Attachment K Data Specifications.xlsx
XLSX spreadsheet 36 KB Posted
- Attached to
- Q201--CCN-Next Gen Medical
- Solicitation number
- 36C10G26R0003
About this file
The file is an Attachment K Data Specifications spreadsheet for a Department of Veterans Affairs (VA) Community Care Network (CCN) Next Generation Medical contract. The document details comprehensive reporting requirements across four primary areas: 1) Cost Avoidance-Recovery, which includes quarterly reporting on overpayments, underpayments, and variance analysis with specific data elements like veteran identifiers, invoice numbers, and recovery amounts; 2) Claims Auditing, specifying metrics on total claims audited, prepayment and postpayment reviews, and provider denials; 3) Clinical Quality reporting on Patient Quality Indicators (PQI) and Improvement Quality Indicators (IQI), tracking issues by severity, provider, and resolution status; and 4) Continuity of Operations Plan (COOP) reporting on system downtime, including planned and unplanned outages, functional impacts, and remediation steps.
The fifth reporting section covers Urgent/Emergent Prescription Performance Metrics, requiring detailed documentation for each prescription, including pharmacy details, medication information, prescription reference numbers, dispensing data, provider information, and cost metrics. Each reporting section mandates precise data specifications, formatting requirements, and comprehensive tracking of medical service, payment, and quality metrics for VA medical care. The reporting framework appears designed to ensure rigorous oversight, cost management, and quality control in the VA's medical service delivery network.
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1a. Cost Avoidance-Recovery
| Item | PWS Task | ID | Deliverable Description |
| 1 | 13.5 | Quarterly Cost Avoidance and Recovery/Recoupment Reports - Summary of Errors |
| Section 13.5 Cost Avoidance and Recovery/Recoupment Reports: Data Specifications | |||
| Error Summary | |||
| A summary of errors by reason category, to include number of cases and dollar value. | |||
| Data Description | Error Reason Category | Number of Cases | Dollar Value |
| New proposed data description | Overpayment / Underpayment Error Reason: Incorrect Veteran, Incorrect Vendor, Not an Eligible Veteran, Excluded or Non-Covered Benefit by Regulation, Lack of VACC Authorization, Service Excluded from Coverage by Authorization, Untimely Submission of Claim or Medical Records, Lack of Regulatory Authority to Pay (38 U.S.C. 1725, Veteran with OHI), Payments for Goods or Services Not Received, Claim Does Not Conform to Contract Requirements, Duplicate Caused by Change on Claim, Duplicate Caused by Data Entry Error, Exact Duplicate | The number of cases per error reason | The dollar amount (overpayment / underpayment) associated with each error reason |
| Overpayments Established | |||||
| Column Header Title | Number of Cases | Requested Date | Received Date | Established Date | Collection Phase Date |
| New proposed data description | Present the number of cases on which the Contractor has performed its initial assessment | Indicate if the Contractor has requested additional documentation from VA | Indicate if the Contractor has received additional documentation from VA, If not date report, case is considered open | Indicate the date the case was established | Indicate the date the case was established and the date the Contractor is prepared to move on to the collection phase |
| Overpayments Collected | |||||
| Collected amounts must only be included in this report if the amount has been successfully collected by the Contractor. Collected amounts must always be shown in a way that allows relation of the collected amount to a specific claim or invoice. | |||||
| Column Header Title | Collected Amount | Invoice Number | Date of Collection | ||
| New proposed data description | The amount collected | Unique invoice number -number that is transmitted to VA on 837 COB | This is the date the collection | ||
| Overpayment Adjustments | |||||
