36C10X18R0133-A00004003.docx

Centralized Administrative Accounting Transaction System (CAATS) Contract Exam Requirements Document - Contractors

October 14, 2015

Revision History The revision history cycle begins once changes or enhancements are requested before the developer has implemented the change.

1.0 Introduction

The Administrative Loan and Accounting Center (ALAC) Centralized Administrative Accounting Transactions System (CAATS) was instructed to develop a module) for creating Veteran Compensation and Services (CS) contracted examination requests. The module should provide the functionality to submit contract examination to third party contractors using secure file protocol (sftp) and track expenditures and funding balances throughout the fiscal year.

1.1 Purpose

The purpose of this document is to document the requirements for the CAATS Contract Exam module for the third party contractors. The document will provide the contractors with an explanation of the purpose, features of the system, interfaces and constraints. The stakeholders and developers of the Contract Exam module are the intended users of this document.

1.2 Project Scope

The Contract Exam module will process CS examination requests and the requests for medical opinions with contracted vendors. The module will be part of the CAATS program which is a web based system. VA internal users will access the system through the CAATS web uniform resource locator (URL). CAATS will export the requests and response files to the vendors servers at scheduled intervals. CAATS will retrieve response, addendum, worksheet CPT, Virtual VA, and invoice files from the vendors’ servers at scheduled intervals.

1.3 Acronyms and Abbreviations

CAATS Centralized Administrative Accounting Transaction System VERIS Veterans Examination Request Information System

1.4 References

Continuous Readiness in Information Security Program website at http://vaww.vhaco.va.gov/CRISP/summary.html National Institute of Standards and Technology (NIST) – Technology Administration (U.S. Department of Commerce) Information Technology Laboratory (ITL) Bulletin Dated April 2006 Office of Health Information Governance – VHA Information Access and Privacy Office Privacy Fact Sheet Dated January 2009 – revised June, 2010 – Volume 09, No. 3

VA Handbook 6500 Risk Management Framework for VA Information Systems – Tier 3: VA Information Security Program Dated September 20, 2012

VA Handbook 6500.3 Certification and Accreditation of VA Information Systems Dated November 24, 2008

VHA Handbook 1605.02 Minimum Standard for Protected Health Information Dated January 23, 2013

NIST Special Publication 800-133 – Recommendations for Cryptographic Key Generations by Elaine Barker and Allen Roginsky Dated December 2012

2.0 Overview of the document

The remainder of the document will provide descriptions of the product functions, user characters and roles, general constraints, assumption and dependencies, functional and non-functional requirements, and interface requirements.

The module contains tabs or sections based on the workflow. The user of the document can access each section individually or follow the sections in a sequential order that mirrors the workflow. The document indices allow the user to identify the specific page number of the document.

2.1 Overall description

The Contract Exam module will be part of the web-based CAATS applications. CAATS user will access the program through the VA’s internal website. Users will be assigned roles based on their job duties. The RO will submit the CAATS employee access request form. The form will annotate the role the user should be assigned.

In addition, certain VA records are deemed sensitive in nature and should be restricted to certain users. Users in the auditors’ role can view sensitive records.

2.2 System Environment

CAATS will transmit files to the various vendors’ servers and retrieve information from the servers via a secure file transfer protocol (SFTP). Since the documents will contain Personal Health Information (PHI) and Personal Identifiable Information (PII), the files will also be encrypted.

2.3 System Interfaces

Listed below is the overview of the system and interfaces:

2.3.1 Exam Request

The CAATS user enters an exam request into CAATS. When the request is moved into Approved status, the exam request is exported to a file via the ExamRequest schema. This file is placed on the vendor SFTP site on a scheduled time.

2.3.2 Vendor Exam Request Response to CAATS

Once the vendor has processed the exam request file, the vendor provides CAATS with a response via the ExamRequestResponse schema.

The vendor can respond in 3 ways:

· AcceptedByContractor – This indicates that the vendor has accepted the request and will begin processing it.

· RejectedByContractor – This indicates that the vendor has rejected the request. This response requires a reason to be provided. Once this is received by CAATS, user’s will be notified of the rejection status. Users will go back to the request and address the issue. Once resolved, the exam will be approved again and the process starts over.

· CancelledByContractor – This is a special case response. It is not provided when the vendor initially receives the file. It can be sent after the exam has been accepted if something occurs (such as failure to receive medical files in a timely matter). This allows the vendor to cancel the contract. This response requires a reason to be provided. Once in CAATS, this exam request will be reviewed by CAATS users. CAATS users will be notified of this status change via email.

If the processing of the Response file by CAATS fails, the ImportResponse file will be sent to the vendor with entries defining the errors. The entries will be under the VendorResponse entry.

