Section_12_Return_to_Provider_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Return To Provider (RTP) and Return To Claimant (RTC) Processes (Section 12)

Central Bill Process

Return To Provider (RTP) and Return To Claimant (RTC) Processes (PWS Section 12) Requirements Specification 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 Return To Provider/Return To Claimant - DFEC

51.1 Return To Provider/Return To Claimant Overview - DFEC

51.2 Return To Provider/Return To Claimant Business Process Description - DFEC

71.3 Return To Provider/Return To Claimant Business Process Flow - DFEC

Return To Provider/Return To Claimant - DEEOIC

82.1 Return To Provider/Return To Claimant Overview - DEEOIC

82.2 Return To Provider/Return To Claimant Business Process Description - DEEOIC

102.3 Return To Provider/Return To Claimant Business Process Flow - DEEOIC

Return To Provider/Return To Claimant - DCMWC

113.1 Return To Provider/Return To Claimant Overview - DCMWC

113.2 Return To Provider/Return To Claimant Business Process Description - DCMWC

133.3 Return To Provider/Return To Claimant Business Process Flow - DCMWC

Return To Provider/Return To Claimant Business Requirements

144.1 Functional Requirements

164.2 Business Rules

Return To Provider/Return To Claimant Supporting Functional Components

205.1 Initial Data Migration

205.2 Interfaces

215.3 Reports

235.4 Letters

Constraints

246.1 Assumptions

246.2 Dependencies

246.3 Issues/Open Items

Appendices

257.1 Terms & Definitions

287.2 Non-PPA RTP/RTC Criteria

357.3 District Office Prompt Pay Verification Checklist

387.4 Prompt Pay Bills Missing Required Information – DEEOIC

1 Return To Provider/Return To Claimant - DFEC

1.1 Return To Provider/Return To Claimant Overview - DFEC

Communication with claimants and providers regarding the bill processing is an essential element of a responsive CBP solution. For any bills that fail up-front or back-end processing, the Contractor will clearly identify all specific deficiencies and provide useful guidance to the submitter on how to submit their bills in the correct manner. The Contractor’s CBP Solution will provide a high level of automated procedures and workflow management tools to process all bill documents that must be returned to the provider or claimant as efficiently as possible.

1.2 Return To Provider/Return To Claimant Business Process Description - DFEC

The 'Front-End' process of Central Bill Process consists of the following functional areas: Central Mailroom, DFEC Imaging, Claimant Bill Development, Bill Scan/Data Entry, and Return To Provider. The narrative of this section is focused on Return To Provider, but because the functional areas of the Front-End process are closely related, references to these other areas are mentioned to provide a complete picture of the functionality. Details of the other Front-End functional areas will be covered in their respective RSD sections.

The CBP Central Mailroom and the workflow contained in the imaging solution will be supplemented with the mailroom automation components described in the Central Mailroom and Bill Scan/Data Entry Sections of the RSD. To support the claimant and provider bill return process, images and data captured during normal processing steps will feed the Contractor’s’s letter generation software packageto populate the RTP/RTC letter in an automated manner for distribution. The RTP/RTC letter images will be stored in the image repository, ensuring that all RTP/RTC images are electronically accessible and viewable within a monthly average of 2 business days or less.

Each paper bill submitted by a claimant or provider will be received in the Contractor’s Central Mailroom, assigned a DCN, and scanned using the image scan application. The application will be used to automate the bill classification and routing. The image scan application will be configured to use pre-defined tables and rule sets to determine:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is there sufficient information to process the bill?

· Does the bill fall under the PPA processing requirements?

If any of these conditions are not met, the document will be electronically removed from the workflow and routed to mailroom staff responsible for the RTP/RTC. The image scan software will generate a reject report in DCN order that will be used to retrieve the original bill. The images will be used to develop the RTP/RTC letter. Data from the scanned bills is captured using OCR. Using the DOL-supplied RTP/RTC template as a basis, the image scan software will populate relevant captured data such as claimant/provider name and address. The RTP/RTC unit staff will review the images and if they agree that the reject is not valid, the bills will be rerouted to the the image scan system for data capture and further processing. If the RTP/RTC staff person agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted and output to a letter generation software package used in the CBP Central Mailroom. The formatted data will be used to populate the RTP/RTC letter.

