Section_11_Prompt_Payment_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Prompt Payment (Section 11)

Central Bill Process

Prompt Payment (PWS Section 11) 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 Prompt Pay - DFEC

61.1 Prompt Pay Overview - DFEC

71.2 Prompt Pay Business Process Description – DFEC

71.2.1 Bill Entry/Identification

71.2.1.1 Mailroom

71.2.1.1.1 Directed Medical Examination Bills

71.2.1.1.2 Voc Rehab and Miscellaneous Paper Bills

71.2.1.1.3 Claimant Maintenance Bills

81.2.1.1.4 Claimant Travel - History Only Bills

81.2.1.1.5 Foreign Bills

81.2.1.2 Web Portal

81.2.1.3 Electronic Files

91.2.2

PPA1/PPA2

91.2.3 Prompt Pay Processing

91.2.3.1 Editing

101.2.3.2 Authorizations

111.2.3.3 Pricing Method

111.2.3.4 Time Limit/Interest Penalties

121.2.4 Reporting and Inquiries

131.3 Prompt Pay Business Workflows – DFEC

131.3.1 Prompt Pay Bill Submission (Mailroom)

141.3.2 Prompt Pay Bill Submission (Other)

151.3.3 Prompt Pay Bill Processing

Prompt Pay – DEEOIC

162.1 Prompt Pay Overview – DEEOIC

172.2 Prompt Pay Business Process Description – DEEOIC

172.2.1

172.2.2

182.2.3

PPA1/PPA2

182.2.4

182.2.4.1

192.2.4.2

192.2.4.3

192.2.4.4

202.2.5

212.3 Prompt Pay Business Workflows – DEEOIC

212.3.1 Prompt Pay Bill Submissions

222.3.2

Prompt Pay – DCMWC

233.1 Prompt Pay Overview – DCMWC

243.2 Prompt Pay Business Process Description – DCMWC

243.2.1

243.2.2

253.2.3

253.2.3.1

253.2.3.2

253.2.3.3

253.2.3.4

263.2.4

273.3 Prompt Pay Business Workflows – DCMWC

273.3.1 Prompt Pay Bill Submissions

283.3.2

Prompt Pay Business Requirements

294.1 Functional Requirements

304.2 Business Rules

Prompt Pay Supporting Functional Components

445.1 Initial Data Migration

445.2 Interfaces

455.3 Reports

515.4 Letters

Constraints

526.1 Assumptions

526.2 Dependencies

526.3 Issues/Open Items

Appendices

537.1 Terms and Definitions

577.2 Homegrown Codes w/PPA classification – DFEC

607.3 Homegrown Codes w/PPA classification - DEEOIC

617.4 Mailroom Processing Checklist for Prompt Pay Bills – DFEC

637.5 Prompt Pay Bills Missing Required Information – DEEOIC

647.6 Determination/CPT Codes w/PPA classification - DCMWC

1 Prompt Pay - DFEC

1.1 Prompt Pay Overview - DFEC

1.2 Prompt Pay Business Process Description – DFEC

1.2.1 Bill Entry/Identification

PPA bills will be classified according to each OWCP program by unique submission criteria. Regardless of the method of entry and based on the type of bill, workflow management will use queues and system alerts to automatically route all Prompt Pay bills within the bill processing application, for accurate and timely payment, in compliance with established PPA rules.

1.2.1.1 Mailroom

Though there are multiple points of entry for Prompt Pay bills, the majority will be submitted on paper bills by the respective District Offices to the Central Mailroom. While automated mailroom software will accurately recognize many document types, the specific rules for identification of DFEC Prompt Pay bills include the following:

· The bill will be sent and received via the specific P.O. Box created for DFEC PPA Bills.

· A PPA Stamp will be clearly indicated on the bill

· Homegrown procedure codes are referenced on the bill and/or diagnostic services billed with the Homegrown procedure or as an attachment to the bills SECOP services.

Additional specifics about the bills submitted to the mailroom are described below.

1.2.1.1.1 Directed Medical Examination Bills

These bills are submitted on an OWCP-1500, with Homegrown procedure codes (SECOP, CNSLT, IMPAR, SUPPL, FOLUP, NOSHO) referenced on the bill, in addition to the possibility of Diagnostic codes (CPT/HCPCS), optionally submitted in conjunction with a SECOP, IMPAR, or CNSLT Prompt Pay bill.

In the case where a Diagnostic charge is not included on the bill with a Homegrown code but is attached to it (which indicates that the fees for these diagnostic services were not paid by the SECOP/IMPAR Provider), the bill for the diagnostic charge will also be identified as a Prompt Pay bill.

1.2.1.1.2 Voc Rehab and Miscellaneous Paper Bills

In addition to the Voc Rehab bills entered on the Web Portal (see section 2.1.2 below), some types of Voc Rehab and other “miscellaneous” Prompt Pay codes (ex. home improvements) will also be submitted as a paper bill submitted by the District Office to the mailroom. These bills may be submitted on an OWCP-1500, but frequently are submitted on a provider’s/contractor’s invoice form. They will include a Prompt Pay stamp, and the District Office will clearly identify the key fields required for processing: Provider number, Case number, Date of Service, Homegrown code, Billed amount. Those submitted on other than an OWCP-1500 will require manual development as a Prompt Pay bill, and will be keyed in the OWCP-1500 Data Element Format.