2.3.3 Vendor Sends Worksheet Addendum to CAATS

Once the veteran has had the exam, any additional worksheets can be added, approval notes added, or worksheets cancelled. The vendor provides CAATS with a worksheet addendum via the WorksheetAddendum schema.

The vendor can place entries in this for one of 3 reasons:

· Add new worksheets. If the veteran’s exam required more worksheets than originally placed in the exam request, the vendor can add worksheets to the request with this file.

· Add notes to an existing worksheet. If the vendor required special approval for diagnostic tests or other pieces of the worksheet, then the vendor should supply a note for the worksheet that indicates the test, who approved it, and when it was approved. This will be used by the reviewer when approving the invoice charges.

· Worksheet cancelled by vendor. This is a special case response. Is is a way for the vendor to indicate that a specific worksheet was not done. It was cancelled by the vendor for some reason. This information is provided via the notes entry as described above. The note should indicate that the worksheet was cancelled and why

If the processing of the Worksheet Addendum file by CAATS fails, the ImportResponse file will be sent to the vendor with entries defining the errors. The entries will be under the WorksheetAddendum entry.

2.3.4 Vendor Sends Worksheet CPT to CAATS

Once the veteran has had the exam, the CPT codes associated with the worksheets must be provided. This must occur after any worksheet addendum changes occur, if required. The vendor provides CAATS with a worksheet CPT via the WorksheetCPT schema. After this step, the vendor can now invoice the exam.

If the processing of the Worksheet CPT file by CAATS fails, the ImportResponse file will be sent to the vendor with entries defining the errors. The entries will be under the WorksheetCPT entry.

2.3.5 Vendor Sends Virtual VA File to CAATS

Once the veteran has had the exam, and the vendor has sent the exam to Virtual VA or VBMS, the vendor must notify CAATS via the SendToVirtualVA schema in order to stop the timeliness check. The file contains the date a specific exam was sent as well as an indicator of where the exam was sent (Virtual VA or VBMS).

If the processing of the Virtual VA file by CAATS fails, the ImportResponse file will be sent to the vendor with entries defining the errors. The entries will be under the VirtualVA entry.

2.3.6 Vendor Sends Invoice to CAATS

Once the vendor has sent the Worksheet CPTs to CAATS, the vendor can invoice the exam. The vendor provides CAATS with an exam invoice via the ExamInvoice schema.

Each invoice must contain a unique invoice number. Only one Original invoice per exam request is permitted.

In this schema, an invoice is provided for each exam. Within the exam, there are several invoice items. Each invoice item represents a CLIN code or a CPT code that is being invoiced.

The invoice will be validated against NCCI Edits. In addition, the amounts being charged will be validated against the Medicare rates.

If the invoice is accepted, the exam will be placed into In Review or In Finance Review status. Once it is reviewed and approved, the invoice will be sent to FMS.

· If the processing of the Exam Invoice file by CAATS fails, the ImportResponse file will be sent to the vendor with entries defining the errors. The entries will be under the Invoice entry.

2.3.7 CAATS Sends Lookup Updates to Vendor

The lookup table file is used to keep the vendor systems in sync with the CAATS system for the various lookup tables (aka name/value pairs). Typically these lists consist of a code and additional fields associated with that code.

Initially, a file containing all values will be provided to the vendor. After the initial download, the file will be sent with the scheduled exam request export. The file at that time will contain references only to those records that were added or modified.

Currently, the following tables that are updated include:

· Body Systems (used in the Diagnostic Codes section of the exam request)

· Diagnostic Codes

· Worksheets

· Special Program Sites (BDD, Quickstart, IDES)

· Special Programs (the special programs that are available e.g. QuickStart, BDD)

· VSO Listings

2.4 User Interfaces

The user will access the CAATS program through their VA computer at the CAATS internal website.

2.4.1 Product functions

The Contract Exam Request module allows the user to enter Veteran claim contentions for compensation and pension. CAATS submits the request to the appropriate vendor while referencing the correct obligation number. After completion of the examination request, the vendor updates the CAATS system that the exam request has been completed. The module includes a quality assessment feature that allows users to access the vendors’ quality in completing the examination request.

2.5 User Characteristics and Roles

The Contract Exam module will contain the following roles and characteristics:

· Initiator/Approver – The Regional Office VSR generally will be assigned this role. The users will enter the exam request. When the user selects submit, the system will approve the exam request. The exam request will remain in the approved status until it is exported to the vendor. If the exam request is rejected by the vendor or cancelled, the initiator/approver role can return the exam request to an editable state. The user can modify the exam request and resubmit it.

· Sensitive – The user has to have the Initiator/Approver role. The sensitive role allows the user to access sensitive Veteran records and exam requests.

· Notification – The user will receive email notifications for exam requests that have been Rejected by Contractor or Cancelled by Contractor. The user will be unable to view the documents unless assigned the Initiator/Approver role. The user may also be assigned the Sensitive role.