| During the course of the audit, there may be situations where the overpayment amount needs to be adjusted. This report will present any of those situations where adjustments have been required and the associated date of those adjustments. | |||||
| Column Header Title | Overpayment Amount | Corrected Invoice Number | Date of Adjustment | ||
| New proposed data description | The amount the claim was overpaid | Unique corrected invoice number -number that is transmitted to VA on 837 COB | This is the date the adjustment (payment change) was made/resubmssion | ||
| Underpayments Identified | |||||
| Column Header Title | Number of Cases Underpaid | Estimated Value | |||
| New proposed data description | Indicate the number of cases that have been identified as having been underpaid | Estimated value of the underpayments |
| Total Reviewed Cases | |||
| Column Header Title | Sample Size | ||
| New proposed data description | The number of reviews completed during each month of the quarter | ||
| Variance Analysis | |||
| Variance analysis for any reporting category with a greater than 15% increase or decrease from the current quarterly report to the previous report, to include any unusual activity even if it does not exceed the percentage. | |||
| New Proposed Column Header Title | Total Monthly Recovery | Variance from Previous Month (%) | Explanation of Variance |
(if greater than 15%)
| New proposed data description | Total recovered in reporting month Format: dollar amount | Percent variance (+ or -) from previous reporting month | Analysis of variance - quarterly data of 15% or higher variance requires analysis |
| Column Header Title | Narrative | ||
| New Proposed Data Description | Free text narrative | ||
| • Trending of overpayments from inception and suggested corrective action. | |||
| • A detailed narrative with graphical and statistical information. |
1b. Payment Calculations
| Item | PWS Task | ID | Deliverable Description |
| 2 | 13.5 | Quarterly Cost Avoidance and Recovery/Recoupment Reports - Over & Under-Payment Calculations |
| Section 13.5 Cost Avoidance and Recovery/Recoupment Reports: Data Specifications | ||||||||||||||
| OVERPAYMENTS | ||||||||||||||
| Veteran Last Name | Veteran First Name | Veteran Middle Initial | Veteran Suffix | Internal Control Number (ICN) | Invoice Number | Claim Date | Billed Amount | Amount Payable | Amount Paid | Amount Recovered | Reason for Recovery | Date of Recovery | ||
| New proposed data description | Provide Veteran's last name - Format: MVI Spec | Provide Veteran's first name - Format: MVI Spec | Provide Veteran's middle initial Format: MVI Spec | Provide Veteran's suffix (if applicable) - Format: MVI Spec | This is the unique identifier for each Veteran from the Master Veteran Index (MVI) | |||||||||
| Format: 11vXXXXX (17 characters) | Unique Invoice Number -number that is transmitted to VA on 837 COB | Date the Contractor submitted the claim to VA via VA Clearinghouse | Total amount billed | Calculated amount payable | Actual amount paid | Amount Recovered from overpayment | Reason Codes to be provided with Database Schema - Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. | Date funds were recovered |
| UNDERPAYMENTS | ||||||||||||||
| Veteran Last Name | Veteran First Name | Veteran Middle Initial | Veteran Suffix | Internal Control Number (ICN) | Invoice Number | Claim Date | Billed Amount | Amount Payable | Amount Paid | Amount Underpaid | Reason for Underpayment | Date of Underpayment | ||
| New proposed data description | Provide Veteran's last name - | |||||||||||||
| Format: MVI Spec | Provide Veteran's first name Format: MVI Spec | Provide Veteran's middle initial Format: MVI Spec | Provide Veteran's suffix (if applicable) - Format: MVI Spec | This is the unique identifier for each Veteran from the Master Veteran Index (MVI) | ||||||||||
| Format: 11vXXXXX (17 characters) | Unique invoice number -number that is transmitted to VA on 837 COB | Date the Contractor submitted the claim to VA via VA Clearinghouse | Total amount billed | Calculated amount payable | Actual amount paid | Amount additionally paid due to underpayment | Reason codes to be provided with database schema - Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing. | Date funds were paid |
1c. Claims Auditing