1.2.1.1.3 Claimant Maintenance Bills

Prompt Pay bills for Claimant Maintenance are submitted by the District Office on an OWCP-915 (Claimant Reimbursement form). These bills represent a reimbursement to the claimant for costs related to his/her participation in a Vocational Rehabilitation Program. As with other Prompt Pay bills, they are appropriately stamped by the District Office, including the PPA Date in the Block titled “FOR DOL USE ONLY.” If the PPA date is not present, the contractor will use the date of receipt in the mailroom as the PPA date. These bills will always have a Homegrown code of “CLMMT” and must be developed as a Prompt Pay bill.

1.2.1.1.4 Claimant Travel - History Only Bills

Another specific type of Prompt Pay bill is for Claimant Travel, submitted by the National Office on an OWCP-957 Medical Travel Refund form. The travel bills are for services that have already been paid at the National Office, using a Government credit card.

In order for the services (air transportation, lodging and some meals) to be paid at the per diem rate, the District Office will make all of the reservations for the Air travel. The invoice for the Air Fare and any other incidentals are sent to the National Office for payment and submission to CBP. The National Office staff will complete an OWCP-957 Travel Refund Form indicating the amount paid, applicable travel procedure codes (ex. A0140, not Homegrown codes), and the appropriate PPA stamp, and then forward it to the CBP mailroom facility. When this type of bill is received in the mailroom, it is to be keyed as a Prompt Pay, “HISTORY ONLY” bill for tracking purposes and agency charge-back activities.

1.2.1.1.5 Foreign Bills

Foreign bills are not categorized as Prompt Pay, but are mentioned here because they utilize a specific set of Homegrown codes (FORGN, SPPAY, PANAM, and PANAC). They are submitted by the National Office to the mailroom for entry into the CBP system, and all but PANAM are keyed as “HISTORY ONLY” bills. They are described in more detail in the Bill Processing RSD.

1.2.1.2 Web Portal

The CBP system will support the option of Web entry of Prompt Pay bills for authorized providers. Contract Nurses and Vocational Rehabilitation Counselors will have secure access to the CBP Portal to submit bills and associated attachments on custom bill entry and report forms designed specifically for that function. The Portal will perform real-time edits during entry that validate the presence of acceptable Homegrown codes, units per day, authorizations and price maximums. If a bill does not meet the required criteria, the bill will not enter the CBP system and the provider will be presented with real-time error messages to correct the bill for resubmission.

Once the bill is successfully entered, workflow will route the bill to a queue to ensure that the bill is reviewed and approved by the appropriate District Office Staff Nurse or Rehab Specialist. These bills will be accessible for review within 1 business day. Through defined security roles and privileges, only Staff Nurses and Rehab Specialists involved in the case will be allowed to view these bills and attachments. When approved, the bills will be transmitted to the CBP for adjudication by way of a systematically formatted electronic file, per the HCFA-1500 layout.

NOTE: In addition to the Voc Rehab services submitted via the Web Portal, some Voc Rehab services are billed on paper submissions from the District Office to the mailroom. They will be processed as any other Prompt Pay paper bill (see 2.1.1.2 above).

1.2.1.3 Electronic Files

Prompt Pay bills for COP Nurse Services are submitted electronically on a file generated by the IFECS System. Specific eligibility scenarios that qualify for the creation of the entries are reviewed and approved by a Staff Nurse, which then signals the generation of the bill entries. An ‘xml’ input file format has been designed for this interface, including a header and detail records. The detail records are consistently populated to allow for easy identification as Prompt Pay bills when they arrive in CBP:

· CLAIM-TYPE always = ‘N’ to denote a Prompt Pay bill

· PROCEDURE-CODE always = ‘COPTN’ (Homegrown code)

The file entries will be subjected to preliminary edits as part of the import process, and those that fail will not continue to the CBP system. The interface requires the return of an acknowledgement file to IFECS to identify those successfully processed/submitted to CBP. It also includes those entries with errors to be corrected in IFECS by the Staff Nurse or DFEC National Office and re-submitted to CBP.

1.2.2 PPA1/PPA2

After successfully identifying Prompt Pay bills, each bill must be further classified as a specific category of Prompt Pay, PPA1 vs. PPA2, based on the service codes being billed:

· PPA1 – the bill includes Homegrown codes specifically designated as PPA1, which are subject to the PPA interest if paid after 21 days.

· PPA2 - the bill is for service codes not designated as PPA1, and therefore not subject to any interest penalties. All Homegrown codes not designated as PPA1 are PPA2. Any claimant Prompt Pay bills (Claimant Maintenance and Claimant Travel History Only) are classified as PPA2.

· If a Diagnostic service is included on a Prompt Pay bill with a PPA1 Homegrown code, it is also considered a PPA1.

· If a Diagnostic service is submitted as an attachment to a Prompt Pay bill and developed as a separate bill, it is classified as PPA2.

When the Prompt Pay bill is classified as a PPA1, then the PPA Date must also be established. That date will be used in conjunction with the actual payment date to determine whether or not it was paid within the mandatory 21 days for Prompt Pay bills. If not, it is subject to an interest penalty and will be reported as such.

· For bills submitted to the mailroom, the PPA date is the date that the bill is received in the facility.

· For Web Portal entries and COP Nurse submissions, the PPA date is the date the bill was actually transmitted to the CBP system.