· Set-up Administrator – The Set-up Administrator will primarily be comprised of users at the C&P Program office. The users have the ability to view all non-sensitive Veterans contain on the Veteran List and Contract Exam request. The users can allocate General Operating Expense (GOE) funds to the ROs through the Budget Management sub-module of the exam request, as well as monitor both GOE and mandatory funds. Special reports were created that allow the user to monitor vendor timeliness, inadequate or insufficient examinations, and funding amounts.

· Auditor – The role will primarily be assigned to Internal and External auditors, and the VA quality assurance staff. The users have the ability to review the exam request to ensure that the request adhere to VA policies and procedures.

· System Administrator – The System Administrators are the CAATS team located at ALAC in Austin, Texas. The users can view all documents and reports contained in the Contract Exam module. The System Administrators have the ability to override documents and return the documents to various states.

2.5.1 Document States

· Working – When the exam request is initiated by the user, it will be in a working status. The exam request will remain in working status until the document is Approved/Submitted by the user.

· Returned to Edit – After the document has been approved, the user can return the exam request to an editable state by viewing the document and selecting the “return to edit” state. The document will return to working once the user begins to modify the document. The user can select submit to return the document back to an approved state. Additionally, if the vendor rejects the exam request, the user must return the exam request to an editable state by selecting the “return to edit” state. After modifying the document, the user can select submit to return the document back to an approved state.

· Submitted/Approved – After the user submits the exam request, the request systematically moves from a submitted to approved state. CAATS exports all exam requests in an approved state during the scheduled export file intervals.

· Submitted to Contractor – When the document is exported to the vendor, the exam request’s status changes from approved to “Submitted to Contractor.” The exam request will remain in the submitted to contractor status until the vendor determines the disposition of the request and updates the CAATS system via a response file as to the status of the exam request. The vendor can either accept the exam request or reject the exam request.

· Accepted by Contractor – If the exam request passes the vendors’ validation and business process, the vendor will accept the exam request for processing. The vendor will notify the CAATS system that the exam request has been accepted by contractor on their response file during the schedule interval file transmission. CAATS will update the status of the exam request from “Submitted to Contractor” to “Accepted by Contractor.”

· Rejected by Contractor – If the exam request does not pass the vendors’ validation or business process, the vendor will reject the exam request for processing. The vendor will notify the CAATS system that the exam request has been rejected by contractor on their response file during the schedule interval file transmission. CAATS will update the status of the exam request from “Submitted to Contractor” to “Rejected by Contractor.”

· Cancelled – As part of the Contract Exam contractual agreement with the vendors, the vendors can cancel an exam request that requires medical files if the medical files have not been received within 7 days. The exam request must be in the “Accepted by Contractor” status to be able to be cancelled by the vendor. The vendor will annotate that the exam request was cancelled on the response file. CAATS will update the status of the exam request from “Accepted by Contractor” to “Cancelled.”

· Completed – The exam request is completed when the completed worksheets and medical information are uploaded into the VA’s Virtual VA file or VBMS system. The vendor will send the date the worksheet was uploaded into the VA’s Virtual VA or VBMS system and the location of the worksheets and related medical information. CAATS will populate the header page of the exam request with the date and location of the file. The status of the exam request will be changed from “Accepted by Contractor” to “Completed.” Completed is the final status of the exam request unless the exam request fails the VA’s quality assessment process.

· Inadequate – The RO will conduct internal quality assessment of worksheets and medical examinations provided by the vendors. If the RO deems the exam request were inadequate, the status will change from “Completed” to “Inadequate.” The exam request will remain in an inadequate status. CAATS will export the inadequate exam request and reason code to the vendor in the CAATS response file to the vendor during scheduled intervals.

2.5.2 Document Status for Querying

· All – All list all the documents for that station in that Contract Exam module. The statuses are as follows: All Active, Working, Returned to Station, Approved, Deleted, Submitted to Contractor, Accepted by Contractor, Rejected by Contractor, Completed, Inadequate, and Cancelled by Contractor.

· All Active Document – Dashboard defaults to All Active status. The status includes all documents in Working and Approved Status.

· Working – When a user first enters an exam request, the request is in a working status. However, for the information to be saved and retained on the dashboard, at a minimum the header page must be saved. The user has not submitted the document.

· Returned to Station – After an exam request is submitted, the user has the option of returning the exam request to edit to make modifications to the exam request prior to the schedule file export time. Once the user selects “Return to Edit”, the exam request is listed as returned to station. The user can enter the document and make changes. The document will then change from return to edit to working once the user selects edit and save of any transaction.

· Approved – After the user submits the exam request, the request is systematically approved. The system deducts the pre-allocated amount from the budget management table. The exam request is displayed on the dashboard as approved. All exam request in “Approved” status at the time of the file export are collected and exported to the vendor.