| Item | PWS Task | ID | Deliverable Description |
| 3 | 13.5 | Quarterly Cost Avoidance and Recovery/Recoupment Reports - Claims Auditing |
| Section 13.5 Cost Avoidance and Recovery/Recoupment Reports: Data Specifications | ||||||||||||||||||||||||
| Total # Claims Audited | Total # Inpatient Claims Audtied | Total # Outpatient | ||||||||||||||||||||||
| Claims Audited | Total # Findings with Errors | Total $ Affected | Type of Finding | Patient | Date of Care | Corrective Action | Line Item Detail for Each Category | # Claims with Prepayment Review | Total # Cases Open | Total # Cases Closed | Prepayment Review Denials - Amount | Prepayment Duplicate Denials - Amount | LEIE Provider Denials | LEIE Provider Name | LEIE Provider NPI | LEIE Provider Effective Date | Postpayment Review Denials - Amount | Postpayment Duplicate Review - Amount | Recoupments - Requested - Amount | Recoupments - Recovered / Refunded - Amount | ||||
| New proposed data description | Numerical count | Numerical count | Numerical count | Numerical count | Sum of dollars affected as a result of findings | EDIPI (Should be MVI - ICN) | Date of service | Narrative of corrective action | Detail of errors by line | Numerical count | Numerical count | Numerical count | Total dollars denied as a result of prepayment review | Total dollars denied as a result of identified duplicates | "Y" if provider is on LEIE (List of Excluded Individuals and Entities) *Should also have the effective dates on LEIE | Total amount denied resulting from postpayment review | Total dollars denied as a result of postpayment identified duplicates | Dollar amount requested in recoupment | Dollar amount recovered and or refunded |
2. Clinical Quality
| Item | PWS Task | ID | Deliverable Description |
| 4 | 14.3 | Clinical Quality and Patient Safety Issues Report |
| Section 14.3 – Quarterly Clinical Quality and Patient Safety Issues Report: Data Specifications | |||||||||||
| Data Description | Type of Issue - PQI / IQI | Referral Number | Category of Care | Severity Level | Network Provider National Provider Identifier (NPI) | Network Provider and/or Organizational Tally within Previous 12 months and Flag Trends | Date PQI / IQI Identified | Resolution Status | Date PQI / IQI Resolved | Reported to Peer Review Committee (Y/N) | Peer Review Committee Final Recommendation |
| New proposed data description | This is an Identifier field - Enter PQI or IQI for issues that: |
(i) occurred in a prior reporting period but remain open in the current reporting period;
(ii) occurred in a prior reporting period but were closed during the current reporting period; or
(iii) occurred during the current reporting period For the PQI / IQI reported in column one, list the referral ID where the PQI / IQI occurred Specify the category of care associated with the PQI / IQI: General Dental; Specialty Dental For the PQI / IQI reported in column 0ne, provide the severity level: 1 - Low, 2 - Medium, or 3 - High Provide the NPI of the network provider involved in the PQI / IQI, if applicable Enter the number of PQI / IQI incidents associated with the provider or organization within the last 12 months. Flag any emerging trends or patterns (e.g., increasing frequency of similar issues) Date the PQI / IQI was identified - Date Format: MM/DD/YYYY Indicate the current resolution status of the PQI / IQI: Open, Closed, Pending Review, Escalated Date the PQI / IQI was resolved - Date Format: MM/DD/YYYY For the PQI / IQI reported in column one, enter the identifier YES or NO - if reported to the Contractor’s peer review committee Report the final Committee recommendation in one of the following ways:
No further action=0;
Corrective action plan (CAP) assigned=1;
Provider recommended for termination=2
3. COOP
| Item | PWS Task | ID | Deliverable Description |
| 5 | 15.3 | Continuity of Operations Plan: COOP Report Data Elements |
| Section 15.3 – Continuity of Operations Plan: COOP Report Data Elements | |||||||||
| Data Description | Type of Downtime | ||||||||
| (Planned/Unplanned) | Date Downtime Started | Time Downtime Started | Date Downtime Ended | Time Downtime Ended | Total Time System was down | Functional Capabilities Impacted | Cause/Reason for the System Downtime | Updates/Changes Made | Summary/Analysis of Downtime |
