Section_10_and_14_Claimant_Eligibility_and_TPL_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Claimant Eligibility & Third Party Liability (Sections 14 & 10)

Central Bill Process

Claimant Eligibility Third Party Liability

(PWS Sections 14 and 10)

Requirements Specifications Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor

Office of Worker’s Compensation Programs

Revision History:

SPECIAL NOTICE: This document is a legacy draft requirements specification document developed between 2011 and 2012. As outlined in the Performance Work Statement, the Contractor will be required to review this RSD and make appropriate updates wherever necessary. (Please refer to PWS R0052 for more details.)

Table of Contents Claimant Eligibility & Third Party Liability – DFEC

61.1 Claimant Eligibility Overview – DFEC

61.1.1 Claimant Eligibility Records Overview

71.2 Claimant Eligibility Business Process Description – DFEC

71.2.1 Claimant Eligibility Records Transmission Process

71.2.1.1 Electronic Transmission Process

71.2.1.1.1 Acknowledgement File

71.2.1.1.2 Error Report File

81.2.1.2 DD Exception Process

81.2.2 Eligibility Records Management and Maintenance

81.2.2.1 Analyze and Manage Eligibility Spans

81.2.2.1.1 Maintain Eligibility History

81.2.2.1.2 Manage Data Security

91.2.3 Claimant Eligibility Validation Process

91.2.3.1 Eligibility Validation during Mail Room Processing

91.2.3.2 Validation during Portal, POS, and Direct Data Entry

91.2.3.3 Validation during Authorization Processing

91.2.3.4 Validation during Eligibility Verification

91.2.3.5 Eligibility Validation during EDI

91.2.3.6 Eligibility Validation during Bill Adjudication

101.2.3.6.1 TPL Validation

101.2.3.6.2 Claimant on Review Validation

101.2.3.6.3 CA-16 Validation

111.2.3.6.4 Short Form Closure (SFC) Eligibility Validation

111.2.3.6.5 UN/UD Validation

111.2.3.6.6 UN/UD with 999.98 Accepted Condition

121.2.3.6.7 Payable Status Validation

131.3 Claimant Eligibility Business Process Flows – DFEC

141.3.1 Claimant Eligibility Overview

151.3.2 Eligibility Records Transmission Overview-FECA

161.3.3 Claimant on Review Workflow – DFEC

Claimant Eligibility & Third Party Liability – DEEOIC

172.1 Claimant Eligibility Overview – DEEOIC

172.1.1

182.2 Claimant Eligibility Business Process Description – DEEOIC

182.2.1

182.2.1.1

182.2.1.1.1

192.2.1.1.2

192.2.2

192.2.2.1

192.2.2.1.1 Maintain Eligibility History

192.2.2.1.2

202.2.3

202.2.3.1 Eligibility Validation during Mailroom Processing

202.2.3.2

202.2.3.3 Validation during Authorization Processing

202.2.3.4

202.2.3.5

212.2.3.6 Validation during Bill Adjudication

212.2.3.6.1 TPL Validation

222.2.3.6.2

222.2.3.6.3

222.2.4 ID Cards and Welcome Packages

222.2.4.1 ID Cards

232.2.4.2 Welcome Packages

232.3 Claimant Eligibility Business Process Flows – DEEOIC

242.3.1 Claimant Eligibility Overview

252.3.2 Eligibility Records Transmission Overview-DEEOIC

262.3.3 Claimant on Review Workflow

Claimant Eligibility & Third Party Liability – DCMWC

273.1 Claimant Eligibility Overview – DCMWC

273.1.1

283.2 Claimant Eligibility Business Process Description – DCMWC

283.2.1

283.2.1.1

283.2.1.1.1

293.2.1.1.2

293.2.2

293.2.2.1

293.2.2.1.1

293.2.3

303.2.3.1 Eligibility Validation during Mailroom Processing

303.2.3.2

303.2.3.3

303.2.3.4

303.2.3.5 Validation during Bill Adjudication

303.2.3.5.1 Medical Offsets

303.2.3.5.2

313.2.3.5.3

313.2.4 ID Cards and Welcome Packages

313.2.4.1 ID Cards

323.2.4.2 Welcome Packages

323.3 Claimant Eligibility Business Process Flows – DCMWC

333.3.1 Claimant Eligibility Overview-DCMWC

343.3.2 Eligibility Records Transmission Overview-DCMWC

353.3.3 Claimant on Review Workflow-DCMWC

Claimant Eligibility & TPL Business Requirements

364.1 Functional Requirements

404.2 Business Rules

Claimant Eligibility Supporting Functional Components

555.1 Initial Data Migration

555.2 Interfaces

575.3 Reports

605.4 Letters

Constraints

616.1 Assumptions

616.2 Dependencies

616.3 Issues/Open Items

Appendices

617.1 Terms & Definitions

1 Claimant Eligibility & Third Party Liability – DFEC

1.1 Claimant Eligibility Overview – DFEC

Claimant eligibility records for the Division of Federal Employees Compensation (DFEC) are maintained by the Government in their case management system (IFECs) and will be sent to the CBP for bill processing. For each claimant, an eligibility record will be established within CBP for each unique case number provided on the eligibility file received from DOL. A DFEC claimant having multiple injuries will have an eligibility record established within CBP for each unique case. There will be an electronic interface between CBP and IFECs to receive DFEC claimant eligibility records and send back appropriate responses. Eligibility records loaded into CBP will be made available throughout the system for its respective functions including but not limited to:

