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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | CCRS_Backlog_By_Scrum_Team_11_17_2017_rev2.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\docs | CCRS_Backlog_By_Scrum_Team_11_17_2017_rev2.xlsx | Fri Jun 15 15:12:09 2018 UTC |
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1 | SHEET: Cov er | |
2 | Department of Vetera ns Affairs | |
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5 | VHACC Cons olidated C CRS Requir ements, | |
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19 | November 2 017, | |
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21 | Version V0 1, | |
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30 | SHEET: ORG CHART_TEA MS_5_6_7_8 | |
31 | TEAM 5 - Referrals Team. Full stack dev elopers wi th experie nce in dev eloping in terfaces u sing J2EE and Back-e nd ETL and SQL Devel opers with data mode ling exper tise, to s upport, de sign and d evelop cod e required to have t he System automatica lly match invoices t o existing referrals within CC RS, so onl y matched invoices a re process ed. This t eam will i nterface w ith CCRA u sing JSON/ XML, web s ervices an d exposed APIs from CCRA to ex tract the referral a nd authori zation dat a and inta ke this da ta into th e CCRS dat a model. T he Referra ls team is also resp onsible fo r gatherin g the auth orization data to be used to v alidate co nformance on 837 inv oices and dataTEAM 6 - Report ing Team. Full stack developer s with exp erience in developin g reports, using SQL reporting services (SSRS), de veloping d ahsboards, and trans actional q ueries and views aga inst the C CRS reposi tory. This team will develop t he tables and entite s required to suppor t reportin g needs. T his team i s skilled in SQL, pl /SQL and v iews and c an extract data from the CCRS system to generate r eports for direct CC RS users, for CCN, g enerate PM PM reports , develop search eng ines in SS RS to deve lop views for search ing invoic e transact ions, numb er of proc essed reco rds, metri cs on paid invoices, invoices that were rejected, reason for non-confo rming and denial, co nfirmation of obliga tions, tre nds of obl igations o ver time, among othe rs special ized repor ts.TEAM 7 - Payment s Team. Fu ll stack d evelopers with exper ience in d eveloping interfaces using J2E E and Back -end ETL a nd SQL Dev elopers wi th data mo deling exp ertise, to support, design and develop c ode requir ed to have the Syste m interfac e with VA Central Fe e. This te am is resp onsible fo r the crea tion of th e integrat ion patter ns and bi- rirectiona l flow of data from CCRS into Central Fe e with pro per instru ctions for payments, including obligatio n amounts and obliga tion numbe r linked t o the refe rrall and the claim/ invoice.TE AM 8 - 83 7 EDI Invo ice Data T eam. Full stack deve lopers wit h experien ce in deve loping int erfaces us ing J2EE a nd Back-en d ETL and SQL Develo pers with data model ing expert ise, to su pport, des ign and de velop code required extract, t ransform a nd load 83 7 x12 data obtained in EDI for mat. This team is re sponsible for the cr eation of the code p atterns an d routines to parse, transform and norma lize EDI d ata and lo ad this da ta into th e CCRS rep ository. T his team w ill update and creat e the CCRS data tabl es require d to save the 837 da ta and mak e it avail able to ot her module s in CCRS. | |
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33 | SHEET: TEA M_5_REFERR ALS_CCRA | |
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35 | Rational I D,Requirem ent,Busine ss Story, | |
36 | 912209,As a CCRS Use r, I need the System to automa tically ma tch invoic es to exis ting refer rals withi n CCRS, so only matc hed invoic es are pro cessed.,• When the s ystem rece ives the r eimburseme nt invoice it needs to be matc hed to exi sting refe rral, | |
37 | • When the system ma tched the invoice wi th referra l it is pr ocessed an d the syst em shows t he payment approved, | |
38 | 912183,As a CCRS Use r, I need the System to deny i nvoices th at have no matching referral, so that we may store and commu nicate den ials.,• Wh en the sys tem receiv es the rei mbursement invoice w ith no mat ching exis ting refer ral, it wi ll be reje cted, | |
39 | • When the system do esn't matc h the invo ice with r eferral it is proces sed with a rejected status, | |
40 | • When the system do esn't matc h the invo ice with r eferral it is added to excepti ons report , | |
41 | • When the reimburse ment invoi ce is reje cted it wi ll list th e rejectio ns reason within the exception report, | |
42 | • Only val idated cla im invoice s will be stored in the CCRS R epository, | |
43 | 912213,As a CCRS Use r, I need the System to create an interf ace with t he Central Fee withi n VA, so t hat I can have the c omplete pa yment info rmation fr om the gen eral ledge r accounti ng of reim bursement payments t o complete claim pay ment disbu rsement.,• When the system rec eives the reimbursem ent invoic e with no matching e xisting re ferral, it will be r ejected, | |
44 | • When the system do esn't matc h the invo ice with r eferral it is proces sed with a rejected status, | |
45 | • When the system do esn't matc h the invo ice with r eferral it is added to excepti ons report , | |
46 | • When the reimburse ment invoi ce is reje cted it wi ll list th e rejectio ns reason within the exception report, | |
47 | 918498,As a CCRS Use r, I need the System to automa tically ma tch invoic es to exis ting refer rals withi n CCRS whe n the invo ice includ es a prior authoriza tion numbe r, so only matched i nvoices ar e processe d.,• When CCRS proce sses an in voice, if there is a prior au thorizatio n the invo ice should display t he existin g matching referral, | |
48 | • When the invoice h as a prior authoriza tion, the system mus t display the existi ng matchin g referral , | |
49 | 918499,As a CCRS Use r, I need the System to deny l ine levels on invoic es that do not have a required prior aut horization number (V A Prior Au thorizatio n List), s o that we may store and commun icate deni als. ,• If the lin e level se rvice is o n the VA P rior Autho rization L ist, there must be a prior aut horization number, | |
50 | • If the l ine level service is on the VA Prior Aut horization List and doesn't ha ve the pri or authori zation num ber, it mu st complet e the invo ice with a denied st atus, | |
51 | • When the invoice i s denied, the system will list the denia l reason, | |
52 | 918500,As a CCRS Use r, I need the System to automa tically pr ocess the invoices u sing the r equired da ta element s within t he matchin g referral so that I can valid ate the in voice is w ithin the scope of t he referra l.,• When the system receives the reimbu rsement in voice with matching referral, it will d isplay as validated if it is w ithin the scope of t he referra l, | |
53 | • 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 , | |
54 | 918501,As a CCRS Use r, I need the System to automa tically ev aluate inv oice line items so t hat I can validate t he line it ems are wi thin the e pisode of care. ,• 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 scope of the re ferral, | |
55 | • 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 , | |
56 | 918503,As a CCRS Use r, I need the System to use th e VA Autho rization L ist to ens ure a prio r authoriz ation numb er was inc luded for line items so that I can proce ss invoice s.,• Line items with in the SEO C and prio r authoriz ation numb er, should display s tatus as a pproved, | |
57 | • Line ite ms with DO S outside of the SEO C and no p rior autho rization n umber, sho uld displa y status a s denied, | |
58 | 918511,As Revenue Op erations, I need to retrieve d ata from m ultiple da ta sources including but not l imited to: CDW, Insu rance Buff er Capture , e-Rpos, and R&A, s o that sta ff are not required to work in multiple systems.,• When RO S taff acces ses the CC RS Reposit ory, they can access all requi red data f rom all so urce syste ms within CCRS, | |
59 | 918524,As Revenue Op erations, all depart ments that determine VA Third Party Bill ing for Co mmunity Ca re program s under wh ich VA is designated Primary P ayer need to have a Third Part y Billing Review Wor klist that is scoped to only a pplicable workload, so that re sources ar e not expe nded on no n-recovery activitie s for reve nue.,• Whe n Revenue Operations Staff acc esses CCRS , Facility Revenue ( FR) can vi ew all app licable sc oped line level clai m data to analyze th e Legal Re view Workl ist to com plete Faci lity Reven ue (FR) re covery act ivities, | |
60 | • When Rev enue Opera tions Staf f accesses CCRS, Ins urance Ver ifiers (IV ) can view all appli cable scop ed line le vel claim data to an alyze the Legal Revi ew Worklis t to compl ete Insura nce Verifi ers (IV) r ecovery ac tivities, | |
61 | • When Rev enue Opera tions Staf f accesses CCRS, Rev enue Utili zation Rev iew (RUR) can view a ll applica ble scoped line leve l claim da ta to anal yze the Le gal Review Worklist to complet e Revenue Utilizatio n Review ( RUR) recov ery activi ties, | |
62 | • When Rev enue Opera tions Staf f accesses CCRS, a B iller can view all a pplicable scoped lin e level cl aim data t o analyze the Legal Review Wor klist to c omplete Bi ller recov ery activi ties, | |
63 | 918502,As a CCRS Use r, I need the System to automa tically ev aluate lin e items on the invoi ce to ensu re they fa ll within the Standa rdized Epi sode of Ca re (SEOC) so that I can proces s the line item. | |
64 | ,• 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 | |
65 | • Line ite ms within the SEOC, should dis play statu s as appro ved | |
66 | • Line ite ms with DO S outside of the SEO C, should display st atus as de nied | |
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71 | Rational I D,Requirem ent,Valida tions,Expe cted Resul ts, | |
72 | 153093,Giv en the sys tem can au tomaticall y match in voices to existing r eferrals,W e validate by confir ming that when invoi ce is rece ived, only referral- matched in voices are processed .,• When t he system receives t he reimbur sement inv oice it ne eds to be matched to existing referral, | |
73 | When invoi ces are re ceived,• W hen the sy stem match ed the inv oice with referral i t is proce ssed and t he system shows the payment ap proved, | |
74 | Then I exp ect CCRS w ill be abl e to only process ma tched invo ices, | |
75 | 153094,Giv en the sys tem can de ny invoice s that hav e no match ing referr al,We vali date by co nfirming t hat when i nvoice is received, invoices w ithout a m atching re ferrals ar e denied a nd a rejec tion statu s is commu nicated wi th the rea son.,• Whe n the syst em receive s the reim bursement invoice wi th no matc hing exist ing referr al, it wil l be rejec ted, | |
76 | When invoi ces are re ceived,• W hen the sy stem doesn 't match t he invoice with refe rral it is processed with a re jected sta tus, | |
77 | Then I exp ect CCRS w ill be abl e to store and commu nicate den ials.,• Wh en the sys tem doesn' t match th e invoice with refer ral it is added to e xceptions report, | |
78 | • When the reimburse ment invoi ce is reje cted it wi ll list th e rejectio ns reason within the exception report, | |
79 | • Only val idated cla im invoice s will be stored in the CCRS R epository, | |
80 | 153097,Giv en the sys tem can cr eate an in terface wi th the Cen tral Fee w ithin VA,W e validate by confir ming the c all to the CCRS Repo sitory run s without failures a nd any lin e item for a claim i nvoice in the CCRS t ransaction al databas e appears when selec ted. Also we validat e by confi rming that the claim s analytic s calls ru n without failure an d claim an alytic act ivities ca n be perfo rmed using all the d ata in the transacti onal datab ase.,• Whe n the CCRS user call s to the C CRS Reposi tory, the user can v iew any se lected lin e item for a claim i nvoice in the CCRS t ransaction al databas e, | |
81 | When invoi ces are re ceived,• W hen the CC RS user ca lls out cl aims analy tics withi n the CCRS Repositor y, the use r can perf orm claim analytic a ctivities within the transacti onal datab ase using all the da ta, | |
82 | Then I exp ect CCRS w ill be abl e to manag e payment informatio n, | |
83 | 153099,Giv en the sys tem can au tomaticall y match in voices to existing r eferrals w ithin CCRS ,We valida te by conf irming tha t when an invoice is processed and there is a prio r authoriz ation, the invoice d isplays th e existing matching referral., • When CCR S processe s an invoi ce, if th ere is a p rior autho rization t he invoice should di splay the existing m atching re ferral, | |
84 | When invoi ces are re ceived and includes a prior au thorizatio n number,• When the invoice ha s a prior authorizat ion, the s ystem must display t he existin g matching referral, | |
85 | Then I exp ect CCRS w ill be abl e to proce ss only th e matched invoices, | |
