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# | Location | File | Last Modified |
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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs | CCRS Reimbursement Rule Inputs.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 Reimbursement Rule Inputs.xlsx | Fri Jun 15 15:07:59 2018 UTC |
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1 | SHEET: Rul es | |
2 | Implemente d, | |
3 | Rule,Descr iption,ID, Conditions ,Yes,No,Q? ,Acceptanc e Criteria ,Rejection Criteria, Notes,Data Inputs, | |
4 | TimelyFili ng,Verify the invoic e claim is received within the timely fi ling perio d, so that the claim is accept ed if the date of se rvice is w ithin the pre-define d period o f time and denied if it is not within th e pre-defi ne period of time.,1 .1,Always deny claim s not subm itted with in one hun dred eight y (180) da ys from th e date of service or date of d ischarge f or passing the timel y filing d eadline.,I f the “Adm it Date” o r “First d ate of ser vice” is 1 80 DAYS ON OR BEFORE the "Clai m Received Date", TH EN status of the cla im is set to ACCEPT. ,If the “Admit Dat e” or “Fir st date of service” is 181 DAY S ON OR AF TER the "C laim Recei ved Date", THEN stat us of the claim is s et to DENI ED for Tim ely Filing (TF). ,Wh en DENYING a claim t he system will recor d a reason code with in industr y standard s with the denial de scription on the com munication transmitt ed back to the contr actor for correction and resub mittal., | |
5 | 1.2,Always grant add itional ti me to the claims fil ing deadli ne require ments for Veterans w ith OHI wh en the pro vider firs t submitte d the clai m to the p rimary pay er, and th e adjudica tion occur red past t he VA fili ng deadlin e. The Con tractor mu st always ensure cla ims for se rvices den ied by ano ther insur er include the Expla nation of Benefits ( EOB) or re mittance a dvice (RA) statement indicatin g the date s of servi ce, amount of the cl aim, and r eason(s) f or denial. The Contr actor must always de ny all OHI claims su bmitted be yond ninet y (90) day s from the date of t he other i nsurer’s a djudicatio n.,If the “Admit Dat e” or “Fir st date of service” is 90 DAYS ON OR BEF ORE the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to AC CEPT. ,If the “Admit Date” OR “First dat e of servi ce” is 91 DAYS ON AF TER the "C laim Recei ved Date f rom VA COB ", THEN st atus of th e claim is set to DE NIED for T imely Fili ng (TF). , | |
6 | Claim Amou nt Thresho ld,2.1, | |
7 | Referrals, Automatica lly match invoices t o existing referrals within CC RS, so onl y matched invoices a re process ed. Deny invoices t hat have n o matching referral, so that d enials can be stored and commu nicated.,3 .1,When th e system r eceives th e reimburs ement invo ice it nee ds to be m atched to existing r eferral,Wh en the sys tem matche d the invo ice with r eferral it is proces sed and th e system s hows the p ayment app roved,When the syste m receives the reimb ursement i nvoice wit h no match ing existi ng referra l, it will be reject ed | |
8 | When the s ystem does n't match the invoic e with ref erral it i s processe d with a r ejected st atus | |
9 | When the s ystem does n't match the invoic e with ref erral it i s added to exception s report | |
10 | When the r eimburseme nt invoice is reject ed it will list the rejections reason wi thin the e xception r eport,Only validated claim inv oices will be stored in the CC RS Reposit ory, | |
11 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE),4 .1, | |
12 | Dates of S ervice,Aut omatically process t he invoice s using th e required data elem ents withi n the matc hing refer ral to val idate the invoice is within th e dates of service,5 .1,The dat e of servi ce must fa ll within the matchi ng referra l.,When th e system r eceives th e reimburs ement invo ice with m atching re ferral, i t will dis play as va lidated if it is wit hin the da tes of ser vice,Invoi ces that a re not wit hin the da tes of ser vice shoul d be annot ated as de nied. | |