· Front End Mailroom validation to support RTP/RTC functions

· Authorization Request Processing

· Direct Portal Data Entry, POS and EDI

· Eligibility Editing:

· Medical Bill Processing

· Pharmacy Bill Processing

· Eligibility Inquiry via the Portal, IVR

The eligibility validation processing and respective decisions will be both programmatic and manual depending upon the business function being executed. As part of the claimant eligibility processes, CBP will implement Government-approved templates and messages including, but not limited to:

· EOBs

· Reports and Letter Templates

· Call Center Scripts

· Real Time Messages when eligibility inquiries are performed via the Portal or IVR

1.1.1 Claimant Eligibility Records Overview

Eligibility records contain claimant’s information and will be maintained in the claimant database within CBP. Eligibility records contain the following categories of data:

· Demographics

· Eligibility

· Reference

· Financials

Demographics: Demographic records include the claimant’s name, address, SSN, gender, contact telephone number, date of birth, and date of death.

Eligibility: Eligibility records include information related to the claimant such as case number, date of injury, date of approval, case and adjudication status, and eligibility date spans.

Reference: Reference records provide additional information about where the claimant’s case is being handled such as the District Office, claims examiner, and agency code.

Financials: Financial records contain claimant’s banking information which can be utilized for claimant payments.

1.2 Claimant Eligibility Business Process Description – DFEC

CBP’s claimant eligibility business function encompasses multiple processes that support determination of eligibility for a claimant and authenticate them to obtain appropriate benefits. These processes include:

· Eligibility Records Transmission Process

· Eligibility Records Maintenance Process

· Eligibility Validation Process

1.2.1 Claimant Eligibility Records Transmission Process

1.2.1.1 Electronic Transmission Process

After the initial baseline eligibility data is established within CBP, only eligibility records that have been updated (including new and old cases) within IFECS will be transmitted through the daily eligibility interface files. This file is sent in the format dictated by the Central Bill Case Reference Data Extract from IFECs. Updated eligibility records received will be considered replacement records (containing the full set of information including updated information for that record). The CBP will support and store all eligibility data transmitted by the IFECS system including foreign addresses, country codes, and zip codes. The eligibility file will be validated by the Contractor during the load process in order to only allow clean and complete data into CBP. This front end validation will check for the presence of the following key data elements:

· Case Number

· Effective dates of the case

· Case status and corresponding adjudication code and adjudication date

· Claimant Name

· Date of Birth

· Social Security Number

· Address

· Data of Injury (DFEC only)

The Eligibility record layout from IFECs will be mapped to CBP’s claimant database and transformation logic will be applied to populate the records appropriately. The record transmission process will also involve generation of response files.

1.2.1.1.1 Acknowledgement File

The Contractor will return an immediate acknowledgement of receipt of the claimant eligibility file to the respective Programs. The acknowledgement file will be in the format specified by the Government, and transmitted via secure FTP.

1.2.1.1.2 Error Report File

Each eligibility interface file will be subjected to error checking consistent with the current process. Records with errors will not be processed, but instead, returned to DOL in an error file using a Government approved format. DOL will correct the records and transmit them back to the Contractor for processing. Once DOL makes corrections to the errors reported, the corrected records will be returned as part of the normal daily transmission of eligibility data. In addition, a report will be created for those errors that need District Office intervention. The District Office will update/correct the record, and the record will be retransmitted to CBP in the next Claimant Eligibility update record.

1.2.1.2 DD Exception Process

In addition to the data elements transmitted by IFECs, the CBP will maintain claimant eligibility status indicators to indicate a claimant/case is on review, or designated as catastrophic. These indicators are not communicated via the eligibility interface files, but rather communicated from DOL management through a DD Exception process to be updated within CBP. The Contractor will maintain specific instructions provided by DOL on the eligibility record as to the action to be taken by resolutions staff. The Contractor will maintain these instructions for processing claimant on review bills until review status as directed by DOL is removed.

1.2.2 Eligibility Records Management and Maintenance

1.2.2.1 Analyze and Manage Eligibility Spans

Eligibility information that is updated by the District Office will be sent to CBP and applied appropriately to the claimant eligibility file. The Contractor must apply all information and understand how to create accurate date spans when case statuses change. The case status drives how a bill will process through CBP for payment or denial of services. All cases initially begin in a UN/UD (un-reviewed, under development) status. When the initial UN/UD case status is updated/changed, there are specific rules around the creation of begin and end dates for the changed span. CBP will apply the correct adjudication date formulae provided by DOL. A mapping of the specific criteria can be found in the requirements/rules section of this document.

1.2.2.1.1 Maintain Eligibility History

For audit purposes, the Contractor will store all historical eligibility records for a claimant. Within CBP eligibility, data will be maintained to show all accepted conditions, up to 99, and their associated dates. In addition, the 10 most recent case and adjudication status codes, along with their date spans will be stored.