All non-PPA related bills that do not meet DOL-supplied criteria for processing will be returned as RTP/RTC. All PPA-related bills that do not meet Government-supplied criteria for processing will be forwarded to the correct District Office (DO) for further processing. Upon receipt of the corrected bill from the DO, the bill will be date stamped with a new date of receipt and processed according to the program-specific PPA rules.

The Contractor’s automated mailroom software will ensure the prompt identification of deficient bills. As a result, The Contractor will return all deficient bills to the provider/claimant within 5 business days of receipt, accompanied by an RTP/RTC letter that includes the unique bill identifier, identifies all the specific deficiencies, and advisement to resubmit the completed/corrected bill form. The scanned images of the returned bills and images of the rejection letters generated by the letter generation software will be stored in the image repository, viewable to authorized users.

The Contractor’s workflow for the RTP/RTC process ensures that at least two separate individuals will review the missing data from a bill submission before an RTP/RTC letter is generated. The Contractor’s technical services staff will perform regular checks to ensure that all software is functioning properly. The Contractor’s supervisory staff will conduct regular audits from a random sample of RTP/RTC letters generated to ensure that staff is following the correct procedures.

1.3 Return To Provider/Return To Claimant Business Process Flow - DFEC The following diagram captures the DFEC Return To Provider/Return To Claimant Business Process flow.

2 Return To Provider/Return To Claimant - DEEOIC

2.1 Return To Provider/Return To Claimant Overview - DEEOIC

Communication with claimants and providers regarding bill processing is an essential element of a responsive CBP solution. For any bills that fail up-front or back-end processing, the Contractor will clearly identify all specific deficiencies and provide useful guidance to the submitter on how to submit their bills in the correct manner. The Contractor’s CBP Solution will provide a high level of automated procedures and workflow management tools to process all bill documents that must be returned to the provider or claimant as efficiently as possible.

2.2 Return To Provider/Return To Claimant Business Process Description - DEEOIC

The 'Front-End' process of Central Bill Process consists of the following functional areas: Central Mailroom, DFEC Imaging, Claimant Bill Development, Bill Scan/Data Entry, and Return To Provider. The narrative of this section is focused on Return To Provider, but because the functional areas of the Front-End process are closely related, references to these other areas are mentioned to provide a complete picture of the functionality. Details of the other Front-End functional areas will be covered in their respective RSD sections.

The CBP Central Mailroom and the workflow contained in the imaging solution will be supplemented with the mailroom automation components described in the Central Mailroom and Bill Scan/Data Entry Sections of the RSD. To support the claimant and provider bill return process, images and data captured during imaging solution’s normal processing steps will feed the Contractor’s letter generation software packageto populate the RTP/RTC letter in an automated manner for distribution. The RTP/RTC letter images will be stored in the image repository, ensuring that all RTP/RTC images are electronically accessible and viewable within a monthly average of 2 business days or less.

Each paper bill submitted by a claimant or provider will be received in the Contractor’s Central Mailroom, assigned a DCN, and scanned using the image scan application. The image scan application will be used to automate the bill classification and routing. The image scan application will be configured to use pre-defined tables and rule sets to determine:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is there sufficient information to process the bill?

· Does the bill fall under the PPA processing requirements?

If any of these conditions are not met, the document will be electronically removed from the workflow and routed to mailroom staff responsible for the RTP/RTC. The imaging software will generate a reject report in DCN order that will be used to retrieve the original bill. The images will be used to develop the RTP/RTC letter. Data from the scanned bills is captured using OCR. Using the DOL-supplied RTP/RTC template as a basis, the imaging software will populate relevant captured data such as claimant/provider name and address. The RTP/RTC unit staff will review the images and if they agree that the reject is not valid, the bills will be rerouted to the imaging system for data capture and further processing. If the RTP/RTC staff person agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted and output to a letter generation software package used in the CBP Central Mailroom. The formatted data will be used to populate the RTP/RTC letter.