13 | Invoices t hat are no t within t he dates o f service should inc lude a rea son for de nial from a standard list (CAR C/RARC).,W hen the sy stem recei ves the re imbursemen t invoice with match ing referr al, if it is not wit hin the da tes of ser vice of th e referral , validati on will li st a denie d status | |
14 | , | |
15 | Duplicates ,Automatic ally ident ify the du plicate li ne item su bmitted wi thin the c ontracted reimbursem ent invoic e using th e unique c ombination of invoic e line dat a so that improper p ayments ca n be preve nted.,6.1, IF claim l ine matche s any othe r claim li ne within the invoic e or withi n another invoice ba sed on uni que combin ation of | |
16 | • Unique I dentifier | |
17 | • Provider Id | |
18 | • Patient Id | |
19 | • Service Date From | |
20 | • Service Date To (o ptional) | |
21 | • Place Of Service | |
22 | • Procedur e Code | |
23 | • Procedur e Modifier (s) (optio nal) | |
24 | • Billed A mount,All rule condi tions list ed (6.1-6. 3) must be met to be considere d a duplic ate | |
25 | • Deny any line item that was previously reimburse d by VA. | |
26 | • Line ite ms that ar e duplicat es should be annotat ed as deni ed. | |
27 | • Line ite ms that ar e duplicat es should include a reason for denial fr om a stand ard list ( CARC/RARC) . | |
28 | • Identify unique Ve terans tha t were rei mbursed in a month f or PMPM pa yments. | |
29 | • Deny any claim tha t was prev iously sub mitted by a provider for the s ame servic e provided to a part icular ind ividual on a specifi ed date of service., Annotate t he claim l ine record as denied with the appropriat e CARC/RAR C reason, | |
30 | 6.2,the ma tching cla im line is not annot ated as pr eviously r ejected or declined, | |
31 | 6.3,the ma tching cla im line is annotated as PAID, | |
32 | ||
33 | ||
34 | ||
35 | SHEET: Que stions | |
36 | ||
37 | Rule ID,Qu estion,Res ponse,Prio rity, | |
38 | 3.1,What i s CARC, RA RC and whi ch codes a re appropr iate for w hich failu res?,Mediu m, | |
39 | 3.1,Where is the CAR C/RARC lis t? Do we h ave a db l ookup tabl e for thes e?,Medium, | |
40 | 3.1,"When the system matched t he invoice with refe rral it is processed and the s ystem show s the paym ent approv ed" - Need s clarific ation? Doe s this ass ume that t he claim h as passed all other rules? Fro m a dev pe rspective, what does payment a pproved me an?,Medium , | |
41 | 3.1,"When the system doesn't m atch the i nvoice wit h referral it is add ed to exce ptions rep ort" - Nee ds Clarifi cation. Wh at is the exceptions report an d what tea m is respo nsible for creating it?,Medium , | |
42 | 3.1,"When the reimbu rsement in voice is r ejected it will list the rejec tions reas on within the except ion report " - Needs Clarificat ion. What is the exc eptions re port and w hat team i s responsi ble for cr eating it? ,Medium, | |
43 | 3.1,"Only validated claim invo ices will be stored in the CCR S Reposito ry" - From a dev per spective, what does validated mean? Whe re/What is the CCRS Repo?,Medi um, | |
44 | 1.1,During some elab oration ac tivities, I believe Meghan ind icated tha t the time ly conditi ons (from attached) are: | |
45 | ||
46 | • The CCNs must proc ess, adjud icate, and send the claim to C CRS within 180 days from claim ’s date of service; | |
47 | • The CCNs must send the claim to CCRS w ithin 30 d ays after they have paid the p rovider; a nd | |
48 | • The CCN’ s must res ubmit a re jected cla im to CCRS within 30 days of r ejection. | |
49 | ||
50 | This diffe rs from th e rule spe c laid out in the Ru le Spec do c: | |
51 | • Always d eny claims not submi tted withi n one hund red eighty (180) day s from the date of s ervice or date of di scharge fo r passing the timely filing de adline. | |
52 | • The Cont ractor mus t always d eny all OH I claims s ubmitted b eyond nine ty (90) da ys from th e date of the other insurer’s adjudicati on. | |
53 | ,Medium, | |
54 | 1.2," the date of th e other in surer’s ad judication ." Is thi s provided to us in some form? Is this i nfo includ ed in 837? ,Medium, | |
55 | ||
56 | ||
57 | ||
58 | ||
59 | ||
60 | ||
61 | SHEET: She et3 | |
62 | Priorities , | |
63 | Low, | |
64 | Medium, | |
65 | High, |
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