1.2.2.1.2 Manage Data Security

All eligibility updates are to be handled via the electronic eligibility file received from DOL. The only exception to this restriction will be updating claimant-on-review and catastrophic case statuses. ‘Authorized’ Contractor staff will be able to manually update on-review status indicators when update requests are received from the Government. Unauthorized Contractor staff will have read-only access to eligibility records. The Contractor DBA will be assigned to manage user access to claimant eligibility records. Users accessing claimant eligibility data will have a specific user profile that is configured in the system. It will require that log-in credentials are validated in order to access claimant sensitive data.

1.2.3 Claimant Eligibility Validation Process

Bills and service authorization requests submitted to CBP, regardless of the medium, are subjected to claimant eligibility validation. This will be performed throughout CBP for processes to include but not limited to:

· Eligibility validation during Mail Room processing

· Eligibility validation at Portal and POS

· Eligibility validation during EDI

· Eligibility validation during authorization approval

· Eligibility validation during bill adjudication, to include medical and pharmacy

1.2.3.1 Eligibility Validation during Mail Room Processing

The Contractor’s Mail Room will validate claimant information for all bill types and authorization requests submitted via mail and fax. The key data element to be validated is case number. All bills must be associated to a claimant’s case number(s). If validation fails, the Mail Room will report any errors back to the submitter. This is done using an RTP (return to provider) or RTC (return to claimant) letter. Multiple errors are consolidated on one report per bill or authorization.

1.2.3.2 Validation during Portal, POS, and Direct Data Entry

Users will utilize the Portal and Pharmacy Point of Sale applications for entering claimant bills directly into CBP database. Each bill will be tied to a claimant’s case number. Bills that do not meet eligibility will post real time edits to inform the user the case number entered is not on file or invalid.

1.2.3.3 Validation during Authorization Processing

The Contractor’s Web Portal will be used to enter authorization requests. Users working an authorization queue will require eligibility data to verify whether the claimant is covered for the services and requested dates. The Portal will also allow users to inquire on claimant eligibility.

1.2.3.4 Validation during Eligibility Verification

Providers often need to verify claimant eligibility before they provide services to claimants. They will utilize Portal functionality to inquire upon claimant eligibility. Providers will be able to verify through the Portal whether the claimant is on file, whether the claimant case status is active, and if the procedures are covered and require authorization.

1.2.3.5 Eligibility Validation during EDI

EDI is another method of bill submission into CBP. EDI will utilize the eligibility file to validate a claimant’s case number. If the claimant is not on file, the record will be rejected back to EDI with a message that the claimant is either not on file or the case number is invalid.

1.2.3.6 Eligibility Validation during Bill Adjudication

Bills associated with a DFEC claimant will be processed according to DFEC rules/edits, as outlined in PWS Section 13 – Edits and Audits RSD. During bill adjudication, the claimant’s eligibility information will be referenced against the case number in the bill. The bill adjudication process will validate whether the claimant is on file as referenced by the case number. In the event that the claimant is available in the system and the bill is not a Prompt Pay, validation will also check for the following and apply business rules as required in bill processing:

· Third Party Liability (TPL)

· Claimant on Review Status

· CA-16 Eligibility

· SFC Eligibility

· Case in UN/UD

· UN/UD with 999.98 or 999.99 Exception

· Case in Payable Status

1.2.3.6.1 TPL Validation

In bill adjudication, TPL editing precedes all other eligibility validations after the case number. CBP will check for the third party flag on file during bill adjudication for all bills except Prompt Pay. In order to verify whether the claimant has TPL, CBP will establish TPL indicators on the eligibility records as per DOL-provided instructions. The value set in the TPL field will determine the presence or absence of TPL for the claimant. DOL will send third party indicators (‘Y’ or ‘N’) in the eligibility record through the electronic interface file. The Contractor will load the claimant’s TPL record into the CBP database. During bill adjudication, the eligibility validation process will look at the claimant’s eligibility record to verify whether the claimant on the bill has TPL. If the claimant has TPL flag = Y, the system will post an appropriate edit (current edit is 265) and deny the bill. When the Third Party obligations have been satisfied, DOL will send the Contractor an updated eligibility record where the TPL indicator flag will be equal to an "N" concurrently with an updated adjudication status. The Contractor will load this update to the eligibility file and apply the eligibility validation against the latest update during bill adjudication.

1.2.3.6.2 Claimant on Review Validation

The eligibility validation process will look to see if the claimant has ‘on review’ status during bill adjudication. On review status can be ‘Y’ (Exception review) or ‘S’ (catastrophic review). As bills are processed for claimants that are 'on review' an edit will post causing the bill to suspend. These bills will be routed to a specific work location where bill resolution instructions will guide the resolution specialist to work and disposition the bill according to Government-approved guidelines.