· Deleted – The user has the option of deleting an exam request while the exam request is in working status. The exam request can be returned to working by returning to edit when the document is in Rejected by Contractor, or Cancelled by Contractor status. The pre-allocated amount is returned to the obligation available balance.

· Submitted to Contractor – When the approved documents are transmitted to the vendor on the XML file, the exam request are changed to Submitted to Contractor status. The requests will remain in this status until the Vendor Response file changes the status of the request to the following: Accepted by Contractor, Rejected by Contractor, or Cancelled by Contractor.

· Accepted by Contractor – When the vendor’s Response file updates the exam request to Accepted by Contractor, the vendor will process the request. The vendor timeliness begins on the date the exam request status changes to Accepted by contractor.

· Rejected by Contractor – The exam request may lack documentation or clarity. The vendor has the option of rejecting the exam request. RO has to option of updating and resubmitting the request or deleting the request.

· Completed – When the Virtual VA import file has updated the exam request with the date and location of the medical file, the exam request’s status changes to completed status. Timeliness ends when the exam request’s status changes to completed status. Completed will be the final state of the exam request unless the request had a negative QA assessment.

· Inadequate – During the rating determination, the RO may determine that the vendor did not complete the exam request satisfactorily. The RO can deem the exam requests as inadequate. The inadequate code and reason are submitted to the vendor on the CAATS export Response file.

· Cancelled by Contractor – Based on the vendor’s contract, the vendor can cancel an exam request if they have not received the Veterans’ medical records within seven days if the medical record is required. The vendor will update the status of the exam request on the vendor Response file. The vendor can also cancel the exam request if the Veteran is a no-show to their appointment.

3.0 General Constraints and Non-Functional Requirements

CAATS is a web-based application. The Contract Exam module will contain Personally Identifiable Information (PII) and Personal Health Information (PHI). The VA has adopted the highest level of security. In addition to transmitting the information via a secure file transfer protocol (SFTP), the Veterans records will be encrypted. The Contract Exam module will be review as new VA standards are issued to ensure continued compliance.

CAATS will display only the last four digits of the Veterans’ social security number (SSN) on the dashboard and within the exam request document.

In addition, special care must be given for employees that work for the Regional Offices (RO) that are either a Veteran or a relative of the Veteran to ensure their privacy is respected. The Contract Exam module will contain sensitive personal information (SPI) and sensitive information/data. Restricted access has been established for SPI and sensitive information/data.

CAATS will have to update the Current Procedural Terminology (CPT) tables annually with the current CPT codes as produced by the American Medical Association (AMA).

4.0 Assumptions and dependencies

CAATS will export the exam request and response files to the vendors’ server via a SFTP. CAATS depends on the servers to be available during the scheduled transmission intervals. CAATS assumes that all server modification or firewall changes by the vendor will be conveyed to the CAATS developers and system administrators within a timely manner.

5.0 Requirements

5.1 Exam Request

The exam request submodule will consist of a Wizard where the user will only have to input certain information for verification of whether that Veteran already exists in the system. Once inside the actual exam request the user will have a header and different tabs which are listed below.

5.1.1 Header Page

5.1.1.1 Wizard

CE2000: the Exam request shall contain a wizard that allows the user to enter the following fields: SSN and/or Claim number, Special Program, Claim Type, and Request Type.

CE2000.1.2 - The SSN field shall require nine characters.

CE2000.1.3 – The field shall only allow for numeric characters.

CE2000.1.4 – If no claim number is entered for the Veteran, the SSN is required. If a claim number is entered, the SSN is not required.

CE2000.2.2 – The Claim number field shall accept a minimum of seven characters and a maximum of eight characters.

CE2000.2.3 – The field shall only accept numeric characters.

CE2000.2.4 – If no SSN is entered for the Veteran, the claim number is required. If a SSN is entered, the claim number is not required.

CE2000.3 – The Special program field shall allow input of the following special programs: None, BDD, IDES, or Quick Start. No other value shall be accepted in the field.

CE2000.3.1 – The user shall select a special program from the drop-down list contained in the field.

CE2000.4 – The Claim type field shall allow input of the following claim types: Appeal, Increase, Original, Remand, Reopen, and Routine. No other value shall be accepted in the field.

CE2000.4.1 – The user shall select the claim type from a drop-down list contained in the field.

CE2000.5 – The request type shall allow input of the following request types: Medical Opinion, Exam Request, or Exam and Medical Opinion. No other value shall be accepted.

CE2000.5.1 – The user shall select the request type from the drop-down list contained in the field.

CE2000.6 – CAATS will valid the field once the user selects the next button.

CE2000.6.1 – If the Veteran SSN and/or Claim number exists in the Contract exam Veteran List database, the module will populate the header page.