1.2.3 Prompt Pay Processing

CBP will use specific criteria, such as the unique Homegrown service codes, to follow specific rules and processes to execute the correct PPA bill process flow. From all points of entry, that criteria will automatically be identified, and the CBP solution will utilize workflow management to ensure all PPA bills are processed timely, accurately, and according to DOL PPA requirements.

1.2.3.1 Editing

Per OWCP requirements, PPA bills will not be subjected to eligibility editing, and will also bypass Treatment Suites. In reality, some level of editing will be performed on all bills, but the disposition of edits specific to the PPA bill type will determine which ones cause the bill to suspend, deny, or pay. The goal is to have minimal impact on the PPA processing. If any edit issues are identified with a Prompt Pay bill, it will be routed immediately to the appropriate District Office for resolution.

· Only an absolute duplicate will cause a Prompt Pay bill to deny.

· All methods of input will incorporate editing to validate critical fields such as case number, provider, procedure code, etc. Errors identified on mailroom submissions will be returned to the District Office. COP Nurse services to IFECS and Web Portal entry will reply with real-time error messages for immediate correction.

· Most normal eligibility edit criteria is ignored; the bill will continue processing even if the case is denied or under development. If the date of service is after the claimant’s date of death, the District Office will still require that the bill be paid

· Treatment Suites processing will occur for Prompt Pay, but outside of the normal logic flow which matches diagnosis codes with accepted condition:

· For Homegrown codes, a specific Treatment Suite will be accessed to validate the Homegrown code, and diagnostic procedure code and to retrieve both the authorization level required and the appropriate PPA1/PPA2 designation (The Contractor will copy all of the diagnostic codes referenced in suite 999.98, into the new suite PPA1 and PPA2 suites).

· Diagnostic Procedure Codes billed on a PPA1 bill, or attached to a PPA1 bill will not be validated in the 999.98 Treatment Suite. However, the Diagnostic Procedure billed on the PPA1 bill will be validated in the procedure file to identify the control code of the diagnostic procedure code, each requiring the following respective actions:

“Covered”

(No control code “D”) but contains an end date for which the date of service billed is after the end date of the procedure Bill will be placed in a work-queue, and the CE will be notified through the work-flow tool of this situation. The CE will be required to contact the Contracted Provider (SECOP, IMPAR, etc.) to obtain the corrected information and provide direction through the work-flow tool on how to process the bill.

1.2.3.2 Authorizations

Diagnostic Services billed in conjunction with or as an attachment to a Prompt Pay bill are not subjected to prior authorization editing. Even though they are validated against the PPA1 and PPA2 Treatment Suite, the authorization level is ignored.

All Homegrown codes will have an authorization level included in the information retrieved from the Treatment Suite. Many of the Homegrown codes typically submitted by the District Office on paper (SECOP, CNSLT, IMPAR) are identified with an authorization level of 1 (no pre-auth required). Those Homegrown codes requiring a level 3 are generally those for Contract Nurse and Voc Rehab, and the Staff Nurse/Rehab Specialist in the District Office would have submitted appropriate authorizations for the dates and service limits payable for any case. If missing, there are specific authorization edit errors which will be returned and dispositioned appropriately.

Other Homegrown codes for expenses such as purchases of equipment or training also require pre-authorizations to have been submitted by the District Office.

1.2.3.3 Pricing Method

Regardless of the medium by which PPA bills are submitted, PPA bills will be processed appropriately for payment, selecting the proper pricing methodology for the type of bill.

· PPA bills submitted for SECOP, IMPAR, FOLUP, NOSHO, SUPPL, CANCL and CNSLT services, are paid to specific providers that are contracted to the Government to perform these services. These services are paid as billed. The Pay Factor Code "B" referenced in the Fee Schedule file dictates the payment of these services.

· If diagnostic services are submitted as an attachment to the PPA SECOP, IMPAR, FOLUP bill, the service will be paid based on the OWCP Fee Schedule RVU's as set for the billed CPT/HCPC.

· If the diagnostic service is incorporated in the same bill as that billed by the contracted provider for SECOP, IMPAR, FOLUP, SUPPL; the bill will be paid based on the RVU's as set forth in the OWCP Fee Schedule.

· Contract Nurse and Voc Rehab PPA bills are priced based on a separate fee schedule pricing not extracted from the normal OWCP Fee Schedule. The fee schedule for these bills and services are based and derived from the hourly rates set forth and by the region in which the District Office is located.

1.2.3.4 Time Limit/Interest Penalties

PPA bills are to be processed within 21 days of receipt so they are not subjected to interest penalties. Workflow management and reporting will actively monitor PPA volumes and results to ensure timely, accurate processing within that timeframe.

A subset of all Prompt Pay bills (identified by specific Homegrown codes) will be subjected to the PPA interest formula established by the U.S. Treasury. Diagnostics included on a PPA1 bill will also qualify for the interest calculation. The application of the interest formula will be date sensitive, derived from the (PPA date +21 days = Due Date), and the date payment is made. (PPA date = the date of receipt in the mailroom facility or the date an electronic bill is submitted to CBP.)

Prompt Payment Interest is calculated from the day after payment was due until the day the payment is made. The interest rate in effect on the day after the payment due date is used to calculate the interest penalty.

The following is an example of the interest calculation formula to determine simple daily interest.