1.2.3.6.3 CA-16 Validation

CA-16 eligibility represents a contract with the claimant that allows medical benefits on specific service categories for a limited span of time of 60 days from the CA-16 effective date. (NOTE: The CA-16 period does not always start at the claimant’s date of injury. This date, which is passed from the IFECs system, can also be the date that the CA-16 form was signed). Bills that process using the CA-16 will bypass authorization and treatment suites. Billed procedures that fall within the CA-16 span are eligible if they meet certain criteria:

· Procedures covered within 1ST 15 days of CA-16 span (surgeries)

· Procedures covered during the entire CA-16 span

If the billed procedures do not qualify under CA-16 eligibility conditions, they should undergo further validation prior to being denied. The bill adjudication process will look for an authorization. If a matching authorization (same claimant, provider, procedure, date of service) is found, the bill will process using that authorization, and will be subject to the standard bill editing including authorization and treatment suite rules.

If no authorization or Level-1 Eligibility coverage is found, the bill will adhere to the CA-16 rules and deny with the appropriate edit (currently 655 or 652).

When a claimant eligibility record is received from IFECs, the Contractor will load the record with a case status of ‘CA’, and create an end date with a 60 day span from the start date as passed from IFECs. This start date as passed from IFECs when a claimant is a CA-16 isn't always the DOI. This date can also be the date the CA-16 Form was signed.

1.2.3.6.4 Short Form Closure (SFC) Eligibility Validation

SFC is an eligibility status which allows claimants to receive medical and pharmacy benefits for up to $1500 for dates of service within the SFC span. When bills are paid for SFC the paid amount will be accumulated and applied to future bills, not to exceed the $1500 threshold. When a claimant eligibility record is received from IFECs and determined to be SFC, the Contractor will calculate the end date of that eligibility span to be DOI + 180 days.

SFC eligibility for a claimant will be determined if the eligibility record contains the following conditions:

· Case status= C1, C2, or C4

· Eligibility record has the SFC Dollar Limit value of $1500

· Eligibility record will contain a flag (status = ‘01’)

· Accepted condition of 999.99

Bills submitted into CBP will be subjected to SFC validation criteria. For a bill to be paid under SFC, it must satisfy the following conditions:

· The bill date of service falls within the SFC span

· The $1500 dollar limit has not been met

When a DFEC bill is denied for exceeding the $1500 limit, the Contractor will send notification that the SFC has been exhausted via an interface file (FLIPS). This notifies DOL that the case needs to be reviewed. Any updates to the eligibility record are transmitted back to CBP through the daily eligibility load process. If the case has both SFC and a CA-16 on file, and the SFC has been used, and the dates of service are within the CA-16 span, it will be used to process the bill.

1.2.3.6.5 UN/UD Validation

Claimants with the case status of UD or UN in the eligibility record are not considered eligible for benefits in normal circumstances. UD status indicates that the case is under development and the benefits are not yet determined. Similarly, the case in UN indicates that it is not yet reviewed and therefore, no benefit determined. Bills submitted while the claimant is in UN/UD status will be denied if no other payable situations exist.

1.2.3.6.6 UN/UD with 999.98 Accepted Condition

While UN status indicates that claimant’s case is not developed or reviewed yet, and the bills submitted while the status is in UN/UD are deniable, there may be an exception existing in the eligibility record. Under this exception the eligibility record will have 999.98 as the Accepted Condition with an eligibility span of 30 days. This allows for diagnostic testing which assists the CE in making adjudication decisions. The eligibility validation process will look for accepted condition of 999.98 in the eligibility record even if the case is found in UN/UD status. If the exception exists, bill processing will determine if the submitted services are payable based upon:

· The billed procedure is in the 999.98 treatment suite

· The date of service in the bill falls within the 30 day span of the 999.98 Accepted Condition or a date span as provided by DOL.

1.2.3.6.7 Payable Status Validation

CBP must interrogate the case status of the claimant on the bill for the submitted date of service to determine if the eligibility is payable. The payment methods described below will be used in bill processing.

1.3 Claimant Eligibility Business Process Flows – DFEC

The following diagrams capture the DFEC Claimant Eligibility Business Process flows.

1.3.1 Claimant Eligibility Overview

1.3.2 Eligibility Records Transmission Overview-FECA

1.3.3 Claimant on Review Workflow – DFEC

2 Claimant Eligibility & Third Party Liability – DEEOIC

2.1 Claimant Eligibility Overview – DEEOIC

Claimant eligibility records for Division of Energy Employees Occupational Injury Compensation (DEEOIC) are maintained by the Government in their case management system (DEEOIC ECS) and will be sent to the CBP for bill processing. For each claimant, an eligibility record will be established within CBP for each unique SSN number provided on the eligibility file received from DOL. DOL will send a complete set of eligibility records per accepted condition when an accepted condition is added to the claimant’s record. There will be an electronic interface between CBP and DEEOIC ECS to receive DEEOIC claimant eligibility records and send back appropriate responses. Eligibility records loaded into CBP will be made available throughout the system for its respective functions including but not limited to:

· Front End Mailroom validation to support RTP/RTC/ID Cards/Member Welcome Package functions

· Authorization Request Processing

· Direct Portal Data Entry, POS and EDI

· Eligibility Editing:

· Medical Bill Processing

· Pharmacy Bill Processing

· Eligibility Inquiry via the Portal, IVR

The eligibility validation processing and respective decisions will be both programmatic and manual depending upon the business function being executed. As part of the claimant eligibility processes, CBP will implement Government-approved templates and messages including, but not limited to:

· EOBs

· Reports and Letter Templates

· Call Center Scripts

· Real Time Messages when eligibility inquiries are performed via the Portal or IVR

2.1.1 Claimant Eligibility Records Overview

Eligibility records contain claimant’s information and will be maintained in the claimant database within CBP. Eligibility records contain the following categories of data:

· Demographics

· Eligibility

· Reference

· Financials

Demographics: Demographic records include the claimant’s name, address, SSN, gender, contact telephone number, date of birth, payee information, and date of death.