86 | 153101,Giv en the sys tem can de ny line le vels on in voices tha t do not h ave a requ ired prior authoriza tion numbe r (VA Prio r Authoriz ation List ),We valid ate by con firming th at when an invoice i s processe d and ther e is no pr ior author ization nu mber, the line level s are deni ed on the invoice.,• If the li ne level s ervice is on the VA Prior Auth orization List, ther e must be a prior au thorizatio n number, | |
87 | When invoi ces are re ceived ,• If the lin e level se rvice is o n the VA P rior Autho rization L ist and do esn't have the prior authoriza tion numbe r, it must complete the invoic e with a d enied stat us, | |
88 | Then I exp ect CCRS w ill be abl e to store and commu nicate den ials,• Whe n the invo ice is den ied, the s ystem will list the denial rea son, | |
89 | 153290,Giv en the sys tem can au tomaticall y process invoices u sing the r equired da ta element s within t he matchin g referral ,We valida te by conf irming tha t when an invoice is processed using all of the re quired dat a elements and is wi thin the s cope of th e referral , the invo ice is val idated. If it is not within th e scope of the refer ral, the i nvoice wil l display a denied status.,• 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 scope of the re ferral, | |
90 | When invoi ces are re ceived ,• When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, if it is not wi thin the s cope of th e referral , validati on will li st a denie d status, | |
91 | Then I exp ect CCRS w ill be abl e to valid ate the in voice is w ithin the scope of t he referra l, | |
92 | 153292,Giv en the sys tem can au tomaticall y evaluate invoice l ine items, 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.,• Whe n the syst em receive s the reim bursement invoice wi th matchin g referral , it will display a s validate d if it is within th e episode of care, | |
93 | When invoi ces are re ceived ,• When the s ystem rece ives the r eimburseme nt invoice with matc hing refer ral, if it is not wi thin the e pisode of care, vali dation wil l list a d enied stat us, | |
94 | 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. , | |
95 | 153299,Giv en the sys tem uses t he VA Auth orization List to en sure a pri or authori zation num ber was in cluded for line item s,We valid ate by con firming th at line it ems includ e prior au thorizatio n number a nd display status as approved. Line item s with no prior auth orization number sho uld displa y status a s denied., • Line ite ms within the SEOC a nd prior a uthorizati on number, should di splay stat us as appr oved, | |
96 | When invoi ces are re ceived ,• Line items with DOS outside of the SEOC and no pri or authori zation num ber, shoul d display status as denied, | |
97 | Then I exp ect CCRS w ill be abl e to proce ss the inv oice, | |
98 | 153435,Giv en the sys tem retrie ves data f rom multip le data so urces,We v alidate by confirmin g that CCR S displays all requi red data f rom all so urce syste ms.,• When RO Staff accesses t he CCRS Re pository, they can a ccess all required d ata from a ll source systems wi thin CCRS, | |
99 | When invoi ces are pa id , | |
100 | Then I exp ect CCRS w ill be abl e to displ ay all dat a, | |
101 | 153518,Giv en the sys tem can al low Revenu e Operatio ns a Third Party Bil ling Revie w Worklist that is s coped to o nly applic able workl oad,We val idate by c onfirming that when Revenue Op erations S taff acces s CCRS, Fa cility Rev enue, Insu rance Veri fiers, Rev enue Utili zation Rev iew and Bi ller can v iew all ap plicable s coped line level cla im data to fulfill t heir own r oles' resp onsibiliti es.,• When Revenue O perations Staff acce sses CCRS, Facility Revenue (F R) can vie w all appl icable sco ped line l evel claim data to a nalyze the Legal Rev iew Workli st to comp lete Facil ity Revenu e (FR) rec overy acti vities, | |
102 | When billi ng informa tion is ne eded,• Whe n Revenue Operations Staff acc esses CCRS , Insuranc e Verifier s (IV) can view all applicable scoped li ne level c laim data to analyze the Legal Review Wo rklist to complete I nsurance V erifiers ( IV) recove ry activit ies, | |
103 | Then I exp ect CCRS w ill be abl e to only use resour ces on non -recovery activities for reven ue,• When Revenue Op erations S taff acces ses CCRS, Revenue Ut ilization Review (RU R) can vie w all appl icable sco ped line l evel claim data to a nalyze the Legal Rev iew Workli st to comp lete Reven ue Utiliza tion Revie w (RUR) re covery act ivities, | |
104 | • When Rev enue Opera tions Staf f accesses CCRS, a B iller can view all a pplicable scoped lin e level cl aim data t o analyze the Legal Review Wor klist to c omplete Bi ller recov ery activi ties, | |
105 | Business R ule,If an 837 does n ot include a referra l number, it will be rejected. | |
106 | , | |
107 | Business R ule,If an 837 does n ot include coordinat ion of ben efits (COB ) informat ion it wi ll be reje cted. | |
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109 | , | |
110 | Business R ule,The in voice must include t he renderi ng provide r’s NPI, t he renderi ng service facility and the se rvice faci lity zip c ode to ens ure accura te payment s. | |
111 | , | |
112 | Business R ule,The re ndering pr ovider mus t be withi n the CCN Network., | |
113 | Business R ule,The re ndering pr ovider mus t have bee n active w ithin the CCN Networ k at the t ime that t he service was provi ded., | |
114 | Business R ule,The NP I number a nd date of service m ust be mad e availabl e when que rying the PPMS syste m to confi rm if the provider w as within network at the time of the cla im invoice service. | |
115 | , | |
116 | Business R ule,The in voice must include t he renderi ng provide r’s NPI, t he renderi ng service facility and the se rvice faci lity zip c ode to ens ure accura te payment s. , | |
117 | TEAM 5 - Referrals Team. Full stack dev elopers wi th experie nce in dev eloping in terfaces u sing J2EE and Back-e nd ETL and SQL Devel opers with data mode ling exper tise, to s upport, de sign and d evelop cod e required to have t he System automatica lly match invoices t o existing referrals within CC RS, so onl y matched invoices a re process ed. This t eam will i nterface w ith CCRA u sing JSON/ XML, web s ervices an d exposed APIs from CCRA to ex tract the referral a nd authori zation dat a and inta ke this da ta into th e CCRS dat a model. T he Referra ls team is also resp onsible fo r gatherin g the auth orization data to be used to v alidate co nformance on 837 inv oices and dataTEAM 5 - Referr als Team. - EPICS | |
118 | ||
119 | Develop th e CCRS dat a entities , update C CRS databa se, develo p data mod el and cod e objects and logica l/physical model to host the r eferral an d authoriz ation data | |
120 | Develop th e conceptu al design and integr ation patt ern to int erface wit h CCRA JSO N/XML and web-servic e | |
121 | Deconstruc t and comp lete data mappings, ensuring a ll CCRS re quired fie lds are pr esent in C CRA feed ( obligation #, etc) | |
122 | Define req uired fiel ds, data t ypes, vali dations,ex ception ha ndling and necesary monitoring and contr oling for the CCRA i nterface | |
123 | Make CCRA data avail able in th e CCRS dat a model fo r other CC RS develop ment teams , includin g removing impedemen ts in CCRS developme nt team ta sks | |
124 | Develop re ports, ext racts, and outbound interface to communi cate to CC RA once re imbursemen ts and pay ments are confirmed by Central Fee | |
125 | Develop co de to chec k when all claim inv oices matc h all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) | |
126 | Develop co de for pro cess Outpa tient invo ices to va lidate inv oices by a pplying ed iting rule s so that the system processes with the proper ref erral appr oval/denia l completi on | |
127 | Develop th e automati on checks to validat e referral for Outpa tient, Inp atient, Ur gent/Emerg ency, Phar macy, | |
128 | Develop ch ecks for l ine item d oes not fa ll within the Standa rized Epis ode of Car e (SEOC) f or procces ing denial s. | |
129 | TEAM 5 - Referrals Team. Sta keholder N eeds; The need is fo r a CCRA i nterface t hat can ca pture the authorizat ion, refer ral and ep isode of c are inform ation so t hat this i nformation can be sh ared with CCRS. CCRS in turn w ill take t he CCRA in formation and use th is informa tion to co mpare the data prese nt in 837 invoices a nd make ed ucated des isions of conforming / non-conf orming inv oices and inform Cen tral Fee o f necesary playment, based on obligation amounts a nd numbers found in the CCRA s tream/stac k. As VHA Office of Community Care (VHA CC), I wan t an autom ated syste m that is able to au tomaticall y match in voices for reimburse ment submi tted by co ntracted e ntities to existing referrals within the system, s o that rei mbursement can be ap proved. AS 8-1-16: The system determine s the reim bursement claim subm ission mat ches on un ique combi nation of the follow ing: Refer ral number , DOS, Sta ndarized E pisodes of Care (SEO C), Contra ctor ID, P atient ID, Authoriza tion numbe r (when ap plicable) - Referenc e table is available for servi ces that r equire pri or auth | |
130 | ||
131 | SHEET: TEA M_6_REPORT ING | |
132 | ||
133 | Rational I D,Requirem ent,Busine ss Story, | |
134 | 912204,As a CCRS Use r, I need the System to automa tically ge nerate a p seudo 835 file or re port, so t hat contra ctors can reconcile reimbursem ent invoic es submitt ed to the VA. | |
135 | ,• When th e reviewer receives the report , it shoul d display all post F M informat ion | |
136 | • When the reviewer receives t he report, it should include a ll 835 lik e data to include CO B and post payments | |
137 | • The 835 like repor t will not be transm itted thro ugh a clea ring house with post FM inform ation | |
138 | , | |
139 | 918509,As a CCRS Use r, I need the System to automa tically id entify the cancelled invoice s o that I c an process payment r eversal. | |
140 | ,• When we have a re versal or corrected claim, the system wi ll identif y them usi ng the Ref erence ID within the EDI trans action. | |
141 | • When fin alized, th e claim re sults shou ld have be en modifie d from pre vious repo rting, the method fo r revision is to rev erse the e ntire clai m and rese nd modifie d data. | |
142 | • When any of the se rvice line s within a claim wer e communic ated as pe nded in th e original transmiss ion when m aking a pa rtial paym ent, the p ayer must reverse th e original payment a nd resend the data w hen paying the pende d lines. | |
143 | • As an al ternative to this me thod a pay er may spl it the cla im prior t o making t he partial payment. | |
144 | • The corr ected clai m payment is provide d as if it were the original p ayment and this must include a ny revised , non-zero , interest or prompt payment d iscount va lues in th e Suppleme ntal Claim Informati on segment . | |
145 | • The CLP0 7 Payer Cl aim Contro l Number i n the reve rsal must be identic al to the CLP07 valu e in the o riginal cl aim paymen t. | |
146 | • The CLP0 7 should h ave the sa me value a s in the o riginal CL P07, when the CLP07 value for the correc ted claim is differe nt than th e CLP07 va lue from t he origina l claim, o ne iterati on of the 2-040REF s egment wit h REF01 eq ual to F8 (Original Reference number) an d REF02 eq ual to the original CLP07 valu e is requi red in the correctio n claim. | |
147 | , | |
148 | 918547,Map Payment A uthority t o claim fi elds ident ifying OHI carrier/p ayment and apply bus iness rule ; ex: If payment au thority = ‘secondary ’ then OHI payment f ields shou ld be supp lied; if m ismatch oc curs, plac e on excep tion repor t. | |
149 | ||
150 | ,Map Payme nt Authori ty to clai m fields i dentifying OHI carri er/payment and apply business rule; ex: If paymen t authorit y = ‘secon dary’ then OHI payme nt fields should be supplied; if mismatc h occurs, place on e xception r eport. | |
151 | ||
152 | , | |
153 | 918523,As a CCRS Use r, the sys tem must a utomatical ly execute the creat ion of the Reconcili ation Reca p list, so they can review all invoiced claim data necessary to relay status on all invoic ed claims. | |
154 | ,• When th e invoices have a co mplete sta tus, then the system will auto generate the report | |
155 | • When the invoice c ompletes p rocessing, the repor ts generat ed will be for two c ategories for paid a nd non-pai d claims | |
156 | • The repo rt will be formatted to be abl e to be tr ansmitted to all rev iewers via the recon ciliation list | |
157 | , | |
158 | 918534,As a CCRS Use r, I need to access all types of invoice informati on within CCRS Repos itory. | |
159 | ,• When PO I Staff ac cesses the CCRS Repo sitory, th ey can acc ess all re quired dat a from all source sy stems with in CCRS | |
160 | • When Adm inistrator s accesses the CCRS Repository , they can access al l required data from all sourc e systems within CCR S | |
161 | • When POI Staff acc esses the CCRS Repos itory, the y can acce ss all req uired data from all source sys tems withi n CCRS to analyze, p revent, an d recover improper p ayments | |
162 | • When VHA CC Operat ions acces ses the CC RS Reposit ory, they can access all requi red data f rom all so urce syste ms within CCRS to ru n claim an alytics | |