CE2000.6.2 – If the Veteran SSN and/or Claim number does not exist in the Contract Exam Veteran List database, the system will direct the user to the Veteran list to enter the Veteran data.

CE2000.6.2.1 – The user will entered the Veteran information as listed above in the Veteran list.

CE2000.6.2.2 – Once the Veteran information is saved in the Veteran list, the user will have the option of being re-directed back to the exam request to complete the request.

CE2000.6.2.3 – The information cannot be changed once the demographic information populates the exam request.

CE2000.6.3 – Based on the user’s selection contained in the wizard, tabs will become visible for the user to enter in the exam request.

CE2000.6.3.1 – If the user selects Increase, Reopen, or Routine as the claim type, the diagnostic tab will become visible to the user and require user input.

CE2000.6.3.1.1 – If the user selects, appeal, original, or remand, the diagnostic tab will not become visible.

CE2000.6.3.1.2 – The field can be changed within the exam request on the header page. The tabs will adjust based on the new selection once the page has been saved.

CE2000.6.3.2 – If the user selects, Medical Opinion or Exam and Medical Opinion, the Medical opinion tab will become visible.

CE2000.6.3.2.1 – The field can be changed within the exam request on the header page. The tabs will adjust based on the new selection once the page has been saved.

CE2000.6.3.3 – If the user selects, Comp or Both (Comp and Pen) – The Compensation text box will be visible on the Claimed Condition tab. If the user selects Pen or Both (Comp and Pen), the Pension text box will be visible on the Claimed Condition tab.

5.1.1.2 Header page - CE3000

CE3000.1 - The header page shall populate the following demographic information from the Veteran based on the Veteran SSN and/or Claim number entered in the Exam Request Wizard: First Name, Last Name, Address Line 1, Address Line 2, City, State, Zip, Country, Phone Number, Alternate Phone Number, Email address, Gender, Date of Birth, Branch of Service, Entry on Duty, Release from Active Duty, Active Duty Service Member, and Veteran Service Organization.

CE3000.2 – The header page will populate with the additional information entered in the Exam Request Wizard: Claim type, Special Program, and Request Type.

CE3000.3 – The user will enter the remaining information on the header page of the exam request.

CE3000.3.2.2 – The user has the option of selecting yes or leaving the field default.

CE3000.3.2.3 – The field is required.

CE3000.3.3 – Benefit program contains following values from the drop-down list contained in the field. Comp (Compensation), Pension (Pen), or Both (Comp and Pen). No other values will be accepted in the field.

CE3000.3.3.1 – The user shall select the benefit program from the drop down list.

CE3000.3.3.2 – The user shall have the option of typing the benefit program.

CE3000.3.3.3 – The field is required.

CE3000.3.4 – Date of Claim – the user will enter the date the Veteran originally submitted the claim for benefits.

CE3000.3.4.3: The date shall be in the following formats: (2-digit month/2-digit day/4-digit year) (XX/XX/XXXX) or all numeric (2-digit month 2-digit day 4-digit year without spaces) (XXXXXXXX)

CE3000.3.4.6: The field shall allow the date to be entered based on the selection of the calendar that should be adjacent to the field.

CE3000.3.4.6.1: The user can select the left < and right > symbols to toggle through the current year.

CE3000.3.4.6.2: If the user clicks on the Month, Year combination, the year will become visible with the months listed in the text box.

CE3000.3.4.6.2.1: The user will select the correct year by selecting the left < and right > symbols to toggle through the year.

CE3000.3.4.6.2.2: When the appropriate year is located, the user selects the correct month.

CE3000.3.4.6.2.3: The user selects the day from the correct month. CAATS will populate that date into the entry on duty date field.

CE3000.3.5 – Comments shall be a free-form text box.

CE3000.3.5.1 – The text box shall allow for alpha-numeric and special characters.

CE3000.3.6 – The contractor will be assigned once the header page is saved and will only be visible to the user once the vendor has been assigned.

CE3000.3.7 – The date of the exam request shall be assigned by the CAATS system based on the current date and time of the user enters the exam request.

CE3000.3.8 – The date exam submitted shall remain blank and will be populated by the vendor on the Virtual VA file. (The requirements will be discussed later in the document.)

CE3000.3.9 – The location exam submitted field shall remain blank and will be populated by the vendor on the Virtual VA file. (The requirements will be discussed later in the document.)

CE3000.3.10 – The Physicians instructions field shall be a free-form text box.

CE3000.3.10.1 – The text box shall allow for alpha-numeric and special characters.

CE3000.3.10.2 – The maximum number of characters shall be 4,000 CE3000.3.10.3 – The field is not required.

CE300.3.11 – The Send Claim File to Contractor Field shall have a drop-down list with the following values: No, Shipping, VBMS, Virtual VA, and eCFT.

