-data w hich is us ed to defi ne the imp lementatio n logic in the secti ons below. | ||
147 | |||
148 | The follow ing table describes the variou s rule pro perties su ch as cond itions, ac tions, att ributes, e tc. that a re require d to imple ment the r ule. | ||
149 | RULE # | ||
150 | RULE NAME | ||
151 | DATE LAST MODIFIED | ||
152 | 001a | ||
153 | Timely Fil ing Outpat ient | ||
154 | 11/20/2017 | ||
155 | Rule Descr iption | ||
156 | 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. | ||
157 | Rule Attri butes | ||
158 | IF the inv oice claim line “Dat e of servi ce” is ove r 180 days over the “Claim Rec eived Date ” | ||
159 | THEN claim line reco rd is anno tated as D enied incl uding the appropriat e CARC/RAR C reason | ||
160 | Rule Condi tions | ||
161 | Always den y claims n ot submitt ed within one hundre d eighty ( 180) days from the d ate of ser vice for p assing the timely fi ling deadl ine. | ||
162 | Condition Deactivate d: Always grant add itional ti me to the claims fil ing deadli ne require ments for Veterans w ith OHI wh en the pro vider firs t submitte d the clai m to the p rimary pay er, and th e adjudica tion occur red past t he VA fili ng deadlin e. The Con tractor mu st always ensure cla ims for se rvices den ied by ano ther insur er include the Expla nation of Benefits ( EOB) or re mittance a dvice (RA) statement indicatin g the date s of servi ce, amount of the cl aim, and r eason(s) f or denial. The Contr actor must always de ny all OHI claims su bmitted be yond ninet y (90) day s from the date of t he other i nsurer’s a djudicatio n. | ||
163 | If an invo ice or cla im line is denied or rejected, the CCN h as 30 days from the date of re jection or denial to resubmit the correc ted invoic e | ||
164 | Rule Actio ns | ||
165 | When the c laim is re ceived it will show the claime d service was perfor med within the autho rized epis ode of car e | ||
166 | If the “Da te of serv ice” is 18 0 DAYS ON OR BEFORE the "Claim Received Date", THE N status o f the clai m is set t o ACCEPT. | ||
167 | If the “Cl aim Receiv ed Date” i s 30 days ON OR BEFO RE CCN not ification of a rejec ted or den ied invoic e or claim , THEN sta tus of the claim is set to ACC EPT. | ||
168 | Deactivate d: If the “Admit Dat e” or “Fir st date of service” is 90 DAYS ON OR BEF ORE the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to AC CEPT. | ||
169 | If the “da te of serv ice” is 18 1 DAYS ON OR AFTER t he "Claim Received D ate", THEN status of the claim is set to DENIED fo r Timely F iling (TF) . | ||
170 | Deactivate d: If the “Admit Dat e” OR “Fir st date of service” is 91 DAYS ON AFTER the "Claim Received Date from VA COB", T HEN status of the cl aim is set to DENIED for Timel y Filing ( TF). | ||
171 | When DENYI NG a claim the syste m will rec ord a reas on code wi thin indus try standa rds with t he denial descriptio n on the c ommunicati on transmi tted back to the con tractor fo r correcti on and res ubmittal. | ||
172 | |||
173 | RULE # | ||
174 | RULE NAME | ||
175 | DATE LAST MODIFIED | ||
176 | 001b | ||
177 | Timely Fil ing Inpati ent | ||
178 | 11/20/2017 | ||
179 | Rule Descr iption | ||
180 | 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. | ||
181 | Rule Attri butes | ||
182 | IF the inv oice claim line “Dat e of Disch arge” is o ver 180 da ys over th e “Claim R eceived Da te” | ||
183 | THEN claim line reco rd is anno tated as D enied incl uding the appropriat e CARC/RAR C reason | ||
184 | Rule Condi tions | ||
185 | Always den y claims n ot submitt ed within one hundre d eighty ( 180) days from the d ate of dis charge for passing t he timely filing dea dline. | ||
186 | Condition Deactivate d: Always grant add itional ti me to the claims fil ing deadli ne require ments for Veterans w ith OHI wh en the pro vider firs t submitte d the clai m to the p rimary pay er, and th e adjudica tion occur red past t he VA fili ng deadlin e. The Con tractor mu st always ensure cla ims for se rvices den ied by ano ther insur er include the Expla nation of Benefits ( EOB) or re mittance a dvice (RA) statement indicatin g the date s of servi ce, amount of the cl aim, and r eason(s) f or denial. The Contr actor must always de ny all OHI claims su bmitted be yond ninet y (90) day s from the date of t he other i nsurer’s a djudicatio n. | ||