163 | • When POI Staff acc esses CCRS , user can view all Claim/Invo ice/837 CO B informat ion consum ed data to analyze a nd conduct all FWA a ctivities | |
164 | ||
165 | , | |
166 | 918545,As a Biller, I need to be able to identify whether or iginal pai d claim da ta is modi fied, so t hat I can recognize the update and I can submit co rrected cl aims to VA Third Par ty Payer i f applicab le. | |
167 | ,• When th e original claim was modified, the syste m will ide ntify the invoice wi th the upd ates so th e Biller c an review the correc ted claim | |
168 | • When the Biller va lidates th e claim as a correct ed claim f rom a prev ious repor ting, if n eeded they can submi t requests to VA Thi rd Party P ayer | |
169 | ||
170 | , | |
171 | 918548,As a Revenue Operations staff, I need to vi ew OHI inf ormation a nd EOB lin e level cl aim data r egardless of program that is w ithin the CCRS Repos itory so t hat I can apply the appropriat e copaymen t charges. | |
172 | ,• When Re venue Oper ations Sta ff receive s OHI EOB or 837 COB transacti on informa tion, they can view all the da ta to dete rmine copa yment char ges | |
173 | • When Rev enue Opera tions Staf f receives OHI EOB o r 837 COB transactio n informat ion, they can docume nt decisio ns on the copayment charges | |
174 | • Revenue Operations Staff can select fi eld within CCRS to e nter decis ion annota tion | |
175 | , | |
176 | 918555,As a CCRS Use r, I need the System to be abl e to provi de informa tional rep orts that provide vi ews of all reimburse ment invoi ce informa tion withi n the syst em so that I can com municate r eimburseme nt payment status. | |
177 | ,• When CC RS complet es process ing, CCRS will provi de reports that disp lay all re imbursemen t invoice informatio n | |
178 | • When CCR S complete s processi ng, CCRS w ill provid e reports that inclu de invoice claim sta tus | |
179 | • The info rmational report vie ws will al low users to adjust views, the n the user will be a ble to sel ect specif ic report view and i nformation al data di splayed | |
180 | , | |
181 | 918556,As a CCRS Use r, I need the System to allow for querie s of all t ypes of in voice info rmation wi thin CCRS Repository . | |
182 | ,• When CC RS complet es process ing, CCRS users will be able t o access t he full CC RS Reposit ory to run operation al queries | |
183 | • When CCR S complete s processi ng, CCRS u sers will select par ameters fr om the pre -defined f ields to r un queries | |
184 | ||
185 | , | |
186 | 918557,As a CCRS Use r, I need the System to allow for displa y views of all types of invoic e informat ion within CCRS Repo sitory. | |
187 | ,• When th e CCRS use r runs the query, th e user wil l see the query resu lts displa yed in col umn and ro w tables d isplaying applicable queried i nvoice inf ormation | |
188 | ||
189 | , | |
190 | 918558,As Revenue Op erations, I need to be able to route pai d claim da ta to othe r Revenue department s (Facilit y Revenue (FR), Insu rance Veri fiers (IV) , Revenue Utilizatio n Review ( RUR), and Billing) s o that we can facili tate VA Th ird Party Billing. | |
191 | ,• When a Facility R evenue (FR ) accesses the CCRS Repository , user can review al l line lev el claim d ata receiv ed to faci litate rec overy of V A Third Pa rty Billin g | |
192 | • When a I nsurance V erifiers ( IV) access es the CCR S Reposito ry, user c an review all line l evel claim data rece ived to fa cilitate r ecovery of VA Third Party Bill ing | |
193 | • When a R evenue Uti lization R eview (RUR ) accesses the CCRS Repository , user can review al l line lev el claim d ata receiv ed to faci litate rec overy of V A Third Pa rty Billin g | |
194 | • When a B iller acce sses the C CRS Reposi tory, user can revie w all line level cla im data re ceived to facilitate recovery of VA Thir d Party Bi lling | |
195 | , | |
196 | ||
197 | Rational I D,Requirem ent, Story Validatio n, Expecte d Results, | |
198 | 153320,Giv en the sys tem automa tically id entifies t he cancell ed invoice | |
199 | When invoi ces are pa id | |
200 | Then I exp ect CCRS w ill be abl e to proce ss payment reversal, We validat e by confi rming that the corre ct claim i s identifi ed using t he Referen ce ID. We should als o check th at when th e correcte d claim is finalized , the enti re claim i s reversed and the m odified da ta is sent again. If any of th e service lines with in aclaim were commu nicated as pending i n the orig inal trans mission wh en making a partial payment, t hen the pa yer is mad e to rever se the ori ginal paym ent and re send the d ata when p aying the pending li nes. ,• Wh en we have a reversa l or corre cted claim , the syst em will id entify the m using th e Referenc e ID withi n the EDI transactio n. | |
201 | • When fin alized, th e claim re sults shou ld have be en modifie d from pre vious repo rting, the method fo r revision is to rev erse the e ntire clai m and rese nd modifie d data. | |
202 | • When any of the se rvice line s within a claim wer e communic ated as pe nded in th e original transmiss ion when m aking a pa rtial paym ent, the p ayer must reverse th e original payment a nd resend the data w hen paying the pende d lines. | |
203 | • As an al ternative to this me thod a pay er may spl it the cla im prior t o making t he partial payment. | |
204 | • The corr ected clai m payment is provide d as if it were the original p ayment and this must include a ny revised , non-zero , interest or prompt payment d iscount va lues in th e Suppleme ntal Claim Informati on segment . | |
205 | • The CLP0 7 Payer Cl aim Contro l Number i n the reve rsal must be identic al to the CLP07 valu e in the o riginal cl aim paymen t. | |
206 | • The CLP0 7 should h ave the sa me value a s in the o riginal CL P07, when the CLP07 value for the correc ted claim is differe nt than th e CLP07 va lue from t he origina l claim, o ne iterati on of the 2-040REF s egment wit h REF01 eq ual to F8 (Original Reference number) an d REF02 eq ual to the original CLP07 valu e is requi red in the correctio n claim. | |
207 | , | |
208 | 153445,Giv en the sys tem can au tomaticall y execute the creati on of the Reconcilia tion Recap list | |
209 | When billi ng informa tion is ne eded | |
210 | Then I exp ect CCRS w ill be abl e to revie w all invo iced claim data nece ssary to r elay statu s on all i nvoiced cl aims.,We v alidate by confirmin g that whe n invoices have a co mplete sta tus, a rep ort will b e autogene rated into either a paid or no n-paid cla im categor y. ,• When the invoi ces have a complete status, th en the sys tem will a uto genera te the rep ort | |
211 | • When the invoice c ompletes p rocessing, the repor ts generat ed will be for two c ategories for paid a nd non-pai d claims | |
212 | • The repo rt will be formatted to be abl e to be tr ansmitted to all rev iewers via the recon ciliation list | |
213 | , | |
214 | 153535,Giv en the sys tem can pu ll all req uire data from all s ource syst ems | |
215 | When billi ng informa tion is ne eded | |
216 | Then I exp ect CCRS w ill be abl e to allow users to access all required data ,We v alidate by confirmin g that whe n POI Staf f, Adminis trators, and VHA CC Operation s access t he CCRS Re pository, they can a ccess all required d ata from a ll source systems wi thin CCRS, • When POI Staff acc esses the CCRS Repos itory, the y can acce ss all req uired data from all source sys tems withi n CCRS | |
217 | • When Adm inistrator s accesses the CCRS Repository , they can access al l required data from all sourc e systems within CCR S | |
218 | • When POI Staff acc esses the CCRS Repos itory, the y can acce ss all req uired data from all source sys tems withi n CCRS to analyze, p revent, an d recover improper p ayments | |
219 | • When VHA CC Operat ions acces ses the CC RS Reposit ory, they can access all requi red data f rom all so urce syste ms within CCRS to ru n claim an alytics | |
220 | • When POI Staff acc esses CCRS , user can view all Claim/Invo ice/837 CO B informat ion consum ed data to analyze a nd conduct all FWA a ctivities | |
221 | ||
222 | , | |
223 | 153586,Giv en the sys tem can di splay whet her origin al paid cl aim data i s modified | |
224 | When billi ng informa tion is ne eded | |
225 | Then I exp ect CCRS w ill be abl e to displ ay any upd ates and c orrected c laims can be submitt ed to VA T hird Party Payer if applicable . ,We vali date by co nfirming t hat when a Biller ac cesses CCR S, whether the paid claim data was modif ied would appear and corrected claims ca n be submi tted if ne eded.,• Wh en the ori ginal clai m was modi fied, the system wil l identify the invoi ce with th e updates so the Bil ler can re view the c orrected c laim | |
226 | • When the Biller va lidates th e claim as a correct ed claim f rom a prev ious repor ting, if n eeded they can submi t requests to VA Thi rd Party P ayer | |
227 | ||
228 | , | |
229 | 153582,Giv en the sys tem can di splay all line level claim dat a | |
230 | When billi ng informa tion is ne eded | |
231 | Then I exp ect CCRS w ill be abl e to deter mine VA co st recover y opportun ities for Third Part y billable health in surance. , We validat e by confi rming that when a Re venue Oper ations sta ff accesse s CCRS, us er can vie w all line level cla im data to analyze T hird Party billable health ins urance. ,• When Reve nue Operat ions Staff accesses the CCRS R epository, user can view all l ine level claim data to analyz e Third Pa rty billab le health insurance | |
232 | , | |
233 | 153586,Giv en the sys tem can di splay whet her origin al paid cl aim data i s modified | |
234 | When billi ng informa tion is ne eded | |
235 | Then I exp ect CCRS w ill be abl e to displ ay any upd ates and c orrected c laims can be submitt ed to VA T hird Party Payer if applicable . ,We vali date by co nfirming t hat when a Biller ac cesses CCR S, whether the paid claim data was modif ied would appear and corrected claims ca n be submi tted if ne eded.,• Wh en the ori ginal clai m was modi fied, the system wil l identify the invoi ce with th e updates so the Bil ler can re view the c orrected c laim | |
236 | • When the Biller va lidates th e claim as a correct ed claim f rom a prev ious repor ting, if n eeded they can submi t requests to VA Thi rd Party P ayer | |
237 | ||
238 | , | |
239 | 153596,Giv en the sys tem can di splay info rmation re ports that provide v iews of al l reimburs ment invoi ce informa tion withi n the syts em | |
240 | When billi ng informa tion is ne eded | |
241 | Then I exp ect CCRS w ill be abl e to provi de reimbur sement pay ment statu s. ,We val idate by c onfirming that when processing is comple ted, multi -view repo rts will a ppear disp laying all reimburse ment invoi ce informa tion and i nclude inv oice claim status. , • When CCR S complete s processi ng, CCRS w ill provid e reports that displ ay all rei mbursement invoice i nformation | |
242 | • When CCR S complete s processi ng, CCRS w ill provid e reports that inclu de invoice claim sta tus | |
243 | • The info rmational report vie ws will al low users to adjust views, the n the user will be a ble to sel ect specif ic report view and i nformation al data di splayed | |
244 | , | |
245 | 153597,Giv en the sys tem can al low for qu eries of a ll types o f invoice informatio n within t he CCRS re pository | |
246 | When billi ng informa tion is ne eded | |
247 | Then I exp ect CCRS w ill be abl e to provi de the inv oice infor mation ,We validate by confirm ing that w hen proces sing is co mpleted, t he selecti on of diff erent para meters wil l run a qu ery to pul l invoice informatio n. ,• When CCRS comp letes proc essing, CC RS users w ill be abl e to acces s the full CCRS Repo sitory to run operat ional quer ies | |
248 | • When CCR S complete s processi ng, CCRS u sers will select par ameters fr om the pre -defined f ields to r un queries | |
249 | ||
250 | , | |
251 | 153599,Giv en the sys tem can di splay view s of all t ypes of in voice info rmation wi thin CCRS Repository | |
252 | When billi ng informa tion is ne eded | |
253 | Then I exp ect CCRS w ill be abl e to provi de differe nt views o f the invo ice inform ation ,We validate b y confirmi ng that af ter runnin g queries of the inv oice infor mation, th e results are edispl ayed in co lumn and r ow tables with the s elected in voice info rmation. , • When the CCRS user runs the query, the user will see the q uery resul ts display ed in colu mn and row tables di splaying a pplicable queried in voice info rmation | |
254 | ||
255 | , | |
256 | 153600,Giv en the sys tem can ro ute paid c laim data to other R evenue Dep artments | |
257 | When billi ng informa tion is ne eded | |
258 | Then I exp ect CCRS w ill be abl e to facil itate VA T hird Party Billing,W e validate by confir ming that when a Fac ility Reve nue, Insur ance Verif ier, Reven ue Utiliza tion Revie w or a Bil ler access es the CCR S Reposito ry, the li ne level c laim data can be see n to facil itate reco very of VA Third Par ty Billing .,• When a Facility Revenue (F R) accesse s the CCRS Repositor y, user ca n review a ll line le vel claim data recei ved to fac ilitate re covery of VA Third P arty Billi ng | |