CE3000.3.11.1 – The field is required.

CE3000.3.11.2 – The field shall accept no other values than the listed choices.

CE3000.3.12 - The user has the option of saving the document or exiting by selecting the options located at the bottom of the exam request page.

5.1.1.3 CAATS Vendor and CLIN selection - CE4000

CE4000.1 – CAATS shall contain a table that allows the System Administrator to select which regional offices participate in the Contract Exam Fee basis program.

CE4000.1.1 - CAATS will have a table located in the CAATS Administrator; the Contract Exam module; then the Contract Exam Contractors section.

CE4000.1.2 - The table should list all the Regional Offices and a field that allows the user to select which region the RO will use for billing purposes.

CE4000.1.3 - The table should include: North Atlantic District, South East District, Midwest District, Continental District and Pacific District.

CE4000.1.4 - The user will select the active button to assign the vendor to the RO.

CE4000.1.4.1 - If the active button is selected, CAATS will assign the vendor to the RO if the RO does not select a special program for the exam request.

CE4000.1.4.2 - If the active button is not selected, the RO will get an error message if an exam request is entered that is not a special program since no vendor is assigned. Example: “Exam Request cannot be processed. No vendor is assigned to this Regional Office. Please contact the C&P Program Office.”

CE4000.1.4.3 - When the administrators select an RO, a warning message will be displayed if the user does not select the active button when the user saves the document. Example: “The active button has not been selected. Vendor will not be assigned to the Regional Office.”

CE4000.1.4.3.1 -The user should still be able to save the record after reading the warning message without selecting the active button.

CE4000.1.4.3.2 - The user should be able to deactivate an active record by unchecking the active box. No warning message should be displayed when the user saves the document.

CE4000.1.5 - CAATS administrator will assign the regions can use a particular vendor for their exam requests. The region will determine which CLIN table CAATS uses to verify the invoice price is correct.

CE4000.1.5.1 – The CAATS administrator shall have an override button that allows the administrator to change the automatic vendor selection. (Exceptions to the current rules may require a different vendor be selected.

CE4000.2.2 - CLINs using the contracted rate use the date of the examination request to determine the appropriate option year table to confirm the CLIN rate.

Note: CLINs using CPT codes will use the date of service (DOS) to confirm the invoiced Medicare rate.

CE4000.3 – The current Regional division is listed below. The CLIN tables are included in the appendix. Note: The Regional Offices may change within a particular region but the table and CLIN for that region will remain the same.

CE4000.4 - All Regional Offices shall be given access to the Contract Exam module should be able to enter an examination request. Regional Offices not contracted but using a special program will have their exam requests assigned to the special program vendor.

CE4000.5 - CAATS shall identify if the exam request has a special program: If the Regional Office (RO) selects BDD, or IDES then CAATS shall assign VENDOR as the vendor (handles special programs).

CE4000.5.1 - If the RO selects Quick start, CAATS will verify the location of the Regional Office.

CE4000.5.1.1 - If the Regional Office is either San Diego (Station 377) or Los Angeles (Station 344), the CAATS will verify the military installation.

CE4000.5.1.1.1 – If the military installation is "000 – No military Installation", the exam request will be assigned to Vet-Fed as the vendor.

CE4000.5.1.1.2 – If the military installation is any other value than "000 – No Military Installation", the exam request will be assigned to VENDOR.

CE40005.1.2 – If the Regional is Office is any other location except San Diego (Station 377) and Los Angeles (Station 344), the CAATS will assign the vendor to VENDOR A or B depending on the vendor that service that area.

CE4000.6 - Once the vendor has been selected, CAATS shall assign the obligation number for the exam request.

CE4000.6.1 - CAATS shall assign the obligation number to the exam request based on the following criteria:

· The Contractor

· The obligation number must be in an active state

· The date of the exam request must be within the beginning and end date of the obligation

· The date of the exam request must be prior to the obligation expiration date CE4000.6.2 - If two or more obligations available for the same vendor that meets the above criteria, CAATS shall select the earliest obligation that still has a minimum of the pre-allocated amount remaining on the obligation balance.

CE4000.7 - CAATS shall assign both the vendor and the obligation number to the exam request.

CE4000.7.1 - The vendor’s name shall be listed on the header page of the exam request in a read only field after the RO saves the page.

CE4000.7.2 - The obligation number shall be included on the export file to the vendor but should not be visible to the CAATS user.

5.1.1.4 Claimed Conditions Tab - CE5000

CE5000.1 – Claim Condition for Compensation shall be visible to the user if the user selects Comp or Comp and Pen as the Benefit Program.

CE5000.1.1 – The user shall select the “Add New Claimed Condition” button.

CE5000.1.2 – A free-form text box shall become visible.

CE5000.1.2.1 – The user can enter a maximum of 4,000 – a minimum of one character.