187 | If an invo ice or cla im line is denied or rejected, the CCN h as 30 days from the date of re jection or denial to resubmit the correc ted invoic e | ||
188 | Rule Actio ns | ||
189 | When the c laim is re ceived it will show the claime d service was perfor med within the autho rized epis ode of car e | ||
190 | If the “Da te of Disc harge” is 180 DAYS O N OR BEFOR E the "Cla im Receive d Date", T HEN status of the cl aim is set to ACCEPT . | ||
191 | If the “Cl aim Receiv ed Date” i s 30 days ON OR BEFO RE CCN not ification of a rejec ted or den ied invoic e or claim , THEN sta tus of the claim is set to ACC EPT. | ||
192 | Deactivate d: If the “Admit Dat e” or “Fir st date of service” is 90 DAYS ON OR BEF ORE the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to AC CEPT. | ||
193 | If the “Di scharge Da te” is 181 DAYS ON O R AFTER th e "Claim R eceived Da te", THEN status of the claim is set to DENIED for Timely Fi ling (TF). | ||
194 | Deactivate d: If the “Admit Dat e” OR “Fir st date of service” is 91 DAYS ON AFTER the "Claim Received Date from VA COB", T HEN status of the cl aim is set to DENIED for Timel y Filing ( TF). | ||
195 | When DENYI NG a claim the syste m will rec ord a reas on code wi thin indus try standa rds with t he denial descriptio n on the c ommunicati on transmi tted back to the con tractor fo r correcti on and res ubmittal. | ||
196 | |||
197 | |||
198 | RULE # | ||
199 | RULE NAME | ||
200 | DATE LAST MODIFIED | ||
201 | 002 | ||
202 | Claim Amou nt Thresho ld | ||
203 | 10/26/2017 | ||
204 | Rule Descr iption | ||
205 | |||
206 | Rule Attri butes | ||
207 | |||
208 | Rule Condi tions | ||
209 | |||
210 | Rule Actio ns | ||
211 | |||
212 | |||
213 | RULE # | ||
214 | RULE NAME | ||
215 | DATE LAST MODIFIED | ||
216 | 003 | ||
217 | Referrals | ||
218 | 11/20/2017 | ||
219 | Rule Descr iption | ||
220 | Automatica lly match invoices t o existing active re ferrals wi thin CCRS, so only m atched inv oices are processed. Deny inv oices that have no m atching re ferral or if the ref erral is n o longer a ctive, so that denia ls can be stored and communica ted. Appr ove invoic es that do not inclu de referra l numbers if the ser vice provi ded was a flu shot. | ||
221 | Rule Attri butes | ||
222 | IF a claim line is n ot for a f lu shot in dicated by a CPT cod e of ‘G000 8’, ‘90658 ’, ‘90656’ , or ‘9066 2’ | ||
223 | AND referr al number of the cla im line do es not mat ch an exis ting activ e referral number du ring the d ate of ser vice | ||
224 | THEN annot ate databa se record as denied within app ropriate C ARC/RARC r eason | ||
225 | Rule Condi tions | ||
226 | Invoices t hat do not contain a flu shot CPT code a nd do not match an a ctive refe rral shoul d be annot ated as de nied. | ||
227 | Invoices t hat do not contain a flu shot CPT code a nd do not match a re ferral sho uld includ e a reason for denia l from a s tandard li st (CARC/R ARC). | ||
228 | Rule Actio ns | ||
229 | When the s ystem rece ives the r eimburseme nt invoice it needs to be matc hed to exi sting refe rral unles s CPT code indicates a flu sho t | ||
230 | When the s ystem rece ives a cla im line wi thout a re ferral wit h a CPT co de indicat ing a flu shot it is processed and the s ystems sho ws the pay ment appro ved | ||
231 | When the s ystem matc hed the in voice with referral it is proc essed and the system shows the payment a pproved | ||
232 | When the s ystem rece ives the r eimburseme nt invoice with no m atching ex isting ref erral, it will be re jected unl ess the CP T code ind icates a f lu shot | ||
233 | When the s ystem does n't match the invoic e with ref erral it i s processe d with a r ejected st atus | ||
234 | When the s ystem does n't match the invoic e with ref erral it i s added to exception s report | ||
235 | When the r eimburseme nt invoice is reject ed it will list the rejections reason wi thin the e xception r eport | ||
236 | Only valid ated claim invoices will be st ored in th e CCRS Rep ository | ||
237 | |||
238 | RULE # | ||
239 | RULE NAME | ||
240 | DATE LAST MODIFIED | ||
241 | 004 | ||
242 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE) | ||
243 | 11/26/2017 | ||