| New proposed data description | The type of system downtime, whether it was planned or unplanned | The date downtime started | |||||||
| Date Format: MM/DD/YYYY | The time downtime started | ||||||||
| Time Format: HH:MM:SS | The date downtime ended | ||||||||
| Date Format: MM/DD/YYYY | The time downtime ended | ||||||||
| Time Format: HH:MM:SS | The total time in minutes the system was down | Functional capabilities impacted by the system down time | The cause/reason leading to system downtime | Updates/changes made to the system during downtime (or steps taken to remediate if no changes) | Summary of any analysis and corrective actions reported to the COR during the reporting period |
4. Urgent Emergent Prescription
| Item | PWS Task | ID | Deliverable Description |
| 6 | 8.3 | Monthly Urgent/Emergent Prescription Performance Metrics Report |
(Prescription Data should be provided consistent with NCPDP standards)
| Minimum Requirements for Section 8.3 Urgent/Emergent Prescription Performance Metrics Report | ||||||||||||||||||||||||||||||||
| Column Header Title | Referral Number | Retail Pharmacy Name | Store Number | Service Provider Street Address Line 1 | Service Provider Street Address Line 2 | Service Provider City Address | Service Provider State/Province Code Address | Service Provider ZIP/Postal Code | Pharmacy Phone Number | Prescription/Service Reference (Rx) Number | Medication's National Drug Code | Medication Description | Quantity | Days' Supply | Dispensed Date | Filled Date | Prescriber's Name | Prescriber's DEA | Prescriber's NPI | Veteran's Unique Identifier | Provider Status | Generic Dispensing | Urgent/Emergent Formulary Compliance | Prior Authorization Required (Y/N) | AWP on Filled Date | Dispensing Fee | AWP - XX% + Dispensing Fee | Total Cost | Approve or Disapprove | Justification | Disaster Response | |
| Data Description | Referral number associated with the episode of care | (583-YK) | ||||||||||||||||||||||||||||||
| Name of network retail pharmacy | (201-B1) | |||||||||||||||||||||||||||||||
| ID assigned to a pharmacy or provider | (B31-7Y) | |||||||||||||||||||||||||||||||
| Line 1 of the street address of the service provider. | (B32-7Z) | |||||||||||||||||||||||||||||||
| Line 2 of the street address of the service provider. | (585-YN) | |||||||||||||||||||||||||||||||
| The city name of the address of the service provider. | (586-YP) | |||||||||||||||||||||||||||||||
| State/Province Code of the service provider | (587-YQ) | |||||||||||||||||||||||||||||||
| Code defining international postal code of the service provider, excluding punctuation. | (834-5Q) | |||||||||||||||||||||||||||||||
| Area code and seven digits | (402-D2) | |||||||||||||||||||||||||||||||
| Reference number assigned by the provider for the dispensed drug/product and/or service provided. | (407-D7) | |||||||||||||||||||||||||||||||
| Numerical designation of the national drug code | (600-28) | |||||||||||||||||||||||||||||||
| Drug name, strength, dosage form, packaging | (442-E7) | |||||||||||||||||||||||||||||||
| Numerical designation of quantity filled | (405-D5) | |||||||||||||||||||||||||||||||
| Numercial designation of the days' supply filled | (401-D1) | |||||||||||||||||||||||||||||||
| Numerical designation of pick-up date (mm/dd/yyyy) | Numerical designation of filled date (mm/dd/yyyy) | Last name, first name, middle initial | Alpha + numerical designation of DEA number | (411-DB) | ||||||||||||||||||||||||||||
| Numerical designation of NPI number | Numerical designation of Veteran's unique patient identifier | Designation of "Non-VA Provider" or "VA Provider" | Designate "Yes" or "No" | Designate "Yes" or "No" | Numerical designation in US currency | Numerical designation in US currency | Numerical designation in US currency | Numerical designation in US currency | Only completed if Column Y (Prior Authorization Required) = YES | Only completed if Column Y (Prior Authorization Required) = YES | Disaster Response = Y / N. Every month there should be no YES unless VA activates this clause |
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