If the formula is “P(r/360*d)”:

P = the invoice amount r = the Prompt Payment interest rate (2.625% through June, 2011) d = the number of days for which interest is being calculated.

If payment is due on June 1 and the payment is not made until June 11, a simple interest calculation will determine the amount of interest owed to the vendor for the late payment. Using the formula above, an invoice in the amount of $1,000 paid 10 days late and at an interest rate of 2.625% would be calculated as follows:

$1,000 (.02625/360*10) = $0.73 interest The Chief of Fiscal Operations as well as the Policy Coordinator will determine if interest calculated and resulting in an amount less than $1.00 will be sufficient to be a burden on the Government.

Note that the interest amount is not added to the actual payment amount of the invoice during the CBP Payment process. The interest amount will be calculated and reported to the Government on a scheduled report. Also, all variables used to derive the amount of interest penalty will be recorded in the bill record for inquiries and audit purposes.

1.2.4 Reporting and Inquiries

The CBP Solution will provide timely responses to PPA inquiries through the CBP Call Center, IVR, Web Portal, and written correspondence. Real-time responses will be returned for inquiries received through the Web Portal and IVR. Inquiries received through written correspondence and the Call Center will be responded to in accordance with Contract SLAs defined for those areas. Since the system will capture and maintain full history of every bill transaction, all bill information (including interest penalties incurred), along with eligibility data and supporting document images will be available for responses to inquiries.

THE CONTRACTOR will support the PPA process for all programs with all necessary reports requested and recorded later in this document.

1.3 Prompt Pay Business Workflows – DFEC

The following diagrams capture the DFEC Prompt Pay Business Process flows.

1.3.1 Prompt Pay Bill Submission (Mailroom)

This diagram depicts the recognition of Prompt Pay paper bills received in the Mailroom and creation of file for submission to CBP.

1.3.2 Prompt Pay Bill Submission (Other)

This diagram depicts the flow of Prompt Pay bills entered on the Web Portal or submitted from IFECS.

1.3.3 Prompt Pay Bill Processing

This diagram depicts the general flow of Prompt Pay bills through CBP processing after submission to the medical bill process .

2 Prompt Pay – DEEOIC

2.1 Prompt Pay Overview – DEEOIC

2.2 Prompt Pay Business Process Description – DEEOIC

2.2.1 Bill Entry/Identification

PPA bills will be classified according to each OWCP program by unique submission criteria. Regardless of the method of entry and based on the type of bill, workflow management will use queues and system alerts to automatically route all Prompt Pay bills within the bill processing application, for accurate and timely payment, in compliance with established PPA rules.

2.2.2 Mailroom

DEEOIC has identified classes of bills that fall under the Prompt Pay Act:

· Reviews by a District Medical Consultant

· Second Opinion/Referee Medical Examinations

· Impairment Rating Examinations These classes are identified and billed using a specific list of Homegrown procedure codes. In addition, related diagnostic charges will be billed with CPT/HCPCS codes, and Claimant Travel expenses may also be submitted as Prompt Pay bills.

Prompt Pay bills will always be submitted by the District Office to the mailroom by way of the specific P.O. Box designated for DEEOIC. Prompt Pay bills will be submitted on an OWCP-1500 or a HCFA 1500/OWCP 1500 or UB-04 (diagnostics). Claimant Travel bills for Prompt Pay will be submitted on an OWCP-957. The bills will be further identified by the following mandatory characteristics:

· “Approved” either written or stamped in the top right hand corner of the billing form, dated and signed in black ink by a CE

· A “Prompt Pay” stamp, in block 11 if on a 1500, in box ‘h’ on a 957 (Claimant Travel), or clearly visible on the form if a HCFA 1500/OWCP 1500 or UB-04 (Diagnostic charges). Note that a proposed change to the 957 will include a checkbox in box ‘h’ to designate Prompt Pay.

· PPA Date – specified in block 11 (if submitted on a 1500); set to equal the date received in the mailroom for a UB-04 (Diagnostic charges) or 957 (Claimant Travel)

If any mandatory element is missing or invalid, the bill will be returned to the District Office for review and correction. A sample of the Missing Information form to accompany the bill to the District Office is included in Appendix 7.4. Corrected bills returned from the District Office will be in the form of a new bill, which will also establish a new PPA date.

DEEOIC Prompt Pay bills will include the following procedure codes:

· Homegrown codes submitted on a 1500, appropriate for the diagnosis code/accepted condition established for the claimant. A complete list of the Homegrown codes can be found in Appendix 7.2.

· CPT or HCPCS codes for diagnostic charges submitted on a 1500 or UB-04. Note that any diagnostic charge received on a bill not identified appropriately as a Prompt Pay bill, will be processed as a regular bill

· Travel procedure codes appropriate for submission on a 957, which includes the possibility of the ‘TRANS’ Homegrown code

2.2.3 PPA1/PPA2

After successfully identifying Prompt Pay bills, each bill must be further classified as a specific category of Prompt Pay, PPA1 vs. PPA2, based on the service codes being billed:

· PPA1 – the bill includes Homegrown codes specifically designated as PPA1, which are subject to the PPA interest if paid after 21 days. A full list of those codes, including the PPA designation is included in Appendix 7.2

· PPA2 - the bill is for service codes not designated as PPA1, and therefore not subject to any interest penalties. All Homegrown codes not designated as PPA1 are PPA2.