259 | • When a I nsurance V erifiers ( IV) access es the CCR S Reposito ry, user c an review all line l evel claim data rece ived to fa cilitate r ecovery of VA Third Party Bill ing | |
260 | • When a R evenue Uti lization R eview (RUR ) accesses the CCRS Repository , user can review al l line lev el claim d ata receiv ed to faci litate rec overy of V A Third Pa rty Billin g | |
261 | • When a B iller acce sses the C CRS Reposi tory, user can revie w all line level cla im data re ceived to facilitate recovery of VA Thir d Party Bi lling | |
262 | , | |
263 | #,Function ality,Desc ription,SS RS Report / View,Vou cher Exami ner,Custom er Service ,Facility Revenue Te chnician,R evenue Uti lization R eview Nurs e,Biller,I nsurance V erificatio n Technici an,Revenue Operation s,Health I nformation Managemen t,Contract ed Entity, Contracted Office/Of ficer,Care Coordinat ion,PI Spe cialist,In formatics, Fiscal,Not es, | |
264 | 1,Search,S earch syst em (CCRS R epository) for all t ypes of in voice info rmation wi thin CCRS Repository . | |
265 | , | |
266 | 2,Search f or Member by specifi ed paramet ers/criter ia,Open In voice reco rd (select a invoice record),x ,X,X,X,X,X ,X,X,X,X, | |
267 | 3,Search f or all lin e level cl aim data,V iew all li ne level c laim data, x,X,X,X,X, X,X,X,X,X, | |
268 | 4,Search f or claim l evel data, View claim level dat a,x,X,X,X, X,X,X,X,X, X, | |
269 | 5,Search f or coordin ation of b enefits in formation, View all l ine level claim data ,x,X,X,X,X ,X,X,X,X,X , | |
270 | 6,Search f or origina l claim fo r reimburs ement info rmation,Vi ew all ori ginal clai m for reim bursement informatio n,x,X,X,X, X,X,X,X,X, X, | |
271 | 7,Search f or origina l payment informatio n includin g line lev el detail, View all o riginal pa yment info rmation in cluding li ne level d etail,x,X, X,X,X,X,X, X,X,X, | |
272 | 8,Search M ember Demo graphic in formation, View Membe r demograp hic detail s,x,X,X,X, X,X,X,X,X, X, | |
273 | 9,Search Member Inv oice Claim Reimburse ment Docum ent Links, Open selec ted docume nt link (s elect docu ment to vi ew),x,X,X, X,X,X,X,X, X,X,X, | |
274 | 10,Search Member In voice Clai m Reimburs ement Docu ment Links ,View sele cted docum ent link,x ,X,X,X,X,X ,X,X,X,X,X , | |
275 | 11,Search Admin Elig ibility , View Admin Eligibili ty list,x, X,X,X,X,X, X,X,X, | |
276 | 12,Search Admin Elig ibility , Work Admin Eligibili ty and com plete,x,X, X,X,X,X, | |
277 | 13,Search Clinical E ligibility ,View Ad min Eligib ility list ,x,X,X,X,X ,X,X,X,X, | |
278 | 14,Search Clinical E ligibility ,Work Ad min Eligib ility and complete,x ,X, | |
279 | 15,Search Clinical E ligibility ,Open cl inical con dition (se lect view) ,x,X,X,X, | |
280 | 16,Search SC/SA elig ibility da ta,View SC /SA eligib ility data ,x,X,X,X,X ,X,X,X, | |
281 | 17,Search SC/SA elig ibility da ta,Work SC /SA eligib ility data ,x,X,X,X, X,X, | |
282 | 18,Search SC/SA elig ibility da ta,Open an d complete worklist work item (select vi ew),x,X,X, X,X,X, | |
283 | 19,Search Other Heal th Insuran ce policy informatio n from VA systems,Vi ew Other H ealth Insu rance list ing and hi story upda tes,x,X,X, X,X,X,X,X, | |
284 | 20,Viewer, View searc h results for all li ne level c laim data, claim lev el data, c oordinatio n of benef its inform ation and all associ ated docum ents withi n a standa rdized vie wer. | |
285 | ,SSRS Repo rt / View, Voucher Ex aminer,Cus tomer Serv ice,Facili ty Revenue Technicia n,Revenue Utilizatio n Review N urse,Bille r,Insuranc e Verifica tion Techn ician,Reve nue Operat ions,Healt h Informat ion Manage ment,Contr acted Enti ty,Contrac ted Office /Officer,C are Coordi nation,PI Specialist ,Informati cs,Fiscal, Notes, | |
286 | 21,View P rofessiona l Invoice Reimbursem ent Claims ,View the Profession al Invoice Reimburse ment Claim s List,x,X ,X,X,X,X,X ,X,X,X, | |
287 | 22,View P rofessiona l Invoice Reimbursem ent Claims ,View the Profession al Claim,x ,X,X,X,X,X ,X,X,X,X, | |
288 | 23,View P rofessiona l Invoice Reimbursem ent Claims ,Work/Crea te work it em the Pro fessional Claim ,x,X , | |
289 | 24,View P rofessiona l Invoice Reimbursem ent Claims ,Open a Pr ofessional Claim ,x, X,X,X,X,X, X,X,X,X, | |
290 | 25,View I nstitution al Invoice Reimburse ment Claim s,View the Instituti onal Invoi ce Reimbur sement Cla ims List,x ,X,X,X,X,X ,X,X,X,X, | |
291 | 26,View I nstitution al Invoice Reimburse ment Claim s,View the Instituti onal Claim ,x,X,X,X,X ,X,X,X,X,X , | |
292 | 27,View I nstitution al Invoice Reimburse ment Claim s,Work/Cre ate work i tem the In stitutiona l Claim ,x ,X, | |
293 | 28,View I nstitution al Invoice Reimburse ment Claim s,Open a I nstitution al Claim , x,X,X,X,X, X,X,X,X,X, | |
294 | 29,View P harmacy In voice Reim bursement Claims,Vie w the Phar macy Invoi ce Reimbur sement Cla ims List,x ,X,X,X,X,X ,X,X,X,X, | |
295 | 30,View P harmacy In voice Reim bursement Claims,Vie w the Phar macy Claim ,x,X,X,X,X ,X,X,X,X,X , | |
296 | 31,View P harmacy In voice Reim bursement Claims,Wor k/Create w ork item t he Pharmac y Claim ,x ,X, | |
297 | 32,View P harmacy In voice Reim bursement Claims,Ope n a Pharma cy Claim , x,X,X,X,X, X,X,X,X,X, | |
298 | 33,View D ental Invo ice Reimbu rsement Cl aims,View the Dental Invoice R eimburseme nt Claims List,x,X,X ,X,X,X,X,X ,X,X, | |
299 | 34,View D ental Invo ice Reimbu rsement Cl aims,View the Dental Claim,x,X ,X,X,X,X,X ,X,X,X, | |
300 | 35,View D ental Invo ice Reimbu rsement Cl aims,Work/ Create wor k item the Dental Cl aim ,x,X, | |
301 | 36,View D ental Invo ice Reimbu rsement Cl aims,Open a Dental C laim ,x,X, X,X,X,X,X, X,X,X, | |
302 | 37,View M edical Doc uments Lin ks,View th e Medical Documents Links,x,X, X,X,X,X,X, X,X,X, | |
303 | 38,View M edical Doc uments Lin ks,Open a Medical Do cument Lin ks,x,X,X,X ,X,X,X,X,X ,X, | |
304 | 39,View M edical Doc uments Lin ks,View th e selected Medical D ocuments L inks,x,X,X ,X,X,X,X,X ,X,X, | |
305 | 40,View Co ordination of Benefi ts informa tion,View Coordinati on of Bene fits infor mation Lis t,x,X,X,X, X,X,X,X,X, X, | |
306 | 41,View Co ordination of Benefi ts informa tion,View the select ed Coordi nation of Benefits i nformation ,x,X,X,X, X,X,X,X,X, X, | |
307 | 42,View Co ordination of Benefi ts informa tion,Open Coordinati on of Bene fits infor mation,x,X ,X,X,X,X,X ,X,X,X, | |
308 | 43,View Co ordination of Benefi ts informa tion,Work the Coord ination of Benefits informatio n ,x,X, | |
309 | 44,View re ason for d enial from a standar d list (CA RC/RARC),V iew reason for denia l from a s tandard (C ARC/RARC) List,x,X,X ,X,X,X,X,X ,X,X, | |
310 | 75,Reports ,View list of Report s | |
311 | ,SSRS Repo rt / View, Voucher Ex aminer,Cus tomer Serv ice,Facili ty Revenue Technicia n,Revenue Utilizatio n Review N urse,Bille r,Insuranc e Verifica tion Techn ician,Reve nue Operat ions,Healt h Informat ion Manage ment,Contr acted Enti ty,Contrac ted Office /Officer,C are Coordi nation,PI Specialist ,Informati cs,Fiscal, Notes, | |
312 | 76,Pseudo 835 file o r report,G enerate re port to re concile re imbursemen t invoices submitted to the VA ,x,X,X,X,X ,X, | |
313 | 77,Reconci liation Re cap List,R eport or b atch repor t - daily or weekly - two cate gories - P aid and No n-Paid,x,X ,X,X,X,X,X ,X,X,X,X,X , | |
314 | 78,Latest Veteran El igibility Informatio n,Generate report to identify claims wit h any disc repancies between th e Eligibil ity and Me ans Test r eported fr om current authorita tive eligi bility dat abase and local Vist a data,x,X ,X,X,X,X,X ,X, | |
315 | 79,OHI dis crepancies ,Generate reports f or invoice claims wi th any dis crepancies between k nown OHI r eported to VA and th e OHI repo rted for t he Veteran in the OH I segments of the Co mmunity Ca re claim d ata,x,X,X, X,X,X,X,X, | |
316 | 80,OHI Pai d in Full Report,Gen erate repo rt to incl ude invoic e claims w here OHI p aid in ful l and offs et the cop ayment req uired so t hat I can run Ad Hoc reports a s needed t o identify claims wh ere no cop ay was iss ued becaus e OHI paym ent met or exceeded required c opayment. | |
317 | ,x,X,X,X,X ,X,X,X,X, | |
318 | 81,All Rei mbursement Invoice I nformation ,Provide v iews of al l reimburs ement invo ice inform ation to c ommunicate reimburse ment payme nt status, x,X,X,X, | |
319 | 82,OHI Pai d in Full Report,Ad Hoc report to identi fy claims where no c opay was i ssued beca use OHI pa yment met or exceede d required copayment | |
320 | ,x,X,X,X,X ,X, | |
321 | 83,Disposi tion Repor t,Ad Hoc r eports to identify c laims wher e no copay was issue d because the Vetera n's care/s ervices wh ere relate d to SC/SA eligibili ty,x,X,X,X ,X,X, | |
322 | 84,Copayme nt Issued Report,Pla ce any inv oice claim s where VA First Par ty Copayme nt was iss ued on a C C Copaymen t Issued R eport,x,X, X,X,X,X,X, X,X,X, | |
323 | 85,Adminis trative Fe es,Detect fees to pr ovide paym ent for se rvices ren dered,x,X, X,X,X, | |
324 | 86,Adminis trative Fe es,Detect claims tha t span mul tiple admi nistrative invoice p eriods,x, | |
325 | 87,Adminst rative Cla im Validat ion,Detect and ident ify claim validation exception s,x,X,X,X, | |
326 | 88,Reports ,View drop down menu list,SSRS Report / View,Vouch er Examine r,Customer Service,F acility Re venue Tech nician,Rev enue Utili zation Rev iew Nurse, Biller,Ins urance Ver ification Technician ,Revenue O perations, Health Inf ormation M anagement, Contracted Entity,Co ntracted O ffice/Offi cer,Care C oordinatio n,PI Speci alist,Info rmatics,Fi scal,Notes , | |
327 | 89,Adminis trative Fe es - Payab les Proces sing,View List,x,X,X ,X,X,X,X,X ,X, | |
328 | 90,Adminis trative Fe es - Paid Accounting Cycles,Se lect Accou nting Cycl e,x,X,X,X, X,X,X,X, | |
329 | 91,Adminis trative Fe es - Paid Accounting Cycles,Vi ew Claims sent for p ayment,x,X ,X,X,X,X,X ,X, | |
330 | 92,Adminis trative Fe es - Remit Processin g,View rem ittances t o be proce ssed,x,X,X ,X,X,X,X,X , | |
331 | 93,Adminis trative Fe es - Remit Processin g,Process remittance s (select Process Re mittances) ,x,X,X,X,X ,X,X,X, | |
332 | 94,Busines s Rules,De fine, crea te, modify , and test business rules used to detect invoice v alidation exceptions ,x,X,X,X,X ,X,X,X, | |
333 | 95,Busines s Rules,Up date polic ies and va lidate rul es,x,X,X, | |
334 | 96,Users,V iew list o f users on ly,x,X,X, | |
335 | 97,Invoice Claim Exc eptions,Vi ew list of Invoice C laim Excep tions,x,X, X,X,X, | |
336 | 98,Eligibi lity Excep tion,View list of El igibility Exceptions ,x,X,X,X,X ,X,X,X,X,X , | |
337 | 99,OHI Exc eptions,Vi ew list of OHI Excep tions,x,X, X,X,X,X,X, X,X,X, | |
338 | 100,Manage Assignmen t Queue,Vi ew list of Manage As signments, x,X,X,X,X, X,X,X, | |
339 | 101,Manage Assignmen t Queue,Re move work flow assig nments (se lect Remov e Assignme nt) ,x,X,X ,X,X,X,X,X , | |
340 | 102,Update Applicati on Setting s,Add a se tting (sel ect Add a Setting),x ,X,X, | |
341 | TEAM 6 - Reporting Team. Full stack dev elopers wi th experie nce in dev eloping re ports, usi ng SQL rep orting ser vices (SSR S), develo ping dahsb oards, and transacti onal queri es and vie ws against the CCRS repository . This tea m will dev elop the t ables and entites re quired to support re porting ne eds. This team is sk illed in S QL, pl/SQL and views and can e xtract dat a from the CCRS syst em to gene rate repor ts for dir ect CCRS u sers, for CCN, gener ate PMPM r eports, de velop sear ch engines in SSRS t o develop views for searching invoice tr ansactions , number o f processe d records, metrics o n paid inv oices, inv oices that were reje cted, reas on for non -conformin g and deni al, confir mation of obligation s, trends of obligat ions over time, amon g others s pecialized reports.T EAM 6 - R eporting T eam. - EPI CS | |
342 | ||
343 | Develop th e CCRS dat a entities , update C CRS databa se, develo p data mod el and cod e objects and logica l/physical model to support sp ecialized reporting of CCRS da ta | |
344 | Develop th e conceptu al design and integr ation patt ern to cod e SSRS rep orts withi n CCRS and makes the se reports available in a brow ser | |
345 | Deconstruc t and comp lete data mappings, ensuring a ll CCRS re quired fie lds are pr esent in i n SSRS rep orts, sear chs and we b-browser views | |
346 | Define req uired fiel ds, data t ypes, vali dations,ex ception ha ndling and necesary monitoring and contr oling for the SSRS r eports | |
347 | Make CCRSd ata availa ble in the SSRS data model for other CCR S developm ent teams, including removing impedement s in CCRS developmen t team tas ks | |
348 | Develop re ports, ext racts, and outbound interface to communi cate CCRS data once reimbursem ents and p ayments ar e confirme d by Centr al Fee | |
349 | Develop re ports and code to ch eck when a ll claim i nvoices ma tch all mi nimum acce ptance cri teria (Ref erral # on invoice, Duplicate, Timely fi ling, Date s of Servi ce, Scope of episode ) | |
350 | Develop re ports code for proce ss Outpati ent invoic es to vali date invoi ces by app lying edit ing rules so that th e system p rocesses w ith the pr oper refer ral approv al/denial completion | |