Eligibility: Eligibility records include information related to the claimant, such as date of approval, adjudication status, and eligibility date spans.

Reference: Reference records provide additional information about where the claimant’s case is being handled, such as the District Office, claims examiner, accepted medical conditions (ICD-9/10 codes), medical condition status, status effective dates, and eligibility dates.

Financials: Financial records contain claimant’s banking information which can be utilized for claimant payments.

2.2 Claimant Eligibility Business Process Description – DEEOIC CBP’s claimant eligibility business function encompasses multiple processes that support determination of eligibility for a claimant and authenticate them to obtain appropriate benefits. These processes include:

· Eligibility Records Transmission Process

· Eligibility Records Maintenance Process

· Eligibility Validation Process

· ID Cards and Welcome Packages Process (DEEOIC)

2.2.1 Claimant Eligibility Records Transmission Process

2.2.1.1 Electronic Transmission Process

After the initial baseline eligibility data is established within CBP, only eligibility records that have been updated within DEEOIC ECS will be transmitted through the daily eligibility interface files. This file is sent in the format dictated by the Central Bill Case Reference Data Extract from DEEOIC ECS. Updated eligibility records received will be considered replacement records (containing the full set of information including updated information for that record). The CBP will support and store all eligibility data transmitted by the DEEOIC ECS system including foreign addresses, country codes, and zip codes. The eligibility file will be validated by the Contractor during the load process in order to only allow clean and complete data into CBP. This front end validation will check for the presence of the following key data elements.

· SSN (Case Number in CBP)

· Claimant Last Name

· Claimant First Name

· Date of Birth

· Full Address

· Adjudication Status

· Adjudication Date The Eligibility record layout from DEEOIC ECS System will be mapped to CBP’s claimant database and transformation logic will be applied to populate the records appropriately. If errors are identified on the eligibility file, the acceptance of that record into CBP will be determined by the specific error:

· Some errors will stop the acceptance of the record into CBP

· Some errors will be sent as a warning, but the eligibility record is still accepted by CBP The record transmission process will also involve generation of response files.

2.2.1.1.1 Acknowledgement File

The Contractor will return an immediate acknowledgement of receipt of the claimant eligibility file to the respective Programs. The acknowledgement file will be in the format specified by the Government, and transmitted via secure FTP.

2.2.1.1.2 Error Report File

Each eligibility interface file will be subjected to validity error checking consistent with the current process. Records with validity errors will not be processed, but instead, returned to DOL in an error file using a Government approved format. DOL will correct the records and transmit them back to the Contractor for processing. Once DOL makes corrections to the errors reported, the corrected records will be returned as part of the normal daily transmission of eligibility data. In addition, a report will be created for those errors that need District Office intervention. The District Office will update/correct the record, and the record will be retransmitted to CBP in the next Claimant Eligibility update record.

In addition to the data elements transmitted by DEEOIC, the CBP will maintain claimant eligibility status indicators to indicate that a claimant is on review. These indicators are not communicated via the eligibility interface files, but rather communicated from DOL management through program management directly to the the Contractor POC to be updated within CBP. The Contractor will maintain specific instructions provided by DOL on the eligibility record as to the action to be taken by resolutions staff. The Contractor will maintain these instructions for processing claimant on review bills until review status, as directed by DOL, is removed.

2.2.2 Eligibility Records Management and Maintenance

2.2.2.1 Analyze and Manage Eligibility Spans

Eligibility information that is updated by the District Office will be sent to CBP and applied appropriately to the claimant eligibility file. DEEOIC will send only approved cases to CBP, and therefore there will be no concept of UN/UD and status changes for DEEOIC claimants. Modifications reflected on subsequent eligibility files will reflect additional accepted conditions, changes to offsets, etc.

It is important to note that although DEEOIC will not be sending denied case records or determination case records, the incumbent does have these types of records in the current system. Thus, when DEEOIC was sending denied records, bills would be submitted and processed against the denied eligibility file. This information will need to be a part of the data migration to retain historical integrity.

2.2.2.1.1 Maintain Eligibility History

For audit purposes, the Contractor will store all historical eligibility records for a claimant. Within CBP eligibility, data will be maintained to show all accepted conditions, up to 99, and their associated dates. There will be no history regarding the status changes in the claimant file for DEEOIC, as a claimant will have only one approved case for over his/her lifetime. In the event this changes, CBP will support and store historical eligibility statuses.