· Prompt Pay bills for Diagnostic services will be classified as a PPA2

· Prompt Pay bills for Claimant Travel will be classified as a PPA2

When the Prompt Pay bill is classified as a PPA1, then the PPA Date is critical for use in conjunction with the actual payment date to determine whether or not it was paid within the mandatory 21 days for Prompt Pay bills. If not, it is subject to an interest penalty and will be reported as such.

· For Prompt Pay bills submitted on a 1500, the PPA Date is recorded in block 11.

· For those submitted on a UB-04 or 957, the PPA date is set to equal the date the bill was actually received in the mailroom.

2.2.4 Prompt Pay Processing

CBP will use specific criteria, such as the unique Homegrown service codes, to follow specific rules and processes to execute the correct PPA bill process flow. From all points of entry, that criteria will automatically be identified, and the CBP solution will utilize workflow management to ensure all PPA bills are processed timely, accurately, and according to DOL PPA rules.

2.2.4.1 Editing

DEEOIC Prompt Pay bills should have all applicable edits posted, including those identified by the normal editing process for Eligibility and Treatment Suites. There is NO special Treatment Suites processing required for DEEOIC Prompt Pay bills. The billed diagnosis and accepted condition in eligibility should match as with any other bill, and the associated Treatment Suites should support the billed procedures.

When any edit is posted with a disposition set to “Deny”, a notification will be sent to the National Office for review of the bill. There are currently 2 edits with such a disposition:

· Exact Duplicate

· Treatment Suite edit 863 – the service is not covered/no Treatment Suite

All Prompt Pay bills with errors set to Suspend will be reviewed by the District Office, and overrides (forced payment) will be allowed for:

· Authorization Edits

· Date of Service is after Date of Death Edit

· Medical Offset Edits

Note that in addition to any errors posted as a result of the edit process, DEEOIC Prompt Pay bills will always suspend for review with edit 613.

2.2.4.2 Authorizations

Authorization for DEEOIC Prompt Pay bills is dictated by the Eligibility file, where appropriate accepted conditions will have been identified which will match to billed diagnosis codes and point to Treatment Suites which include the expected billed procedure codes. Additional validation of a prior authorization is not required for Homegrown codes on a Prompt Pay bill. However, the existence of required pre-authorizations is validated for diagnostic charges following the normal criteria based on Treatment Suites auth level designations. DEEOIC only requires receipts when travel expenses are greater than $75.00.

2.2.4.3 Pricing Method

DEEOIC Prompt Pay bills contain specific ICD-9/10/Homegrown or CPT/HCPCS code combinations, and all services are subject to the standard Fee Schedules established by the DEEOIC.

The current fee schedule for PPA Homegrown codes are as follows:

· FR001, FR003, FR004 are paid at $75.00 per unit. Maximum allowed units is 32.

· WL001, SEP01, REF01, CNSLT are paid up to a maximum allowed amount $2400.00.

· MR001 is paid up to a maximum of $100.00.

PPA 2 bills with a CPT-4 or HCPCS (e.g. diagnostic or travel related services) are paid according to the OWCP fee schedule.

2.2.4.4 Time Limit/Interest Penalties

PPA bills are to be processed within 21 days of the PPA date so they are not subjected to interest penalties. Workflow management and reporting will actively monitor PPA volumes and results to ensure timely, accurate processing within that timeframe.

A subset of all Prompt Pay bills (identified by specific Homegrown codes) will be subjected to the PPA interest formula established by the U.S. Treasury. Diagnostics included on a PPA1 bill will also qualify for the interest calculation. The application of the interest formula will be date sensitive, derived from the (PPA date +21 days = Due Date), and the date payment is made. (PPA date = the PPA date in block 11 of the HCFA. For Diagnostic and Travel PPA related bills the PPA =date of receipt in the mailroom facility.)

Prompt Payment Interest is calculated from the day after payment was due until the day the payment is made. The interest rate in effect on the day after the payment due date is used to calculate the interest penalty.

The following is an example of the interest calculation formula to determine simple daily interest.

If the formula is “P(r/360*d)”:

P = the invoice amount r = the Prompt Payment interest rate (2.625% through June, 2011) d = the number of days for which interest is being calculated.

If payment is due on June 1 and the payment is not made until June 11, a simple interest calculation will determine the amount of interest owed to the vendor for the late payment. Using the formula above, an invoice in the amount of $1,000 paid 10 days late and at an interest rate of 2.625% would be calculated as follows:

$1,000 (.02625/360*10) = $0.73 interest

The Chief of Fiscal Operations as well as the Policy Coordinator will determine if interest calculated and resulting in an amount less than $1.00 will be sufficient to be a burden on the Government.

Note that the interest amount is not added to the actual payment amount of the invoice during the CBP Payment process. The interest amount will be calculated and reported to the Government on a scheduled report. Also, all variables used to derive the amount of interest penalty will be recorded in the bill record for inquiries and audit purposes.

2.2.5 Reporting and Inquiries

The CBP Solution will provide timely responses to PPA inquiries through the CBP Call Center, IVR, Web Portal, and written correspondence. Real-time responses will be returned for inquiries received through the Web Portal and IVR. Inquiries received through written correspondence and the Call Center will be responded to in accordance with Contract SLAs defined for those areas. Since the system will capture and maintain full history of every bill transaction, all bill information (including interest penalties incurred), along with eligibility data and supporting document images will be available for responses to inquiries.