351 | Develop th e reports checks to validate r eferral fo r Outpatie nt, Inpati ent, Urgen t/Emergenc y, Pharmac y, - inclu ding recon ciliation cap lists and CCN re ports and PMPM repor ts | |
352 | Develop re ports for line item does not f all within the Stand arized Epi sode of Ca re (SEOC) for procce sing denia ls. | |
353 | TEAM 6 - Reporting Team. Sta keholders Needs; As a CCRS Use r, I need to view al l invoice claim info rmation, i n a web-ba sed report , so that I may lear n the stat us of the claim invo ice, searc h, view tr ansactions , confirmi ng, non-co nforming m etrics, s o that I m ay respond to an inq uiry or co mplete wor k assigned to me. As a CCRS U ser, I nee d to enter multiple criteria t o search t o view all types of invoice in formation within CCR S Reposito ry, using standard r eports in a web-brow ser, so th at I can r eview all line level claim dat a, claim l evel data, coordinat ion of ben efits info rmation an d all asso ciated doc uments wit hin a stan dardized r eport web- based view er. Our pr ocess allo ws for a s ingle CCRS repositor y in which we will h ave access to view, search and have repo rts for al l claim in voice and payment in formation to perform analysis, respond t o invoice inquiries and provid e payment for servic es rendere d | |
354 | ||
355 | ||
356 | ||
357 | SHEET: TEA M_7_PAYMEN TS_CENTRAL FEE | |
358 | ||
359 | ||
360 | ||
361 | ||
362 | ||
363 | ||
364 | ||
365 | ||
366 | ||
367 | ||
368 | ||
369 | ||
370 | ||
371 | ||
372 | Rational I D,Business Story,Acc eptance Cr iteria, | |
373 | 912194,As a CCRS Use r, I want an automat ed system that is ab le to proc ess invoic es for rei mbursement for multi ple types of service so that a ppropriate editing r ules will be applied when vali dating the claim. ( Note: Typ es of serv ices inclu de Outpati ent, Inpat ient, Urge nt/Emergen cy, Pharma cy, Durabl e Medical Equipment, others to be determ ined),• In voice matc hes all mi nimum acce ptance cri teria (Ref erral # on invoice, Duplicate, Timely fi ling, Date s of Servi ce, Scope of episode ) , | |
374 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
375 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
376 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
377 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e , | |
378 | 912211,As a CCRS Use r, I need the System to automa tically pr ocess Outp atient inv oices to v alidate in voices by applying c orrespondi ng editing rules so that the s ystem proc esses with the prope r approval /denial co mpletion a nd assignm ent to cor responding workflow as needed. ,• Invoice matches a ll minimum acceptanc e criteria (Referral # on invo ice, Dupli cate, Time ly filing, Dates of Service, S cope of ep isode) , | |
379 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
380 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
381 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
382 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
383 | 912207,As a CCRS Use r, I need the System to automa tically pr ocess Inpa tient invo ices to va lidate inv oices by a pplying co rrespondin g editing rules so t hat the sy stem proce sses with the proper approval/ denial com pletion an d assignme nt to corr esponding workflow a s needed., • Invoice matches al l minimum acceptance criteria (Referral # on invoi ce, Duplic ate, Timel y filing, Dates of S ervice, Sc ope of epi sode) , | |
384 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
385 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
386 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
387 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
388 | 912197,As a CCRS Use r, I need the System to automa tically pr ocess Urge nt/Emergen cy invoice s to valid ate invoic es by appl ying corre sponding e diting rul es so that the syste m processe s with the proper ap proval/den ial comple tion and a ssignment to corresp onding wor kflow as n eeded.,• I nvoice mat ches all m inimum acc eptance cr iteria (Re ferral # o n invoice, Duplicate , Timely f iling, Dat es of Serv ice, Scope of episod e) , | |
389 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
390 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
391 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
392 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
393 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
394 | 912206,As a CCRS Use r, I need the System to automa tically pr ocess Phar macy invoi ces so th at the inv oice is va lidated by applying the corres ponding ed iting rule s so that it's rerou ted to the correspon ding workf low queue for appro val/denial completio n. **Natio nal Counci l for Pres cription D rug Progra ms, (NCPDP )**,• Invo ice matche s all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) , | |
395 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
396 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
397 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
398 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
399 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
400 | 912181,As a CCRS Use r, I need the System to automa tically pr ocess Dura ble Medica l Equipmen t invoices so that t he invoice is valida ted by app lying the correspond ing editin g rules so that it's rerouted to the cor responding workflow queue for approval/ denial com pletion.,• Invoice m atches all minimum a cceptance criteria ( Referral # on invoic e, Duplica te, Timely filing, D ates of Se rvice, Sco pe of epis ode) , | |
401 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules, | |
402 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
403 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
404 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
405 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
406 | 912214,As a CCRS Use r, I need the System to automa tically pr ocess Dent al invoice s so that the invoic e is valid ated by ap plying the correspon ding editi ng rules s o that it' s rerouted to the co rrespondin g workflow queue fo r approval /denial co mpletion., • Invoice matches al l minimum acceptance criteria (Referral # on invoi ce, Duplic ate, Timel y filing, Dates of S ervice, Sc ope of epi sode) | |
407 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules | |
408 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. , | |
409 | 912204,As a CCRS Use r, I need the System to automa tically ge nerate a p seudo 835 file or re port, so t hat contra ctors can reconcile reimbursem ent invoic es submitt ed to the VA.,• When the revie wer receiv es the rep ort, it sh ould displ ay all pos t FM infor mation, | |
410 | • When the reviewer receives t he report, it should include a ll 835 lik e data to include CO B and post payments , | |
411 | • The 835 like repor t will not be transm itted thro ugh a clea ring house with post FM inform ation, | |
412 | 912208,As a CCRS Use r, I need the System to store reimbursem ent paymen t informat ion for al l line ite ms for a c laim invoi ce within the VA aut horitative system, s o that pay ment infor mation can be manage d.,• When the CCRS u ser calls to the CCR S Reposito ry, the us er can vie w any sele cted line item for a claim inv oice in th e CCRS tra nsactional database, | |
413 | • When the CCRS user calls to the CCRS R epository, the user can view a ny selecte d line ite m for a cl aim invoic e in the C CRS transa ctional da tabase, | |
414 | • When the CCRS user calls out claims an alytics wi thin the C CRS Reposi tory, the user can p erform cla im analyti c activiti es within the transa ctional da tabase usi ng all the data, | |
415 | 912213,As a CCRS Use r, I need the System to create an interf ace with t he Central Fee withi n VA, so t hat I can have the c omplete pa yment info rmation fr om the gen eral ledge r accounti ng of reim bursement payments t o complete claim pay ment disbu rsement.,• When the system rec eives the reimbursem ent invoic e with no matching e xisting re ferral, it will be r ejected, | |
416 | • When the system do esn't matc h the invo ice with r eferral it is proces sed with a rejected status, | |
417 | • When the system do esn't matc h the invo ice with r eferral it is added to excepti ons report , | |
418 | • When the reimburse ment invoi ce is reje cted it wi ll list th e rejectio ns reason within the exception report, | |
419 | 912199,As a CCRS Use r, I need the System to automa tically id entify the duplicate reimburse ment invoi ce claims using the unique com bination o f claim li ne data so that I ca n validate the reimb ursement c laim using this comb ination fo r frontend processin g claim re jection.,• The syste m will det ect duplic ate claims utilizing the claim unique id entifier a nd prevent payment o f duplicat es, | |
420 | • 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: , | |
421 | - Uniqu e Identifi er, | |
422 | - Provi der Id , | |
423 | - Patie nt Id , | |
424 | - Servi ce Date Fr om , | |
425 | - Servi ce Date To (optional ) , | |
426 | - Place Of Servic e , | |
427 | - Proce dure Code , | |
428 | - Proce dure Modif ier(s) (op tional) , | |
429 | - Bille d Amount , | |
430 | • 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 , | |
431 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} , | |
432 | • 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 , | |
433 | • 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', | |
434 | 918504,As a CCRS Use r, I need the System to automa tically id entify the duplicate line item submitted within th e contract ed reimbur sement inv oice using the uniqu e combinat ion of inv oice line data so th at I can p revent imp roper paym ents.,• Th e system w ill detect duplicate claims ut ilizing th e claim un ique ident ifier and prevent pa yment of d uplicates, | |
435 | • 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: , | |
436 | - Uniqu e Identifi er, | |
437 | - Provi der Id, | |
438 | - Patie nt Id, | |
439 | - Servi ce Date Fr om, | |
440 | - Servi ce Date To (optional ), | |
441 | - Place Of Servic e, | |
442 | - Proce dure Code, | |
443 | - Proce dure Modif ier(s) (op tional), | |
444 | - Bille d Amount, | |
445 | • 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, | |
446 | • When the re is more than one claim modi fier, then it will b e flagged as a dupli cate when all modifi ers match, | |
447 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} , | |
448 | • 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, | |
449 | • 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', | |
450 | 918505,As a CCRS Use r, I need the System to apply the valida te payment ammounts, so that I can make sure the p ayment is correct. , • When the claim inv oice is ac cepted, it should in clude the CLIN numbe r in the r eferral, | |
451 | • When the claim inv oice inclu des the CL IN number, it should display t he determi ned author ity (Mill Bill) and payment me thodology, | |
452 | • When fee schedules are appli ed, it sho uld be cal culated ba sed on loc ality, pla ce of serv ice, docto r (vs. aut horized ph ysician) a nd type of service, | |
453 | • When the provider is flagged by PPMS a t a differ ent negoti ated rate, the payme nt should display th e correct calculated amount, | |
454 | • When the provider is flagged by PPMS a t a differ ent negoti ated rate, the payme nt should allow for post payme nt adjustm ents, | |
455 | • When the negotiate d rate for the provi der is adj usted, the payment s hould allo w for hist orical tra cking by a dding a us er, date a nd time st amp of the adjustmen t, | |
456 | • When the provider' s fee sche dule is a negotiated rate, it should dis play the f lag or ide ntifier fo r payment verificati on, | |
457 | • When the payment i s calculat ed, the fi nal paymen t will be calculated using the Medicare Pricer, | |
458 | • When the payment i s calculat ed, the Me dicare Pri cer will a llow flexi bility by allowing u sers to mo dify provi der data t o reflect different values, | |
459 | 918506,As a CCRS Use r, I need the System to automa tically id entify the payment a uthority a ssociated to the rei mbursement invoice s o that I c an validat e it doesn 't match t he invoice and valid ate paymen t denial., • When the claim inv oice is fo r authorit y 1703 and 1728, it should be validated under cont ract 8153 – Title 38 and show payment ap proved, | |
460 | • When the validated claim inv oice is un der contra ct 8153 – Title 38, it should not displa y payment authority Mill Bill (1725) and it should show paym ent denied , | |
461 | • When the claim inv oice inclu des the CL IN number, it should display M ill Bill ( 1725) paym ent author ity, | |
462 | ||
463 | Rational I D,Requirem ent,Valida tions,Expe cted Resul ts, | |
464 | 152906,Giv en the sys tem can pr ocess invo ices for r eimburseme nt for mul tiple type s of servi ce,We vali date by co nfirming t hat for ea ch type of service, the invoic e is proce ssed and/o r the appr opriate ed iting rule s are appl ied.,• Inv oice match es all min imum accep tance crit eria (Refe rral # on invoice, D uplicate, Timely fil ing, Dates of Servic e, Scope o f episode) , | |