244 | Rule Descr iption | ||
245 | Deny when a provider is on LEI E list | ||
246 | Rule Attri butes | ||
247 | |||
248 | |||
249 | Rule Condi tions | ||
250 | Provider N PI OR Prov ider TAX I D is on th e "LEIE Li st" AND Pr ovider ent ry exist w ith no Rei nstate Dat e (i.e an active ent ry) ANDCla im line Se rvice Date To >= t he "LEIE L ist" exclu sion date ANDProvide r ID is no t "0000000 00" ANDTAX ID is not "00000000 0" | ||
251 | Translatio n: | ||
252 | Provider. | ||
253 | Rule Actio ns | ||
254 | |||
255 | |||
256 | RULE # | ||
257 | RULE NAME | ||
258 | DATE LAST MODIFIED | ||
259 | 005 | ||
260 | Dates of S ervice | ||
261 | 11/21/2017 | ||
262 | Rule Descr iption | ||
263 | Automatica lly proces s the invo ices using the requi red data e lements wi thin the m atching ac tive refer ral to val idate the invoice is within th e dates of service s pecified w ithin the current re ferral | ||
264 | Rule Attri butes | ||
265 | IF the inv oice claim line does not fall within the dates of service in dicated wi thin the m atching ac tive refer ral | ||
266 | THEN annot ate databa se record as denied with appro priate CAR C/RARC rea son | ||
267 | Rule Condi tions | ||
268 | The date o f service must be ma tched with the refer ral active at the ti me of the initial re ferral | ||
269 | The date o f service must fall within the matching referral. | ||
270 | Invoices t hat are no t within t he dates o f service should be annotated as denied. | ||
271 | Invoices t hat are no t within t he dates o f service should inc lude a rea son for de nial from a standard list (CAR C/RARC). | ||
272 | Rule Actio ns | ||
273 | When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, it w ill displa y as valid ated if it is within the dates of servic e | ||
274 | When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, if it is not wi thin the d ates of se rvice of t he referra l, validat ion will l ist a deni ed status | ||
275 | |||
276 | RULE # | ||
277 | RULE NAME | ||
278 | DATE LAST MODIFIED | ||
279 | 006 | ||
280 | Duplicates | ||
281 | 10/26/2017 | ||
282 | Rule Descr iption | ||
283 | Automatica lly identi fy the dup licate lin e item sub mitted wit hin the co ntracted r eimburseme nt invoice using the unique co mbination of invoice line data so that i mproper pa yments can be preven ted. | ||
284 | Rule Attri butes | ||
285 | IF claim l ine matche s any othe r claim li ne within the invoic e or withi n another invoice ba sed on uni que combin ation of | ||
286 | Unique Ide ntifier | ||
287 | Provider I d | ||
288 | Patient Id | ||
289 | Service Da te From | ||
290 | Service Da te To (opt ional) | ||
291 | Place Of S ervice | ||
292 | Procedure Code | ||
293 | Procedure Modifier(s ) (optiona l) | ||
294 | Billed Amo unt | ||
295 | AND the ma tching cla im line is not annot ated as pr eviously r ejected or declined | ||
296 | AND the ma tching cla im line is annotated as PAID | ||
297 | THEN annot ate the cl aim line r ecord as d enied with the appro priate CAR C/RARC rea son | ||
298 | Rule Condi tions | ||
299 | Deny any l ine item t hat was pr eviously r eimbursed by VA. | ||
300 | Line items that are duplicates should be annotated as denied . | ||
301 | Line items that are duplicates should in clude a re ason for d enial from a standar d list (CA RC/RARC). | ||
302 | Identify u nique Vete rans that were reimb ursed in a month for PMPM paym ents. | ||
303 | 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. | ||
304 | Rule Actio ns | ||
305 | The system will dete ct duplica te claims utilizing the claim unique ide ntifier an d prevent payment of duplicate s | ||
306 | • When the system de termines t he reimbur sement cla im submiss ion claim line match es any oth er claim l ines based on unique combinati on of the following: | ||
307 | - Uniqu e Identifi er | ||
308 | - Provi der Id | ||
309 | - Patie nt Id | ||
310 | - Servi ce Date Fr om | ||
311 | - Servi ce Date To (optional ) | ||
312 | - Place Of Servic e | ||
313 | - Proce dure Code | ||
314 | - Proce dure Modif ier(s) (op tional) | ||
315 | - Bille d Amount | ||
316 | • When the matching related cl aim line(s ) has been paid and shows an a llowed amo unt >0, th en the cla im will be flagged a s a duplic ate • When ther e is more than one c laim modif ier, then it will be flagged a s a duplic ate when a ll modifie rs match | ||