The Contractor will support the PPA process for all programs with all necessary reports requested and recorded later in this document.

2.3 Prompt Pay Business Workflows – DEEOIC

The following diagrams capture the DEEOIC Prompt Pay Business Process flows.

2.3.1 Prompt Pay Bill Submissions

This diagram depicts the flow of Prompt Pay bills submitted to the Mailroom.

2.3.2 Prompt Pay Bill Processing

This diagram depicts the general flow of Prompt Pay bills through CBP processing after submission to medical bill processing.

3 Prompt Pay – DCMWC

3.1 Prompt Pay Overview – DCMWC

3.2 Prompt Pay Business Process Description – DCMWC

3.2.1 Bill Entry/Identification

PPA bills will be classified according to each OWCP program by unique submission criteria. Regardless of the method of entry and based on the type of bill, workflow management will use queues and system alerts to automatically route all Prompt Pay bills within the bill processing application, for accurate and timely payment, in compliance with established PPA rules.

3.2.2 Mailroom

For DCMWC, Prompt Pay bills will always be submitted by the District Office to the mailroom by way of the specific P.O. Box designated for DCMWC, fax or FedEx. Prompt Pay bills will be submitted on an OWCP-1500 or HCFA 1500. Claimant Travel bills for Prompt Pay will be submitted on an OWCP-957. The bills will be further identified by the following mandatory characteristics:

· “Determination” or “Black Lung Determination” or “Determination Bill Approved” stamped on the billing form and signed and dated by the District Office.

· The PPA date will be placed above the stamp. This information will be in block 11 of the HCFA-1500.

· Signature and approval in Block 11 on the HCFA

· Diagnosis code “V81.30.”

· Modifiers 1D, 1Q, or 1V

· The presence of DOL Determination or standard CPT-4 procedure codes.

If any mandatory element is missing or invalid, the bill will be returned to the District Office for review and correction.

DCMWC Prompt Pay bills will include the following procedure codes:

· A complete list of the Determination/CPT codes with the corresponding Diary Action Codes (DAC) can be found in Appendix 7.6.

· CPT or HCPCS codes for charges submitted on a 1500. Note that any charge received on a bill not identified appropriately as a Prompt Pay bill, will be processed as a regular bill

· Travel procedure codes appropriate for submission on a 957 Procedure codes for PPA bills are pre-authorized for payment by Diary Action Codes (DAC). The District Office will enter the DACs and forward to the medical bill processing system.

3.2.3 Prompt Pay Processing

CBP will use specific criteria, such as the unique Determination/CPT service codes, and PPA stamp signed and dated by the District Office, to follow specific rules and processes to execute the correct PPA bill process flow. From all points of entry, that criteria will automatically be identified, and the CBP solution will utilize workflow management to ensure all PPA bills are processed timely, accurately, and according to DOL PPA rules.

3.2.3.1 Editing

DCMWC PPA codes, including determination travel codes, will be subjected to the current Black Lung fee schedule. Determination travel bills (OWCP-957) approved by the District Office should be paid. No editing should occur for excessive mileage, meals or lodging on these bills. All approved expenses/charges will be located in/keyed from the “DOL Use Only” box.

For DCMWC PPA bills, Determination procedure codes are not exempt from Treatment Suites processing. All approved prompt pay bills submitted with Determination codes or standard CPT-4 codes will be processed against Treatment Suites V81.30 (diagnostic testing).

If a DCMWC prompt pay bill is received without a diagnosis of V81.30, it should post an edit, and the District Office should be notified via the workflow tool.

3.2.3.2 Authorizations

Authorization for DCMWC Prompt Pay bills is dictated by the submission of Diary Action Codes via an electronic interface file from DOL. Any PPA bill that posts an authorization edit should be routed to the District Office for resolution.

3.2.3.3 Pricing Method

DCMWC Prompt Pay bills contain specific ICD-9/10/Determination or CPT/HCPCS code combinations, and all services are subject to the Determination Fee Schedules established by the DCMWC.

3.2.3.4 Time Limit/Interest Penalties

PPA bills are to be processed within 21 days of the PPA date so they are not subjected to interest penalties. Workflow management and reporting will actively monitor PPA volumes and results to ensure timely, accurate processing within that timeframe.

Prompt Pay bills will be subjected to the PPA interest formula established by the U.S. Treasury. The application of the interest formula will be date sensitive, derived from the (PPA date +21 days = Due Date), the bill should be reviewed for a PPA date; if it does not appear exactly in block 11; it should appear near block 11. The PPA review period starts from the PPA date on the bill, and must be processed 21 days from that date. The following is an example for calculating the PPA date:

District Office Receipt Date = 5/1/96

Review Deadline Date = 5/21/96

PPA Start Date = 5/22/96

Prompt Payment Interest is calculated from the day after payment was due until the day the payment is made. The interest rate in effect on the day after the payment due date is used to calculate the interest penalty.

The following is an example of the interest calculation formula to determine simple daily interest. If the formula is “P(r/360*d)”:

P = the invoice amount r = the Prompt Payment interest rate (2.625% through June, 2011) d = the number of days for which interest is being calculated.