CE5000.1.2.4 – The user shall have the option of cancelling the transaction or saving.

CE5000.1.2.5 – Once the field is saved, the user shall have options to edit or delete the record.

CE5000.1.2.6 – The user can add additional claim conditions by selecting the “Add New Claimed Condition.”

CE5000.2 – Claim Condition for Pension shall be visible to the user if the user selects Pen or Comp and Pen as the Benefit Program.

CE5000.1.1 – The user shall select the “Add New Claimed Condition” radial button.

CE5000.1.2 – A free-form text box shall become visible.

CE5000.1.2.1 – The user can enter a maximum of 4,000 – a minimum of one character.

CE5000.1.2.4 – The user shall have the option of cancelling the transaction or saving.

CE5000.1.2.5 – Once the field is saved, the user shall have options to edit or delete the record.

CE5000.1.2.6 – The user can add additional claim conditions by selecting the “Add New Claimed Condition.”

5.1.1.5 Worksheets - CE6000

CE6000.1 – A table shall be established in the database that lists all the Disability Benefit Questionnaire (DBQ) and the Automated Medical Information Exchange (AMIE) for the disability exam requirement.

CE6000.1.1 – The database shall be able to distinguish between DBQ and AMIE worksheets.

CE6000.1.2 – The DBQ and AMIE worksheet database shall contain the worksheets’ related body system.

CE6000.1.3 – The database shall indicate if a Specialist is required – choices shall be always yes, always no, or the user has the option to select yes or no.

CE6000.1.4 – The database shall indicate if a Stressor is required –the user has the option to select yes or no.

CE6000.2 – The Graphical User Interface (GUI) shall be created to allow user to select the correct worksheet.

CE6000.2.1 – The body system field shall allow the user to select the body system from the list of body systems for all worksheet types in the database.

CE6000.2.1.1 – The user shall select the body system from the drop-down list of body system.

CE6000.2.2 – Once the body system is select, the DBQ/Worksheet field shall be populated with the list of worksheets that relate to that body system. No other worksheets shall be visible to the user.

CE6000.2.2.1 – The user shall select the body system from the drop-down list of worksheets.

CE6000.2.2.2 – The user shall have the option of typing the worksheet number or worksheet name to populate the field.

CE6000.2.2.3 – The field is required.

CE6000.2.3 – Special Required field – Boolean True equals yes; False equals no.

CE6000.2.4 – The field maybe defaulted to yes or no based on information contained in the database. The user shall have the ability to edit the selection.

CE6000.2.2 – The user shall select yes or no.

CE6000.2.6 – The field is required.

CE6000.3.3 – Stressor Required field – Boolean True equals yes; False equals no.

CE6000.2.4 – The field maybe defaulted to yes or no based on information contained in the database. The user shall have the ability to edit the selection.

CE6000.2.5 – The user will select yes or no.

CE6000.3.4.1 – The field shall be defaulted to no. Users cannot adjust this field.

CE6000.3.4.2 - The field shall be systematically changed to yes, when the vendor adds worksheet via an Addendum file. (The Addendum file will be discussed later in this document.)

CE6000.3.5 – Vendor Notes: Read only field for users.

CE6000.3.5.1 – The field shall be updated systematically with information contained in the vendors Addendum file.

CE6000.3.5.2 – Users shall not be able to edit or delete items from the field.

CE6000.3.5.3 - The field is a free-form text field.

CE6000.3.5.4 - The field shall accept alpha-numeric and special characters.

CE6000.3.6 - The user shall have the option of cancelling the record or saving the worksheet.

CE6000.3.6.1 – If the user selects save, the worksheet will be added to the exam request.

CE6000.3.6.1.1 – After the worksheet is saved, the user has the option to edit or delete the worksheet.

CE6000.3.6.1.1.1 – If the user deletes the worksheet, the worksheet will be deleted from the exam request.

CE6000.3.6.1.1.2 – If the user edits the worksheet, the user can adjust the body system, DBQ/AMIE worksheet, Special required and Stressor required field.

CE6000.3.6.1.1.2.1 – If the body system is changed, the worksheet must be changed to a worksheet that relates to the selected body system.

CE6000.3.6.1.1.2.2 – Once the worksheet is edited and saved, the worksheet shall be added to the exam request.

CE6000.3.6.2 – If the user selects cancel, the worksheet will not be added to the exam request.

CE6000.4 – The user shall not be able to enter a duplicate worksheet.

CE6000.4.1 – When the user selects to save the worksheet, the system shall verify if the worksheet entered has already been entered. (duplicate) CE6000.4.1.1 – If the worksheet is a duplicate, the user shall receive an error message stating the following: Duplicate Worksheet Selected 9999: Each worksheet can be selected only once.