317 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} | ||
318 | • When the matching claim line s are not part of th e same cla im, then i t will be flagged as a duplica te | ||
319 | • When bot h the matc hing relat ed claim l ine(s) and the claim line(s) s how a prev ious Pay F lag set to 'Yes' | ||
320 | |||
321 | RULE # | ||
322 | RULE NAME | ||
323 | DATE LAST MODIFIED | ||
324 | 007 | ||
325 | Standardiz ed Episode of Care | ||
326 | 10/26/2017 | ||
327 | Rule Descr iption | ||
328 | Automatica lly evalua te line it ems on the invoice t o ensure t hey fall w ithin the Standardiz ed Episode of Care ( SEOC) so t he line it em can be processed. | ||
329 | Rule Attri butes | ||
330 | If CPT cod e within a n invoice line item is not inc luded as a part of t he SEOC id entified w ithin the referral | ||
331 | Or | ||
332 | If CPT cod e Date of Service wi thin invoi ce line it em does no t fall wit hin SEOC d efined fre quency of service | ||
333 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | ||
334 | Rule Condi tions | ||
335 | If a line item does not fall w ithin the Standardiz ed Episode of Care ( SEOC) it w ill be den ied. | ||
336 | Invoices t hat do not match a r eferral sh ould be an notated as denied. | ||
337 | Invoices t hat do not match a r eferral sh ould inclu de a reaso n for deni al from a standard l ist (CARC/ RARC). | ||
338 | Rule Actio ns | ||
339 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item date of servic e (DOS) ar e within t he SEOC | ||
340 | Line items within th e SEOC, sh ould displ ay status as approve d | ||
341 | Line items with DOS outside of the SEOC, should di splay stat us as deni ed | ||
342 | |||
343 | RULE # | ||
344 | RULE NAME | ||
345 | DATE LAST MODIFIED | ||
346 | 008 | ||
347 | Payment Au thority | ||
348 | 11/21/2017 | ||
349 | Rule Descr iption | ||
350 | Automatica lly evalua te line it ems on the invoice t o ensure t he payment authority for refer ral matche s payment authority in the 837 COB. Obli gation Num ber and Pa yment Auth ority are equivalent . | ||
351 | Rule Attri butes | ||
352 | If payment authority for refer ral in an invoice li ne item do es not mat ch the pay ment autho rity in th e 837COB | ||
353 | Then annot ate databa se record for the in voice line as denied including CARC/RARC code for denial | ||
354 | Rule Condi tions | ||
355 | If the pay ment autho rity in th e 837COB d oes not ma tch the pa yment auth ority in t he referra l, it will be denied . | ||
356 | Invoices t hat do not match a r eferral sh ould be an notated as denied. | ||
357 | Invoices t hat do not match a r eferral sh ould inclu de a reaso n for deni al from a standard l ist (CARC/ RARC). | ||
358 | Rule Actio ns | ||
359 | The valida ted invoic e will onl y show eva luated lin e item, it should di splay line item Paym ent Author ity includ ed in the referral | ||
360 | Line items matching the referr al, should display s tatus as a pproved | ||
361 | Line items with a Pa yment Auth ority that does not match the referral, should dis play statu s as denie d | ||
362 | |||
363 | |||
364 | Rule Sets | ||
365 | This secti on defines the rule sets withi n the appl ication. | ||
366 | If-then Ru le Sets | ||
367 | Decision T ables | ||
368 | Decision T rees | ||
369 | Rule Flows | ||
370 | |||
371 | The table below prov ides detai ls on the Rule Flows within th e applicat ion. | ||
372 | Rule Flow# | ||
373 | Rule Flow Name | ||
374 | Rule Flow Descriptio n | ||
375 | Rule Name | ||
376 | Rule Evalu ation Resu lt | ||
377 | |||
378 | |||
379 | |||
380 | |||
381 | |||
382 | Rule Flow Details | ||
383 | |||
384 | |||
385 | Rules Impl ementation | ||
386 | This secti on describ es the imp lementatio n and inte gration de tails for the rules into the a pplication . | ||
387 | Developmen t of the R ules Subsy stem | ||
388 | Descriptio n of how t he applica tion is in voking the rules (JR ules expor t methodol ogy, execu tion metho d?) | ||
389 | Integratio n of the R ules Subsy stem | ||
390 | Any interf aces the r ules subsy stem might need can be documen ted here ( ccrsdb?). |
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