If payment is due on June 1 and the payment is not made until June 11, a simple interest calculation will determine the amount of interest owed to the vendor for the late payment. Using the formula above, an invoice in the amount of $1,000 paid 10 days late and at an interest rate of 2.625% would be calculated as follows:

$1,000 (.02625/360*10) = $0.73 interest

The Chief of Fiscal Operations as well as the Policy Coordinator will determine if interest calculated and resulting in an amount less than $1.00 will be sufficient to be a burden on the Government.

Note that the interest amount is not added to the actual payment amount of the invoice during the CBP Payment process. The interest amount will be calculated and reported to the Government on a scheduled report. Also, all variables used to derive the amount of interest penalty will be recorded in the bill record for inquiries and audit purposes.

The only DCMWC PPA bill that can accrue interest is a provider PPA bill that has not been adjusted. All claimant PPA bills (CM-915 and CM-957), as well as adjusted provider PPA bills, will not accrue interest. Interest rate changes will occur twice per year. The Contractor will notify/remind DOL when rate changes should occur.

3.2.4 Reporting and Inquiries

The CBP Solution will provide timely responses to PPA inquiries received at CBP Call Center. IVR, Web Portal, and written correspondence will be directed to the District Office. Real-time responses will be returned for inquiries received through the Web Portal and IVR. Inquiries received through written correspondence and the Call Center will be responded to in accordance with Contract SLAs defined for those areas. Since the system will capture and maintain full history of every bill transaction, all bill information (including interest penalties incurred), along with eligibility data and supporting document images will be available for responses to inquiries.

THE CONTRACTOR will support the PPA process for all programs with all necessary reports requested and recorded later in this document.

3.3 Prompt Pay Business Workflows – DCMWC

The following diagrams capture the DCMWC Prompt Pay Business Process flows.

3.3.1 Prompt Pay Bill Submissions

This diagram depicts the flow of Prompt Pay bills submitted to the Mailroom.

3.3.2 Prompt Pay Bill Processing

This diagram depicts the general flow of Prompt Pay bills through CBP processing after submission to medical bill processing.

4 Prompt Pay Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 11 – Prompt Pay of the PWS. For requirements traceability purposes, IDs have been assigned to each functional requirement and business rule. The first two characters of each ID represent the related Program number, (B1 (Core/DFEC), B2 (DEEOIC), B3 (DCMWC), followed by PWS Section, followed by a 3 digit sequentially assigned number within each Build/PWS Section. The Program column indicates whether the requirement/rule is Core (i.e., applies to all programs) or if it is DFEC, DEEOIC, and/or DCMWC specific.

DCMWC, 412-413

DEEOIC, 414-417

4.1 Functional Requirements

PWS

Req # Functional

Req ID

R0400

R0401 R0015

B2-11-BR001

B3-11-BR001

Core

R0400

R0411

B1-11-BR002

B1-11-BR003

DFEC

R0400

B1-11-BR005

DFEC

R0400

R0402

R0403

R0404

R0405

R0406

R0407

R0412

B1-11-BR006

B2-11-BR006

B3-11-BR006 B1-11-BR007

B1-11-BR008

B1-11-BR009

B1-11-BR010

B1-11-BR011

Core

R0407

R0408

R0409

R0411

R0413

B2-11-BR012

B3-11-BR012

B1-11-BR013

B2-11-BR013

B3-11-BR013

Core

R0408

R0400

R0407

R0410

R0411

B1-11-FR007

B2-11-BR015

B3-11-BR015

Core

R0401

R0402

R0403

B1-11-FR008

B2-11-BR016

B3-11-BR016

Core

R0402

B1-11-FR009

R0401

R0402

R0419

B1-11-FR011

4.2 Business Rules

· Prompt Pay bills received in mailroom to be directed to manual key data entry:

· Claimant Maintenance (CLMMT) submitted on OWCP-915

· Claimant Travel – Prompt Pay submitted on OWCP-957, already paid by the Government. Key as “History Only”

· Voc Rehab and “Other” Homegrown codes submitted on misc provider paper invoice forms

· Voc Rehab and Contract Nurse bills entered on Portal require alert to District Office for Rehab Specialist/Staff Nurse approval

· Bill with Foreign Homegrown codes (not Prompt Pay) are to be directed to Operations for key data entry, per instructions on batch header sheets

· Paper bills failing the authorization edit will be suspended in a special location until the contractor has notified the appropriate District Office via the workflow that resolution is required.

· Workflow volumes for Prompt Pay bills will be monitored to insure timely payment per PPA rules

DFEC

· Paper bills failing the authorization edit will be suspended in a special location until the contractor has notified the appropriate District Office via the workflow that resolution is required.

· Workflow volumes for Prompt Pay bills will be monitored to insure timely payment per PPA rules

DEEOIC

· Paper bills failing the authorization edit will be suspended in a special location until the contractor has notified the appropriate District Office via the workflow that resolution is required.

· Workflow volumes for Prompt Pay bills will be monitored daily to insure timely payment per PPA rules

DCMWC

· On-line entry forms will differ depending on whether being accessed by a Contract Nurse or Voc Rehab Counselor.

· Homegrown codes allowed will be restricted by the type of entry form (Contract Nurse vs. Voc Rehab).

· Contract Nurse and Voc Rehab bills will always be classified as PPA1 (subject to interest if paid after 21 days).