CE6000.4.1.2 – The worksheet shall not save. The user shall have the option to change the worksheet selection and then save or cancel the worksheets.

5.1.1.6 Diagnostic Codes Tab - CE7000

CE7000.1 – A table that contains the diagnostic codes and diagnostic code numbers shall be created in the database.

CE7000.2 - The Diagnostic Code tab will only become visible when the user selects the Increase, Routine, and Reopen as the claim type on the Exam Request Wizard or the Header page.

CE7000.3 – The GUI shall allow the user add new diagnostic codes by selecting the “add new diagnostic code” CE7000.3.1 – The user shall have the ability to select the diagnostic code from the drop-down list.

CE7000.3.2 – The user shall have the ability to enter the diagnostic code number or description in the field.

CE7000.4 – The user shall have the option of cancelling or saving the diagnostic code to the worksheet.

CE7000.4.1 – If the user selects save, the diagnostic code will be added to the exam request.

CE7000.4.1.1 – After the diagnostic code is saved, the user has the option to edit or delete the diagnostic code.

CE7000.4.1.1.1 – If the user deletes the diagnostic code, the diagnostic code will be deleted from the exam request.

CE7000.4.1.1.2 – If the user edits the diagnostic code, the user shall adjust the diagnostic code.

CE7000.4.1.1.2.1 – Once the diagnostic code is edited and saved, the revised diagnostic code shall be added to the exam request.

CE7000.4.2 – If the user selects cancel, the diagnostic code will not be added to the exam request.

5.1.1.7 Medical Opinion Tab CE8000

CE8000.1 – The medical opinion tab shall contain seven free-text form boxes with the following titles: Issues, Claimant’s Contention, Evidence, Service Records, Private Medical Records, Other, and Requested Opinion.

CE8000.2 – Issues field shall be a free-form text box.

CE8000.2.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.3.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.4.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.5.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.6.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.7.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.8.1 - The field shall allow for a maximum of 3,000 characters.

CE8000.9 – The user shall have the option of cancelling or saving the medical opinion information to the exam request.

CE8000.9.1 – If the user selects save, the medical opinion text will be added to the exam request.

CE9000.9.1.1 – After medical opinion is saved, the user has the option to edit or delete the medical opinion.

CE9000.9.1.1.1 – If the user deletes the medical opinion, the medical opinion will be deleted from the exam request.

CE9000.9.1.1.2 – If the user edits the medical opinion, the user shall adjust the one or all of the text boxes.

CE9000.9.1.1.2.1 – Once the medical opinion is edited and saved, the revised medical opinion shall be added to the exam request.

CE8000.9.2 – If the user selects cancel, the medical opinion will not be added to the exam request.

5.1.1.8 Worksheet CPTs - CE9000

CE9000.1 – CAATS shall develop a table of the imported Current Procedural Terminology (CPT) codes.

CE9000.1.1 – The table shall contain the five digit CPT code.

CE9000.1.1.1 – The table shall contain the abbreviated CPT code description.

CE9000.1.1.2 – The table shall contain the unabbreviated CPT code description.

CE9000.2 - The worksheets and their related worksheets shall be imported into the CAATS system from the Worksheet CPT (Current Procedural Terminology) file. (The file will be discussed later in the document.)

CE9000.2.1 – The fields shall be read only.

CE9000.3 – The Code field shall allow for the import of the worksheet codes listed on the examination request.

CE9000.3.1 – Code field - CAATS shall validate that the worksheet exists on the worksheet table.

CE9000.3.1.1 – If the worksheet exists on the worksheet table, CAATS will validate that the worksheet was included in the exam request.

CE9000.3.1.1.1.1 – If the worksheet exists on the exam request, CAATS shall import into the exam request on the Worksheet CPT Code page provided all other validations pass.

CE9000.3.1.1.1.2 – If the worksheet does not exists on the exam requests, CAATS shall reject the record on the import file.

CE9000.3.1.2 – If the worksheet does not exists on the worksheet table, the record will be rejected on the file.

CE9000.3.1.3 – The worksheet code is required on the Worksheet CPT file import.

Note: The procedure for handling rejected import files has the same procedure. The procedure will be described in the Response Export file section.

CE9000.3.2 – Name field - CAATS shall validate that the worksheet name with the name listed for that worksheet code on the CAATS worksheet table.

CE9000.3.2.1 – CAATS will verify that the name and worksheet code pair matches the combination contained in the worksheet table.

CE9000.3.2.1.1 – If the name field and code pair matches the worksheet code pair in the worksheet table, CAATS shall import the record.

CE9000.3.2.1.2 – If the name field and code pair does not match the worksheet code pair in the worksheet table, CAATS will reject the record on the import file.

CE9000.3.2.1.3 – The name field is required on the Worksheet CPT file import.

CE9000.3.3 - Body System Field – CAATS shall validate that the body system with the…