465 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
466 | Then I exp ect CCRS w ill be abl e to apply appropria te editing rules,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
467 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
468 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
469 | 152957,Giv en the sys tem can pr ocess Outp atient inv oices by a pplying co rrespondin g editing rules,We v alidate by confirmin g that for each Outp atient inv oice, the system pro cesses wit h the prop er approva l/denial c ompletion and assign ment to co rrespondin g workflow .,• Invoic e matches all minimu m acceptan ce criteri a (Referra l # on inv oice, Dupl icate, Tim ely filing , Dates of Service, Scope of e pisode) , | |
470 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
471 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
472 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
473 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
474 | 152959,Giv en the sys tem can pr ocess Inpa tient invo ices by ap plying cor responding editing r ules,We va lidate by confirming that for each Inpat ient invoi ce, the sy stem proce sses with the proper approval/ denial com pletion an d assignme nt to corr esponding workflow., • Invoice matches al l minimum acceptance criteria (Referral # on invoi ce, Duplic ate, Timel y filing, Dates of S ervice, Sc ope of epi sode) , | |
475 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
476 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
477 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
478 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
479 | 152960,Giv en the sys tem can pr ocess Urge nt/Emergen cy invoice s by apply ing corres ponding ed iting rule s,We valid ate by con firming th at for eac h Urgent/E mergency i nvoice, th e system p rocesses w ith the pr oper appro val/denial completio n and assi gnment to correspond ing workfl ow.,• Invo ice matche s all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) , | |
480 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
481 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
482 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
483 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
484 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
485 | 152963,Giv en the sys tem can pr ocess Urge nt/Emergen cy invoice s by apply ing corres ponding ed iting rule s,We valid ate by con firming th at for eac h Urgent/E mergency i nvoice, th e system p rocesses w ith the pr oper appro val/denial completio n and assi gnment to correspond ing workfl ow.,• Invo ice matche s all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) , | |
486 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
487 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
488 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
489 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
490 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
491 | 152964,Giv en the sys tem can pr ocess Dura ble Medica l Equipmen t invoices by applyi ng corresp onding edi ting rules ,We valida te by conf irming tha t for each Durable M edical Equ ipment inv oice, the system pro cesses wit h the prop er approva l/denial c ompletion and assign ment to co rrespondin g workflow .,• Invoic e matches all minimu m acceptan ce criteri a (Referra l # on inv oice, Dupl icate, Tim ely filing , Dates of Service, Scope of e pisode) , | |
492 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
493 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
494 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
495 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
496 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
497 | 153086,Giv en the sys tem can pr ocess Dent al invoice s by apply ing corres ponding ed iting rule s,We valid ate by con firming th at for eac h Dental i nvoice, th e system p rocesses w ith the pr oper appro val/denial completio n and assi gnment to correspond ing workfl ow.,• Invo ice matche s all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) , | |
498 | When invoi ces are re ceived and validated ,• System processes 100% of re imbursemen t invoices that are not assign ed to a wo rkflow que ue due to business a nd editing rules, | |
499 | Then I exp ect CCRS w ill be abl e to proce ss with th e proper a pproval/de nial compl etion and assignment to corres ponding wo rkflow as needed,• C omplete in voice reim bursement within 7 d ays or rec eipt by CC RS. , | |
500 | • Pharmacy invoices will be pr ocessed us ing NCPDP data inter change sta ndards for the pharm acy servic es, | |
501 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow, | |
502 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e, | |
503 | 153095,Giv en the sys tem can au tomaticall y a pseudo 835 file or report, We validat e by confi rming that when revi ewer recei ves the re port, all post FM in formation is display ed includi ng COB and post paym ent data., • When the reviewer receives t he report, it should display a ll post FM informati on, | |
504 | When invoi ces are re ceived,• W hen the re viewer rec eives the report, it should in clude all 835 like d ata to inc lude COB a nd post pa yments , | |
505 | Then I exp ect CCRS w ill be abl e to recon cile reimb ursement i nvoices su bmitted to the VA.,• The 835 l ike report will not be transmi tted throu gh a clear ing house with post FM informa tion, | |
506 | 153096,Giv en the sys tem can st ore reimbu rsement in formation for all li ne items f or a claim invoice,W e validate by confir ming that when invoi ce is rece ived, the reimbursem ent inform ation is a ll stored and able t o be calle d when nee ded.,• Whe n the CCRS user call s to the C CRS Reposi tory, the user can v iew any se lected lin e item for a claim i nvoice in the CCRS t ransaction al databas e, | |
507 | When invoi ces are re ceived,• W hen the CC RS user ca lls to the CCRS Repo sitory, th e user can view any selected l ine item f or a claim invoice i n the CCRS transacti onal datab ase, | |
508 | Then I exp ect CCRS w ill be abl e to manag e payment informatio n,• When t he CCRS us er calls o ut claims analytics within the CCRS Repo sitory, th e user can perform c laim analy tic activi ties withi n the tran sactional database u sing all t he data, | |
509 | 153097,Giv en the sys tem can cr eate an in terface wi th the Cen tral Fee w ithin VA,W e validate by confir ming the c all to the CCRS Repo sitory run s without failures a nd any lin e item for a claim i nvoice in the CCRS t ransaction al databas e appears when selec ted. Also we validat e by confi rming that the the c laims anal ytics call s run with out failur e and clai m analytic activitie s can be p erformed u sing all t he data in the trans actional d atabase.,• When the CCRS user calls to t he CCRS Re pository, the user c an view an y selected line item for a cla im invoice in the CC RS transac tional dat abase, | |
510 | When invoi ces are re ceived,• W hen the CC RS user ca lls out cl aims analy tics withi n the CCRS Repositor y, the use r can perf orm claim analytic a ctivities within the transacti onal datab ase using all the da ta, | |
511 | Then I exp ect CCRS w ill be abl e to manag e payment informatio n, | |
512 | 153098,Giv en the sys tem can au tomaticall y identify duplicate reimburse ment invoi ce claims using the unique com bination o f claim li ne data,We validate by confirm ing that a duplicate claim is rejected a nd flagged when the claim line matches a ny other c laim line based on t he unique combinatio n.,• The s ystem will detect du plicate cl aims utili zing the c laim uniqu e identifi er and pre vent payme nt of dupl icates, | |
513 | When invoi ces are re ceived,• W hen the sy stem deter mines the reimbursem ent claim submission claim lin e matches any other claim line s based on unique co mbination of the fol lowing: , | |
514 | Then I exp ect CCRS w ill be abl e to valid ate the re imbursemen t claim us ing the co mbination for fronte nd process ing claim rejection, - Uniqu e Identifi er, | |
515 | - Provi der Id , | |
516 | - Patie nt Id , | |
517 | - Servi ce Date Fr om , | |
518 | - Servi ce Date To (optional ) , | |
519 | - Place Of Servic e , | |
520 | - Proce dure Code , | |
521 | - Proce dure Modif ier(s) (op tional) , | |
522 | - Bille d Amount , | |
523 | • 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 , | |
524 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} , | |
525 | • 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 , | |
526 | • 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', | |
527 | 153305,Giv en the sys tem automa tically id entifies t he duplica te line it em submitt ed within the contra cted reimb ursement i nvoice usi ng the uni que combin ation of i nvoice lin e data,We validate b y confirmi ng that a claim that has alrea dy been pa id with du plicate li ne items i s flagged as a dupli cate.,• Th e system w ill detect duplicate claims ut ilizing th e claim un ique ident ifier and prevent pa yment of d uplicates, | |
528 | When invoi ces are re ceived ,• When the s ystem dete rmines the reimburse ment claim submissio n claim li ne matches any other claim lin es based o n unique c ombination of the fo llowing: , | |
529 | Then I exp ect CCRS w ill be abl e to rejec t and prev ent improp er payment s, - Uni que Identi fier, | |
530 | - Provi der Id, | |
531 | - Patie nt Id, | |
532 | - Servi ce Date Fr om, | |
533 | - Servi ce Date To (optional ), | |
534 | - Place Of Servic e, | |
535 | - Proce dure Code, | |
536 | - Proce dure Modif ier(s) (op tional), | |
537 | - Bille d Amount, | |
538 | • 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, | |
539 | • When the re is more than one claim modi fier, then it will b e flagged as a dupli cate when all modifi ers match, | |
540 | • When the matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'}, | |
541 | • 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, | |
542 | • 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', | |
543 | 153308,Giv en the sys tem applie s the corr esponding fee schedu le,We vali date by co nfirming t hat a clai m is paid with the a ppropriate correspon ding fee s chedule. W hen there is a diffe rent negot iated rate , there sh ould be a post payme nt adjustm ent.,• Whe n the clai m invoice is accepte d, it shou ld include the CLIN number in the referr al, | |
544 | When invoi ces are pa id ,• Whe n the clai m invoice includes t he CLIN nu mber, it s hould disp lay the de termined a uthority ( Mill Bill) and payme nt methodo logy, | |
545 | Then I exp ect CCRS w ill be abl e to provi de accurat e payment, • When fee schedules are appli ed, it sho uld be cal culated ba sed on loc ality, pla ce of serv ice, docto r (vs. aut horized ph ysician) a nd type of service, | |
546 | • When the provider is flagged by PPMS a t a differ ent negoti ated rate, the payme nt should display th e correct calculated amount, | |
547 | • When the provider is flagged by PPMS a t a differ ent negoti ated rate, the payme nt should allow for post payme nt adjustm ents, | |
548 | • When the negotiate d rate for the provi der is adj usted, the payment s hould allo w for hist orical tra cking by a dding a us er, date a nd time st amp of the adjustmen t, | |
549 | • When the provider' s fee sche dule is a negotiated rate, it should dis play the f lag or ide ntifier fo r payment verificati on, | |
550 | • When the payment i s calculat ed, the fi nal paymen t will be calculated using the Medicare Pricer, | |
551 | • When the payment i s calculat ed, the Me dicare Pri cer will a llow flexi bility by allowing u sers to mo dify provi der data t o reflect different values, | |
552 | 153311,Giv en the sys tem automa tically id entifies t he payment authority associate to the re imbursemen t invoice, We validat e by confi rming that a claim i nvoice val idated und er conract 8153- Tit le 38 show s payment is approve d. Also we validate by confirm ing that a claim inv oice under contract 8153- Titl e 38, then payment a uthority M ill Bill ( 1725) does not displ ay and the refore sho w payment is denied. ,• When the claim invoice is for autho rity 1703 and 1728, it should be validat ed under c ontract 81 53 – Title 38 and sh ow payment approved, | |
553 | When invoi ces are pa id ,• Whe n the vali dated clai m invoice is under c ontract 81 53 – Title 38, it sh ould not d isplay pay ment autho rity Mill Bill (1725 ) and it s hould show payment d enied, | |
554 | 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,• When t he claim i nvoice inc ludes the CLIN numbe r, it shou ld display Mill Bill (1725) pa yment auth ority, | |
555 | Business R ule,If an 837 does n ot include a referra l number, it will be rejected. | |
556 | , | |
557 | Business R ule,If an 837 does n ot include coordinat ion of ben efits (COB ) informat ion it wi ll be reje cted. | |
558 | ||
559 | , | |
560 | Business R ule,The in voice must include t he renderi ng provide r’s NPI, t he renderi ng service facility and the se rvice faci lity zip c ode to ens ure accura te payment s. | |