· PPA Date is the date the bill is transmitted to CBP.

· Time will be recorded in units up to 2 decimal places.

· User will be allowed to attach appropriate attachments/reports to the bill to support the data entered. Reports will be available in electronic form to the Government.

· On-line entry will be subjected to real-time edits (see B1-11-BR013 below for list of real time edits); entry cannot be approved/transmitted to CBP with invalid data.

DFEC

· Specific list of D.O. Staff Nurse and Rehab Specialists to be provided by DOL

· Bills and Attachments are to be accessible via the Portal within 1 business day

· Security should be enforced to allow users involved in the case to view only their respective bills and attachments

DFEC

· Per current COP Interface Design Document, the (xml) input file from IFECS includes a Header and multiple detail records containing new entries

· As part of a Preliminary “loader” process, edits are performed to validate key fields such as Case and Provider number, in addition to other edits typically done within CBP

· Records with errors are noted appropriately and rejected; acceptable records are loaded into CBP

· All detail records submitted from IFECS must be accounted for in an Acknowledgement file returned to IFECS; file includes Header and multiple detail records

DFEC

B1-11-BR005

· TOTAL CHARGE AMT = 100.00

· DIAGNOSIS CODE = 999.9

· BILLED AMOUNT = 100.00

· BILLED UNITS = 1

· PLACE OF SERVICE = 99

· PROCEDURE CODE = COPTN

· COP Nurse bills will always be classified as PPA1 (subject to interest if paid after 21 days).

· PPA Date is the date the bill is successfully transmitted to CBP

DFEC

They will be recognized by:

· the PPA Stamp indicated on the bill

· the Homegrown Code (s) referenced on the bill (possibly accompanied by a diagnostic procedure code)

· the bill sent and received via the specific P.O. Box as specified by the contractor for receipt of DFEC PPA Bills.

PPA classification for ALL Homegrown codes will be included in a new Treatment Suite proposed specifically for Homegrown codes. The new PPA1 and PPA2 Treatment Suites will also contain same diagnostic services that are listed in the 999.98 suite.

· PPA bills for Second Opinion and Impartial Medical Examiner codes (SECOP, CNSLT, IMPAR, SUPPL, FOLUP, NOSHO, CANCL) are submitted on OWCP-1500 and classified as PPA1, subject to interest

· PPA Date is derived as the date the bill was received in the mailroom. In the event that a bill must be corrected and resubmitted by the D.O., the PPA date is the day the corrected bill is received in the mailroom.

See Appendix 7.2 for ALL Homegrown codes submitted (Web Portal, Paper and Electronic file)

DFEC

· Reviews by a District Medical Consultant

· Second Opinion/Referee Medical Examinations

· Impairment Rating Examinations.

Prompt Pay bills will always be submitted:

· by the District Office

· to mailroom in specific P.O. Box

· on an OWCP-1500 or a UB-04 (diagnostics).

· Claimant Travel bills for Prompt Pay will be submitted on an OWCP-957.

The bills are further identified by the mandatory characteristics:

· “Approved” written/stamped in the top right hand corner of the billing form, dated and signed in black ink by a CE

· A “Prompt Pay” stamp, in block 11 (on 1500), in box ‘h’ (on a 957), or clearly visible on the UB-04. A proposed change to the 957 may include a checkbox in box ‘h’ to designate Prompt Pay.

· A PPA Date – specified in block 11 ( on 1500); set to equal the date received in the mailroom for a UB-04 (Diagnostic charges) or 957 (Claimant Travel)

If any mandatory element is missing or invalid:

· the bill will be returned to the District Office for review and correction.

· A sample of the Missing Information form to accompany the bill to the District Office is included in Appendix 7.4.

· Corrected bills returned from the District Office will be in the form of a new bill, which will also establish a new PPA date.

DEEOIC Prompt Pay bills will include the following procedure codes:

· A list of specific Homegrown codes submitted on a 1500, appropriate for the diagnosis code/accepted condition established for the claimant. A complete list of the Homegrown codes can be found in Appendix 7.2.

· CPT or HCPCS codes for diagnostic charges submitted on a 1500 or UB-04. Any diagnostic charge received on a bill not identified appropriately as a Prompt Pay bill, will be processed as a regular bill

· Travel procedure codes appropriate for submission on a 957, which includes the possibility of the ‘TRANS’ Homegrown code

After successfully identifying Prompt Pay bills, each bill must be further classified as a specific category of Prompt Pay, PPA1 vs. PPA2, based on the service codes being billed:

· PPA1 – the bill includes Homegrown codes specifically designated as PPA1, which are subject to the PPA interest if paid after 21 days. A full list of those codes, including the PPA designation is included in Appendix 7.2

· PPA2 - the bill is for service codes not designated as PPA1, and therefore not subject to any interest penalties. All Homegrown codes not designated as PPA1 are PPA2.

· Prompt Pay bills for Diagnostic services will be classified as a PPA2

Prompt Pay bills for Claimant Travel will be classified as a PPA2

DEEOIC

· by the District Office

· to mailroom in specific P.O. Box, fax or FedEx

· on an OWCP-1500.

· Claimant Travel bills for Prompt Pay will be submitted on an OWCP-957.

· with Diagnosis code “V81.30.”

Provider (OWCP-1500) and miner (CM-915 and CM-957) bills are further identified by the…