2.2.2.1.2 Manage Data Security

All eligibility updates are to be handled via the electronic eligibility file received from DOL. The only exception to this restriction will be updating claimant-on-review. ‘Authorized’ Contractor staff will be able to manually update on-review status indicators when update requests are received from the Government. Unauthorized Contractor staff will have read-only access to eligibility records. The Contractor DBA will be assigned to manage user access to claimant eligibility records. Users accessing claimant eligibility data will have a specific user profile that is configured in the system. It will require that log-in credentials are validated in order to access claimant sensitive data.

2.2.3 Claimant Eligibility Validation Process

Bills and service authorization requests submitted to CBP, regardless of the medium, are subjected to claimant eligibility validation. This will be performed throughout CBP for processes to include but not limited to:

· Eligibility validation during Mail Room processing

· Eligibility validation at Portal and POS

· Eligibility validation during EDI

· Eligibility validation during authorization approval

· Eligibility validation during bill adjudication, to include medical and pharmacy

2.2.3.1 Eligibility Validation during Mailroom Processing

The Contractor Mail Room will validate claimant information for all bill types and authorization requests submitted via mail and fax. The key data element to be validated is case number. All bills must be associated to a claimant’s case. If validation fails, the Mail Room will report any errors back to the submitter. This is done using a RTP (return to provider) or RTC (return to claimant) letter. Multiple errors are consolidated on one report per bill or authorization.

2.2.3.2 Validation during Portal, POS, and Direct Data Entry

Users will utilize the Portal and Pharmacy Point of Sale applications for entering claimant bills directly into CBP database. Each bill will be tied to a claimant’s case number. Bills that do not meet eligibility will post real time edits to inform the user the case number entered is not on file or invalid.

2.2.3.3 Validation during Authorization Processing

The Contractor Portal will be used to enter authorization requests. Users working an authorization queue will require eligibility data to verify whether the claimant is covered for the services and requested dates. The Portal will also allow users to inquire on claimant eligibility.

2.2.3.4 Validation during Eligibility Verification

Providers often need to verify claimant eligibility before they provide services to claimants. They will utilize Portal functionality to inquire upon claimant eligibility. Providers will be able to verify through the Portal whether the claimant is on file, whether the claimant case status is active, and if the procedures are covered and require authorization.

2.2.3.5 Eligibility Validation during EDI

EDI is another method of bill submission into CBP. EDI will utilize the eligibility file to validate a claimant’s case number. If the claimant is not on file, the record will be rejected back to EDI with a message that the claimant is either not on file or the case number is invalid.

2.2.3.6 Validation during Bill Adjudication

Bills associated with a DEEOIC claimant will be processed according to DEEOIC rules/edits, as outlined in PWS Section 13 – Edits and Audits RSD. During bill adjudication, the claimant’s eligibility information will be referenced against the case number in the bill. The bill adjudication process will validate whether the claimant is on file as referenced by the case number. In the event that the claimant is available in the system and the bill is not a Prompt Pay, validation will also check for the following and apply business rules as required in bill processing:

· Third Party Liability (TPL)

· Claimant on Review Status

· Case in Payable Status

2.2.3.6.1 TPL Validation

In bill adjudication, TPL editing precedes all other eligibility validations after the SSN. CBP will check for the third party flag (offset indicator) on file during bill adjudication for all bills except Prompt Pay. In order to verify whether the claimant has TPL, CBP will establish TPL/offset indicators on the eligibility records per accepted condition as per DOL-provided instructions. The value set in the TPL field will determine the presence or absence of TPL for the claimant. DOL will send third party indicators (‘O’ or ‘A’) in the eligibility record through the electronic interface file. The Contractor will load the claimant’s TPL record into the CBP database. During bill adjudication, the eligibility validation process will look at the claimant’s eligibility record to verify whether the claimant on the bill has TPL. If the claimant has TPL indicator = ‘O’ for a given diagnosis, the system will post an appropriate edit (current edit 557 for unsatisfied). When the Third Party obligations have been satisfied, DOL will send the Contractor an updated eligibility record indicating the end of the offset time frame by having an 'A' for the accepted condition where an 'O' is currently recorded. The latest update date (CAS_UPDT_DT) on the Eligibility file will be recorded as the offset end date for that accepted condition. When multiple accepted conditions have a medical offset, the medical offset end date will be applied appropriately for each accepted condition, per the eligibility file entries. The Contractor will load this update to the eligibility file and apply the eligibility validation against the latest update during bill adjudication.

DEEOIC bills will go through the Treatment Suites process to match to an accepted condition with the additional consideration of the offset indicator recorded for the accepted condition. When the Treatment Suites process identifies a payable accepted condition, which has a satisfied offset, the bill will pay as long as the date of service is after the offset end date. (Details on Treatment Suites looping process on offsets are described in PWS-section 17 RSD)

Bills denied during third party hold periods will not be paid if resubmitted again after claimant obligations have been met. Such bills should be submitted directly to the District Office. If submitted directly to the mailroom, they will be subjected to normal processing, have appropriate edits (557 or 227) posted and be routed to the District Office.