561 | , | |
562 | Business R ule,The re ndering pr ovider mus t be withi n the CCN Network., | |
563 | Business R ule,The re ndering pr ovider mus t have bee n active w ithin the CCN Networ k at the t ime that t he service was provi ded., | |
564 | Business R ule,The NP I number a nd date of service m ust be mad e availabl e when que rying the PPMS syste m to confi rm if the provider w as within network at the time of the cla im invoice service. | |
565 | , | |
566 | Business R ule,The in voice must include t he renderi ng provide r’s NPI, t he renderi ng service facility and the se rvice faci lity zip c ode to ens ure accura te payment s. , | |
567 | TEAM 7 - Payments T eam. Full stack deve lopers wit h experien ce in deve loping int erfaces us ing J2EE a nd Back-en d ETL and SQL Develo pers with data model ing expert ise, to su pport, des ign and de velop code required to have th e System i nterface w ith VA Cen tral Fee. This team is respons ible for t he creatio n of the i ntegration patterns and bi-rir ectional f low of dat a from CCR S into Cen tral Fee w ith proper instructi ons for pa yments, in cluding ob ligation a mounts and obligatio n number l inked to t he referra ll and the claim/inv oice.TEAM 7 - Payme nts Team. - EPICS | |
568 | ||
569 | Develop th e CCRS dat a entities , update C CRS databa se, develo p data mod el and cod e objects and logica l/physical model to host the C entral Fee data | |
570 | Develop th e conceptu al design and integr ation patt ern to int erface wit h Central Fee API, a nd web-ser vice | |
571 | Deconstruc t and comp lete data mappings, ensuring a ll CCRS re quired fie lds are pr esent to s upport Cen tral Fee i nterface ( obligation #, etc) | |
572 | Define req uired fiel ds, data t ypes, vali dations,ex ception ha ndling and necesary monitoring and contr oling for the Centra l Fee inte rface | |
573 | Make Centr al Fee dat a availabl e in the C CRS data m odel for o ther CCRS developmen t teams, i ncluding r emoving im pedements in CCRS de velopment team tasks | |
574 | Develop re ports, ext racts, and outbound interface to communi cate to Ce ntral Fee once confi rming reim bursements and payme nts are co nfirmed an d send ins tructions for paymen t to Centr al Fee | |
575 | Develop co de to chec k when all claim inv oices matc h all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) | |
576 | Develop co de for pro cess Outpa tient invo ices to va lidate inv oices by a pplying ed iting rule s so that the system processes with the proper ref erral appr oval/denia l completi on | |
577 | Develop th e code to extract re imbursemen t data fro m CCRS and develop t he code to interface with Cent ral Fee fo r proper r eimburseme nts TEAM 7 - Paymen ts Team. S takeholder s Needs. T he need is for a ded icated Cen tral Fee i nterface t hat can re ceive CCRS instructi ons for re imbursemen ts of paym ents for 8 37 invoice s. This is a bi-rire ctional in terface an d Central Fee will r eport back to CCRS o ne invoice s have bee n processe d and amou nts have b een obliga ted. CCRS will infor m the CCN contractor s once pay ment has b een confir med. As a CCRS User, I need th e System t o automati cally gene rate reimb ursement p ayment inf ormation f or each ap proved lin e item for each appr oved claim invoice, so that co ntractors will be re imbursed f or service s paid to CCN provid ers on beh alf of the VA. As a CCRS User, I need th e System t o store re imbursemen t payment informatio n for all line items for a cla im invoice within th e VA autho ritative s ystem, so that payme nt informa tion can b e managed. As a CCRS User, I n eed the Sy stem to cr eate an in terface wi th the Cen tral Fee w ithin VA, so that I can have t he complet e payment informatio n from the general l edger acco unting of reimbursem ent paymen ts to comp lete claim payment d isbursemen t. As VHA Office of Community Care (VHA CC), I wan t an autom ated syste m that is able to de tect dupli cate invoi ce for rei mbursement submitted by contra cted entit ies, so th at imprope r payments are preve nted. | |
578 | ||
579 | SHEET: TEA M_8_EDI_83 7INVOICES | |
580 | ||
581 | Rational I D,Requirem ent,Busine ss Story, | |
582 | 912201,As a CCRS Use r, I need the System to receiv e all invo ices submi tted 837I (Instituti onal) reim bursement claims dir ectly from the clear inghouse s o that the System re ceives all claims th at pass fr ont end ed its. | |
583 | ,•System r eceives 83 7I (Instit utional) d irectly fr om clearin ghouse | |
584 | •Submissio n will inc lude all r equired re imbursemen t claims d ata | |
585 | •All reimb ursement c laims will include t he require d referral number | |
586 | , | |
587 | 912202,As a CCRS Use r, I need the System to receiv e all invo ices submi tted 837P (Professio nal) reimb ursement c laims dire ctly from the cleari nghouse so that the System rec eives all claims tha t pass fro nt end edi ts. | |
588 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
589 | • Submissi on will in clude all required r eimburseme nt claims data | |
590 | • All reim bursement claims wil l include the requir ed referra l number | |
591 | , | |
592 | 922203,As a CCRS Use r, I need the System to receiv e all invo ices 837D (Dental) r eimburseme nt claims directly f rom the cl earinghous e so that the System receives all claims that pass front end edits.,• System rec eives 837D (Dental) directly f rom cleari nghouse | |
593 | • Submissi on will in clude all required r eimburseme nt claims data | |
594 | • All reim bursement claims wil l include the requir ed referra l number | |
595 | , | |
596 | 912190,As a CCRS Use r, I need the System to receiv e all invo ices Pharm acy form N CPDP D.0 r eimburseme nt claims directly f rom the cl earinghous e so that the System receives all claims that pass front end edits.,• System rec eivesNCPDP D.0 direc tly from c learinghou se | |
597 | • Submissi on will in clude all required r eimburseme nt claims data | |
598 | • All reim bursement claims wil l include the requir ed referra l number | |
599 | , | |
600 | 912191,If an 837 doe s not incl ude a refe rral numbe r, it will be reject ed. | |
601 | ,• System receives 837P (Prof essional) directly f rom cleari nghouse | |
602 | • Submissi on will in clude all required r eimburseme nt claims data, | |
603 | 912192,If an 837 doe s not incl ude coordi nation of benefits ( COB) infor mation it will be r ejected. | |
604 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
605 | • Submissi on will in clude all required r eimburseme nt claims data, | |
606 | 912193,The invoice m ust includ e the rend ering prov ider’s NPI , the rend ering serv ice facili ty and the service f acility zi p code to ensure acc urate paym ents. | |
607 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
608 | • Submissi on will in clude all required r eimburseme nt claims data, | |
609 | 912194,The rendering provider must be wi thin the C CN Network . | |
610 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
611 | • Submissi on will in clude all required r eimburseme nt claims data, | |
612 | 912195,The rendering provider must have been activ e within t he CCN Net work at th e time tha t the serv ice was pr ovided. | |
613 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
614 | • Submissi on will in clude all required r eimburseme nt claims data, | |
615 | 912196,The NPI numbe r and date of servic e must be made avail able when querying t he PPMS sy stem to co nfirm if t he provide r was with in network at the ti me of the claim invo ice servic e. | |
616 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
617 | • Submissi on will in clude all required r eimburseme nt claims data, | |
618 | 912197,The invoice m ust includ e the rend ering prov ider’s NPI , the rend ering serv ice facili ty and the service f acility zi p code to ensure acc urate paym ents. | |
619 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
620 | • Submissi on will in clude all required r eimburseme nt claims data, | |
621 | 912198,Map fields fo r comparis on between EOB and P IT databas e/system a nd apply b usiness ru le; ex: I f payment on claim i s shown, b ut not 835 /EOB is NO T found; p lace on EO B Exceptio ns Worklis t. | |
622 | ,• System receives 8 37P (Profe ssional) d irectly fr om clearin ghouse | |
623 | • Submissi on will in clude all required r eimburseme nt claims data, | |
624 | 912199,As VHA Office of Commun ity Care ( VHA CC), I want an a utomated s ystem that validates all requi red data e lements ar e included in the El ectronic D ata Interc hange 837 claim tran saction (c oordinated claim) su bmitted by a Communi ty Care Ne twork cont ractor, so that reim bursement will be ap proved. | |
625 | ||
626 | ,• System receives 837P (Prof essional) directly f rom cleari nghouse | |
627 | • Submissi on will in clude all required r eimburseme nt claims data, | |
628 | ClaimsStor y004,As a CCRS User, I need th e System t o transfor m the 837 COB into a consumabl e claim in voice into CCRS, so that the i nvoices ca n be evalu ated. | |
629 | ,• System transforms 837 COB i nto a cons umable cla im invoice | |
630 | • Submissi on will in clude all COB claims data | |
631 | • All COB claims dat a is accep ted, store d and view able in th e CCRS Rep ository | |
632 | , | |
633 | 912200,As a CCRS Use r, I need the System to evalua te the cla im invoice to ensure data comp leteness, so that on ly complet e claim in voices are accepted into CCRS. | |
634 | ,• Submiss ion includ es all req uired reim bursement claims dat a | |
635 | • Submissi on accepts all requi red reimbu rsement cl aims data, user can view and v alidate da ta fields from sourc e system a nd CCRS | |
636 | ||
637 | , | |
638 | 912194,If an invoice does not include a referral n umber, it will be re jected. | |
639 | ,NA, | |
640 | 912211,If an invoice does not include an y COB data it will r ejected. | |
641 | ,NA, | |
642 | 912207,The invoice m ust includ e the rend ering prov ider’s NPI , the rend ering serv ice facili ty and the service f acility zi p code to ensure acc urate paym ents. | |
643 | ,NA, | |
644 | 912197,The rendering provider must be wi thin the C CN Network .,NA, | |
645 | 912206,The rendering provider must have been activ e within t he CCN Net work at th e time tha t the serv ice was pr ovided.,NA , | |
646 | 912181,The NPI numbe r and date of servic e must be made avail able when querying t he PPMS sy stem to co nfirm if t he provide r was with in network at the ti me of the claim invo ice servic e. ,NA, | |
647 | 912189,The invoice m ust includ e the rend ering prov ider’s NPI , the rend ering serv ice facili ty and the service f acility zi p code to ensure acc urate paym ents. ,NA , | |
648 | 912191,As a CCRS Use r, I need the System to reject claim inv oices that failed da ta complet eness edit s, so that we may st ore and co mmunicate rejections . | |
649 | ,• When al l claim in voices mat ch all min imum accep tance crit eria (Refe rral # on invoice, D uplicate, Timely fil ing, Dates of Servic e, Scope o f episode) , accept the claim invoice da ta | |
650 | • When cla im invoice data is i ncomplete, the syste m will rej ect that t ransmissio n and comm unicate re jection re ason | |
651 | • Only com plete clai m invoice data will be stored in the CCR S Reposito ry | |
652 | , | |
653 | 912203,Cla ims that f ailed data completen ess edits should be annotated as rejecte d. | |
654 | ,NA, | |
655 | 912212,Cla ims that f ailed data completen ess edits should inc lude a rea son for re jection fr om a stand ard list ( CARC/RARC) | |
656 | ,NA, | |
657 | 912205,As a CCRS Use r, I need the System to store all accept ed claim i nvoices th at passed data compl eteness ed its, so th at we may process fo r reimburs ement. | |
658 | ||
659 | ,• Only co mplete cla im data wi ll be pass ed, then i t will be stored in the CCRS R epository, | |
660 | 912193,As a CCRS Use r, I need an interna l unique i dentifier for each a ccepted cl aim, so th at I may t rack and m anage clai m invoices . | |
661 | ,• When th e claim in voice is a ccepted, i t will gen erate the internal u nique iden tifier | |
662 | • The inte rnal uniqu e identifi er will be assigned to each ac cepted cla im invoice , it will be a searc heable num ber within CCRS to t rack and m anage acce pted claim s | |
663 | , | |
664 | 912194,For VHA Offic e of Commu nity Care (VHA CC) S ystems Man agement | |
665 | ||
666 | Who must v alidate su bmitted cl aim invoic es for rei mbursement by the co ntracted e ntities | |
667 | ||
668 | The future Community Care Reim bursement System (CC RS) | |
669 | ||
670 | That allow s CCRS to only proce ss accepte d invoices that pass all busin ess rules and edits | |
671 | ||
672 | Unlike the current s ystem that does not process re imbursemen t or gener ates payme nt | |
673 | ||
674 | Our proces s allows f or a singl e reimburs ement syst em to vali date accep ted claim invoices t hat passed all busin ess rules and edits and automa tically pr ocess and generate t he accurat e reimburs ement paym ents | |
675 | ||
676 | ,NA, | |
677 | 912195,As VHA Office of Commun ity Care ( VHA CC), I want an a utomated s ystem that is able t o process invoices f or reimbur sement for multiple types of s ervice so that appro priate edi ting rules will be a pplied whe n validati ng the cla im. (Note : Types o f services include O utpatient, Inpatient , Urgent/E mergency, Pharmacy, Durable Me dical Equi pment, oth ers to be determined ) | |
678 | ||
679 | ,NA, | |
680 | 912194,As a CCRS Use r, I want an automat ed system that is ab le to proc ess invoic es for rei mbursement for multi ple types of service so that a ppropriate editing r ules will be applied when vali dating the claim. ( Note: Typ es of serv ices inclu de Outpati ent, Inpat ient, Urge nt/Emergen cy, Pharma cy, Durabl e Medical Equipment, others to be determ ined) | |
681 | ||
682 | ,• Invoice matches a ll minimum acceptanc e criteria (Referral # on invo ice, Dupli cate, Time ly filing, Dates of Service, S cope of ep isode) | |
683 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules | |
684 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. | |
685 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow | |
686 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e | |
687 | ||
688 | , | |
689 | 912211,As a CCRS Use r, I need the System to automa tically pr ocess Outp atient inv oices to v alidate in voices by applying c orrespondi ng editing rules so that the s ystem proc esses with the prope r approval /denial co mpletion a nd assignm ent to cor responding workflow as needed. | |
690 | ,• Invoice matches a ll minimum acceptanc e criteria (Referral # on invo ice, Dupli cate, Time ly filing, Dates of Service, S cope of ep isode) | |
691 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules | |
692 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. | |
693 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow | |
694 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e | |
695 | ||
696 | , | |
697 | ||
698 | Rational I D,Requirem ent,Valida tions,Expe cted Resul ts, | |
699 | 152797,Giv en the sys tem intake process t hat receiv ed and par sed 837I | |
700 | When invoi ces are re ceived fro m EDI | er epos inter face | |
701 | Then I exp ect CCRS w ill be abl e to recei ve and sto re the inv oices,We v alidate by confirmin g the pars ing job fo r EDI | er epos ran w ithout fai lures, we can valida te that th e parsing occurred a s recently as the la st 24 hour s. We shou ld check h ow many in voices wer e received and how m any were ‘ intaked’ i nto CCRS. Check any errors tha t prevente d the inte rface to c omplete. C heck for r equired da ta and ref erral numb er,•System receives 837I (Inst itutional) directly from clear inghouse | |
702 | •Submissio n will inc lude all r equired re imbursemen t claims d ata | |
703 | •All reimb ursement c laims will include t he require d referral number | |
704 | , | |
705 | 152812,Giv en the sys tem intake process t hat receiv ed and par sed 837P | |
706 | When invoi ces are re ceived fro m EDI | er epos inter face | |
707 | Then I exp ect CCRS w ill be abl e to recei ve and sto re the inv oices,We v alidate by confirmin g the pars ing job fo r EDI | er epos ran w ithout fai lures, we can valida te that th e parsing occurred a s recently as the la st 24 hour s. We shou ld check h ow many in voices wer e received and how m any were ‘ intaked’ i nto CCRS. Check any errors tha t prevente d the inte rface to c omplete. C heck for r equired da ta and ref erral numb er,• Syste m receives 837P (Pro fessional) directly from clear inghouse | |
708 | • Submissi on will in clude all required r eimburseme nt claims data | |
709 | • All reim bursement claims wil l include the requir ed referra l number | |
710 | , | |
711 | 152814,Giv en the sys tem intake process t hat receiv ed and par sed 837D | |
712 | When invoi ces are re ceived fro m EDI | er epos inter face | |
713 | Then I exp ect CCRS w ill be abl e to recei ve and sto re the inv oices,We v alidate by confirmin g the pars ing job fo r EDI | er epos ran w ithout fai lures, we can valida te that th e parsing occurred a s recently as the la st 24 hour s. We shou ld check h ow many in voices wer e received and how m any were ‘ intaked’ i nto CCRS. Check any errors tha t prevente d the inte rface to c omplete. C heck for r equired da ta and ref erral numb er,• Syste m receives 837D (Den tal) direc tly from c learinghou se | |
714 | • Submissi on will in clude all required r eimburseme nt claims data | |
715 | • All reim bursement claims wil l include the requir ed referra l number | |
716 | , | |
717 | 152816,Giv en the sys tem intake process t hat receiv ed and par sed NCPDP D.0 | |
718 | When invoi ces are re ceived fro m EDI | er epos inter face | |
719 | Then I exp ect CCRS w ill be abl e to recei ve and sto re the inv oices,We v alidate by confirmin g the pars ing job fo r EDI | er epos ran w ithout fai lures, we can valida te that th e parsing occurred a s recently as the la st 24 hour s. We shou ld check h ow many in voices wer e received and how m any were ‘ intaked’ i nto CCRS. Check any errors tha t prevente d the inte rface to c omplete. C heck for r equired da ta and ref erral numb er,• Syste m receives NCPDP D.0 directly f rom cleari nghouse | |
720 | • Submissi on will in clude all required r eimburseme nt claims data | |
721 | • All reim bursement claims wil l include the requir ed referra l number | |
722 | , | |
723 | 152826,Giv en the sys tem intake process t hat transf ormed 837 COB | |
724 | When invoi ces are re ceived fro m EDI | er epos inter face | |
725 | Then I exp ect CCRS w ill be abl e to evalu ate the in voices,We validate b y confirmi ng the tra nsformatio n job for EDI | erep os (not su re if I ma de this up ) ran with out failur es, we can validate that the t ransformat ion occurr ed as rece ntly as th e last 24 hours. We should che ck how man y invoices were rece ived and h ow many we re evaluat ed by CCRS . Check an y errors t hat preven ted the in terface to complete. Check for required data and r eferral nu mber,• Sys tem transf orms 837 C OB into a consumable claim inv oice | |
726 | • Submissi on will in clude all COB claims data | |
727 | • All COB claims dat a is accep ted, store d and view able in th e CCRS Rep ository | |
728 | , | |
729 | 152833,Giv en the sys tem intake process t hat evalua ted for da ta complet eness | |
730 | When invoi ces are re ceived fro m EDI | er epos inter face | |
731 | Then I exp ect CCRS w ill be abl e to accep t only com plete clai m invoices ,We valida te by conf irming tha t all requ ired data as well as the refer ral number are inclu ded in the invoice. ,• Submiss ion includ es all req uired reim bursement claims dat a | |
732 | • Submissi on accepts all requi red reimbu rsement cl aims data, user can view and v alidate da ta fields from sourc e system a nd CCRS | |
733 | ||
734 | , | |
735 | 152835,Giv en the sys tem intake process t hat reject ed claim i nvoices th at failed data compl eteness ed its | |
736 | When invoi ces are re ceived fro m EDI | er epos inter face | |
737 | Then I exp ect CCRS w ill be abl e to store and commu nicate rej ections,We validate by confirm ing that t he rejecti on job ran without f ailures an d that the data for rejection is stored in appropr iate datab ase.,• Whe n all clai m invoices match all minimum a cceptance criteria ( Referral # on invoic e, Duplica te, Timely filing, D ates of Se rvice, Sco pe of epis ode), acc ept the cl aim invoic e data | |
738 | • When cla im invoice data is i ncomplete, the syste m will rej ect that t ransmissio n and comm unicate re jection re ason | |
739 | • Only com plete clai m invoice data will be stored in the CCR S Reposito ry | |
740 | , | |
741 | 152838,Giv en the sys tem intake process t hat stored accepted claim invo ices that passed dat a complete ness edits | |
742 | When invoi ces are re ceived fro m EDI | er epos inter face | |
743 | Then I exp ect CCRS w ill be abl e to proce ss for rei mbursement ,We valida te by conf irming tha t the acce ption job ran withou t failures and that the data f or accepte d claim in voices is stored and processed . ,• Only complete c laim data will be pa ssed, then it will b e stored i n the CCRS Repositor y, | |
744 | 152840,Giv en the sys tem intake process t hat stored accepted claim invo ices | |
745 | When invoi ces are re ceived fro m EDI | er epos inter face | |
746 | Then I exp ect CCRS w ill be abl e to creat e an inter nal unique identifie r for each .,We valid ate by con firming th at the acc epted clai m invoice has an ide ntifer tha t is uniqu e from any other of the identi fiers. ,• When the c laim invoi ce is acce pted, it w ill genera te the int ernal uniq ue identif ier | |
747 | • The inte rnal uniqu e identifi er will be assigned to each ac cepted cla im invoice , it will be a searc heable num ber within CCRS to t rack and m anage acce pted claim s | |
748 | , | |
749 | 152906,Giv en the sys tem can pr ocess invo ices for r eimburseme nt for mul tiple type s of servi ce | |
750 | When invoi ces are re ceived and validated | |
751 | Then I exp ect CCRS w ill be abl e to apply appropria te editing rules,We validate b y confirmi ng that fo r each typ e of servi ce, the in voice is p rocessed a nd/or the appropriat e editing rules are applied. , • Invoice matches al l minimum acceptance criteria (Referral # on invoi ce, Duplic ate, Timel y filing, Dates of S ervice, Sc ope of epi sode) | |
752 | • System p rocesses 1 00% of rei mbursement invoices that are n ot assigne d to a wor kflow queu e due to b usiness an d editing rules | |
753 | • Complete invoice r eimburseme nt within 7 days or receipt by CCRS. | |
754 | • System m ust assign reimburse ment invoi ce to the correspond ing workfl ow | |
755 | • System w ill transm it alert t o work gro up of new work item in the wor kflow queu e | |
756 | ||
757 | , | |
758 | TEAM 8 - 837 EDI In voice Data Team. Ful l stack de velopers w ith experi ence in de veloping i nterfaces using J2EE and Back- end ETL an d SQL Deve lopers wit h data mod eling expe rtise, to support, d esign and develop co de require d extract, transform and load 837 x12 da ta obtaine d in EDI f ormat. Thi s team is responsibl e for the creation o f the code patterns and routin es to pars e, transfo rm and nor malize EDI data and load this data into the CCRS r epository. This team will upda te and cre ate the CC RS data ta bles requi red to sav e the 837 data and m ake it ava ilable to other modu les in CCR S. TEAM 8 - 837 EDI Invoice D ata Team. - EPICS | |
759 | ||
760 | Develop th e CCRS dat a entities , update C CRS databa se, develo p data mod el and cod e objects and logica l/physical model to host the 8 37 data | |
761 | Develop th e conceptu al design and data m odels and code patte rn to extr act 837 da ta and nor malize the EDI infor mation int o the CCRS repositor y | |
762 | Deconstruc t and comp lete data mappings, ensuring a ll CCRS re quired fie lds are pr esent to s upport EDI transacti onal proce ssing | |
763 | Define req uired fiel ds, data t ypes, vali dations,ex ception ha ndling and necesary monitoring and contr oling for the EDI pa rsing of 8 37 data | |
764 | Make EDI, 837 data a vailable i n the CCRS data mode l for othe r CCRS dev elopment t eams, incl uding remo ving imped ements in CCRS devel opment tea m tasks | |
765 | Develop ro utines, ba tches and ETL, extra cts, to st ore confir ming reimb ursements and paymen ts in CCRS repositor y | |
766 | Develop co de to chec k when all claim inv oices matc h all mini mum accept ance crite ria (Refer ral # on i nvoice, Du plicate, T imely fili ng, Dates of Service , Scope of episode) | |
767 | Develop co de for pro cess inpat ient-Outpa tient invo ices to va lidate inv oices by a pplying ed iting rule s so that the system processes with the proper ref erral appr oval/denia l completi on | |
768 | Develop th e code to import rei mbursement data into CCRS and provide da ta to othe r teams fo r proper r eimburseme nts proce ssingTEAM 8 - 837 E DI Invoice Data Team . Stakehol ders Needs ; Orchestr ate a high ly automat ed claims processing system to be used w ithin the newly esta blished Co mmunity Ca re Network (CCN) to reimburse CCN contra ctors for payments m ade for ca re provide d under th is network . This in cludes the receipt a nd validat ion of 837 Coordinat ion of Ben efits (coo rdinated) claims, re imbursemen t, post-pa yment audi t activiti es, and fa cilitation of revenu e operatio n activiti es (i.e., first part y billing and third party liab ility). Cl aims submi tted for c are provid ed by non- VA provide rs in the CCN networ k. Receipt and valid ation of a post-paym ent 837 cl aims, reim bursement, post-paym ent audit activities , and faci litation o f revenue operation activities (i.e., fi rst party billing). As a CCRS User, I w ant an aut omated sys tem that i s able to receive El ectronic D ata Interc hange 837 claim tran sactions ( Coordinati on of Bene fits; coor dinated cl aims) from a Communi ty Care Ne twork cont ractor via a clearin ghouse so that we ca n ensure r eceipt of verified c laims. | |
769 | ||
770 |
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