When an offset is satisfied, the District Office will create/submit a batch of all bills with batch header sheet to the mailroom which were used to satisfy the offset:

· These bills will be clearly marked to be entered as 'History Only' bills.

These bills must be marked and entered as "Paid” and dupe check logic will be applied.

2.2.3.6.2 Claimant on Review Validation

The eligibility validation process will look to see if the claimant has ‘on review’ status during bill adjudication. The DEEOIC Claimant eligibility file in the CBP will contain the flag “Y”, indicating that a claimant is on review, which will be set based upon instruction from the National Office regarding claimants on review. As bills are processed for claimants that are 'on review', an edit will post causing the bill to suspend. These bills will be routed to a specific work location where bill resolution instructions will guide the resolution specialist to work and disposition the bill according to Government-approved guidelines.

2.2.3.6.3 Payable Status Validation

CBP must interrogate the case status of the claimant on the bill for the submitted date of service to determine if the eligibility is payable. The payment methods described below were used historically in bill processing. Note that U and D status codes have been provided to describe legacy data; in the current state for DEEOIC, only Approved cases will be sent.

2.2.4 ID Cards and Welcome Packages

2.2.4.1 ID Cards

Eligible DEEOIC claimants will be issued member ID cards. The issuance of ID cards will be subject to eligibility verification based on the claimant eligibility records received from the DEEOIC claimant management system. The Contractor’s Mailroom will print and distribute member ID cards to eligible claimants as per DEEOIC business requirements. ID Cards will be produced for all new, approved cases with some exceptions. ID cards will not be produced if:

· The accepted conditions are only Prompt Pay

· Offsets are recorded in the accepted conditions

· Date of death is recorded for the claimant, or

· Eligibility end date is other than 99/99/9999.

If the offsets are removed or member has at least one non-Prompt Pay accepted condition, members are eligible for ID cards.

The detailed specifications on card design and contents are available in B2-14-BR026 and B2-14-BR027.

2.2.4.2 Welcome Packages

DEEOIC claimants will receive Welcome Packages along with the ID cards upon eligibility determination based on the eligibility records received from DEEOIC ECS system. Once the members are accepted into DEEOIC program and have been provided with an accepted condition, they will be sent welcome packages approximately 4-5 pages long in letter format. The language and the content of the member package will be determined by the government and sent to the Contractor. The member packages will be printed and distributed from the the Contractor Central Mailroom, however, Welcome Packages are not to be included with the ID cards mailed as replacements.

Welcome package eligibility details are available in B2-14-BR028.

2.3 Claimant Eligibility Business Process Flows – DEEOIC

The following diagrams capture the DEEOIC Claimant Eligibility Business Process flows.

2.3.1 Claimant Eligibility Overview

2.3.2 Eligibility Records Transmission Overview-DEEOIC

2.3.3 Claimant on Review Workflow

3 Claimant Eligibility & Third Party Liability – DCMWC

3.1 Claimant Eligibility Overview – DCMWC

Claimant eligibility records for DCMWC are maintained by the Government in their case management system and will be sent to the CBP for bill processing. For each claimant, an eligibility record will be established within CBP for each unique SSN number provided on the eligibility file received from DOL. There will be an electronic interface between CBP and DCMWC Automated Support Package (ASP) to receive DCMWC claimant eligibility records and send back appropriate responses. Eligibility records loaded into CBP will be made available throughout the system for its respective functions including but not limited to:

· Front End Mailroom validation to support RTP/RTC/ID Cards/Member Welcome Package functions

· Direct Portal Data Entry, POS and EDI

· Eligibility Editing:

· Medical Bill Processing

· Pharmacy Bill Processing

· Eligibility Inquiry via the Portal, IVR

The eligibility validation processing and respective decisions will be both programmatic and manual depending upon the business function being executed. As part of the claimant eligibility processes, CBP will implement Government-approved templates and messages including, but not limited to:

· EOBs

· Reports and Letter Templates

· Call Center Scripts

· Real Time Messages when eligibility inquiries are performed via the Portal or IVR

3.1.1 Claimant Eligibility Records Overview

Eligibility records contain claimant’s information and will be maintained in the claimant database within CBP. Eligibility records contain the following categories of data:

· Demographics

· Eligibility

· Reference

· Financials

Demographics: Demographic records include the claimant’s name, address, SSN, gender, contact telephone number, date of birth, payee information, and date of death.

Eligibility: Eligibility records include information related to the claimant, such as entitlement date, claim type (LM, LW), case status, medical offset and eligibility date spans.

Reference: Reference records provide additional information about where the claimant’s case is being handled, such as the District Office claims examiner, medical condition status, status effective dates, and eligibility dates.

Financials: Financial records contain claimant’s banking information which can be utilized for claimant payments.

3.2 Claimant Eligibility Business Process Description – DCMWC CBP’s claimant eligibility business function encompasses multiple processes that support determination of eligibility for a claimant and authenticate them to obtain appropriate benefits. These processes include:

· Eligibility Records Transmission Process

· Eligibility Records Maintenance Process

· Eligibility Validation Process

· ID Cards and Welcome Packages Process

3.2.1 Claimant Eligibility Records Transmission Process

3.2.1.1 Electronic Transmission Process

After the initial baseline eligibility data is established within CBP, only eligibility records that have been updated within DCMWC ASP will be transmitted through the daily eligibility interface files. This file is sent in the format dictated by the Central Bill Case Reference Data Extract from DCMWC ASP. Updated eligibility records received will be considered replacement records (containing the full set of information including updated information for that record). The CBP will support and store all eligibility data transmitted by the DCMWC ASP system including foreign addresses, country codes, and zip codes. The eligibility file will be validated by the Contractor during the load process in order to only allow clean and complete data into CBP. This front end validation will check for the presence of the following key data elements.

· Miner SSN (Case Number in CBP)

· Claim record number (used to look up Diary Action Authorizations)

· Claim type (LM, LW)

· Case status

· Application date

· Miner Date of Death

The Eligibility record layout from DCMWC ASP System will be mapped to CBP’s claimant database and transformation logic will be applied to populate the records appropriately. If errors are identified on the eligibility file, the acceptance of that record into CBP will be determined by the specific error:

· Some errors will stop the acceptance of the record into CBP

· Some errors will be sent as a warning, but the eligibility record is still accepted by CBP

The record transmission process will also involve generation of response files.

3.2.1.1.1 Acknowledgement File

The Contractor will return an immediate acknowledgement of receipt of the claimant eligibility file to the respective Programs. The acknowledgement file will be in the format specified by the Government, and transmitted via secure FTP.

3.2.1.1.2 Error Report File

Each eligibility interface file will be subjected to validity error checking consistent with the current process. Records with validity errors will not be processed, but instead, returned to DOL in an error file using a Government approved format. DOL will correct the records and transmit them back to the Contractor for processing. Once DOL makes corrections to the errors reported, the corrected records will be returned as part of the normal daily transmission of eligibility data. In addition, a report will be created for those errors that need District Office intervention. The District Office will update/correct the record, and the record will be retransmitted to CBP in the next Claimant Eligibility update record.

In addition to the data elements transmitted by DCMWC, the CBP will maintain claimant eligibility status indicators to indicate that a claimant is on review. These indicators are not communicated via the eligibility interface files, but rather communicated from DOL management through program management directly to the Contractor’s POC to be updated within CBP. The Contractor will maintain specific instructions provided by DOL on the eligibility record as to the action to be taken by resolutions staff. The Contractor will maintain these instructions for processing claimant on review bills until review status, as directed by DOL, is removed.

3.2.2 Eligibility Records Management and Maintenance

3.2.2.1 Analyze and Manage Eligibility Spans

Eligibility information that is updated by the District Office will be sent to CBP and applied appropriately to the claimant eligibility file. Modifications reflected on subsequent eligibility files such as changes in case status, changes to eligibility dates, or changes to offsets will be applied and retain historical date spans.

3.2.2.1.1 Manage Data Security

All eligibility updates are to be handled via the electronic eligibility file received from DOL. The only exception to this restriction will be updating claimant-on-review. ‘Authorized’ Contractor staff will be able to manually update on-review status indicators when update requests are received from the Government. Unauthorized Contractor staff will have read-only access to eligibility records. DOL will approve employee access to the Contractor CBP. DOL will forward signed access forms to the Contractor DBA for internal processing. The Contractor DBA will then manage user access to claimant eligibility records. Users accessing claimant eligibility data will have a specific user profile that is configured in the system. It will require that log-in credentials are validated in order to access claimant sensitive data.

3.2.3 Claimant Eligibility Validation Process

Bills submitted to CBP, regardless of the medium, are subjected to claimant eligibility validation. This will be performed throughout CBP for processes to include but not limited to:

· Eligibility validation during Mail Room processing

· Eligibility validation at Portal and POS

· Eligibility validation during EDI

· Eligibility validation during bill adjudication, to include medical and pharmacy

3.2.3.1 Eligibility Validation during Mailroom Processing

The Contractor’s Mail Room will validate claimant information for all bill types submitted via mail and fax. The key data element to be validated is case number. All bills must be associated to a claimant’s case. If validation fails, the Mail Room will report any errors back to the submitter. This is done using a RTP (return to provider) or RTC (return to claimant) letter. Multiple errors are consolidated on one report per bill or authorization.

3.2.3.2 Validation during Portal, POS, and Direct Data Entry

Users will utilize the Portal and Pharmacy Point of Sale applications for entering claimant bills directly into CBP database. Each bill will be tied to a claimant’s case number. Bills that do not meet eligibility will post real time edits to inform the user the case number entered is not on file or invalid.

3.2.3.3 Validation during Eligibility Verification

Providers often need to verify claimant eligibility before they provide services to claimants. They will utilize Portal functionality to inquire upon claimant eligibility. Providers will be able to verify through the Portal whether the claimant is on file, whether the claimant case status is active, and if the procedures are covered and require authorization.

3.2.3.4 Eligibility Validation during EDI

EDI is another method of bill submission into CBP. EDI will utilize the eligibility file to validate a claimant’s case number.