All non-PPA related bills that do not meet DOL-supplied criteria for processing will be returned as RTP/RTC. All PPA-related bills that do not meet Government-supplied criteria for processing will be forwarded to the correct District Office (DO) for further processing. Upon receipt of the corrected bill from the DO, the bill will be date stamped with a new date of receipt and processed according to the program-specific PPA rules.

The Contractor’s automated mailroom software will ensure the prompt identification of deficient bills. As a result, the Contractor will return all deficient bills to the provider/claimant within 5 business days of receipt, accompanied by an RTP/RTC letter that includes the unique bill identifier, identifies all the specific deficiencies, and advisement to resubmit the completed/corrected bill form. The scanned images of the returned bills and images of the rejection letters generated by the letter generation software will be stored in the image repository, viewable to authorized users.

The Contractor’s workflow for the RTP/RTC process ensures that at least two separate individuals review the missing data from a bill submission before an RTP/RTC letter is generated. The Contractor’s technical services staff will perform regular checks to ensure that all software is functioning properly. The Contractor’s supervisory staff will conduct regular audits from a random sample of RTP/RTC letters generated to ensure that staff is following the correct procedures.

2.3 Return To Provider/Return To Claimant Business Process Flow - DEEOIC

The following diagram captures the DEEOIC Return To Provider/Return To Claimant Business Process flow.

3 Return To Provider/Return To Claimant - DCMWC

3.1 Return To Provider/Return To Claimant Overview - DCMWC

Communication with claimants and providers regarding the bill processing is an essential element of a responsive CBP solution. For any bills that fail up-front or back-end processing, the Contractor will clearly identify all specific deficiencies and provide useful guidance to the submitter on how to submit their bills in the correct manner. The Contractor’s CBP Solution provides a high level of automated procedures and workflow management tools to process all bill documents that must be returned to the provider or claimant as efficiently as possible.

3.2 Return To Provider/Return To Claimant Business Process Description - DCMWC The 'Front-End' process of Central Bill Process consists of the following functional areas: Central Mailroom, DFEC Imaging, Claimant Bill Development, Bill Scan/Data Entry, and Return To Provider. The narrative of this section is focused on Return To Provider, but because the functional areas of the Front-End process are closely related, references to these other areas are mentioned to provide a complete picture of the functionality. Details of the other Front-End functional areas will be covered in their respective RSD sections.

The CBP Central Mailroom and the workflow contained in the imaging solution will be supplemented with the mailroom automation components described in the Central Mailroom and Bill Scan/Data Entry Sections of the RSD. To support the claimant and provider bill return process, images and data captured during imaging software’s normal processing steps will feed the Contractor’s letter generation software packageto populate the RTP/RTC letter in an automated manner for distribution. The RTP/RTC letter images will be stored in the image repository, ensuring that all RTP/RTC images are electronically accessible and viewable within a monthly average of 2 business days or less.

Each paper bill submitted by a claimant or provider will be received in the Contractor’s Central Mailroom, assigned a DCN, and scanned using the image scan application. The image scan application will be used to automate the bill classification and routing. The image scan application will be configured to use pre-defined tables and rule sets to determine:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is there sufficient information to process the bill?

· Does the bill fall under the PPA processing requirements?

If any of these conditions are not met, the document will be electronically removed from the workflow and routed to mailroom staff responsible for the RTP/RTC. The imaging software will generate a reject report in DCN order that will be used to retrieve the original bill. The images will be used to develop the RTP/RTC letter. Data from the scanned bills is captured using OCR. Using the DOL-supplied RTP/RTC template as a basis, the image scan software will populate relevant captured data such as claimant/provider name and address. The RTP/RTC unit staff will review the images and if they agree that the reject is not valid, the bills will be rerouted to the image scan system for data capture and further processing. If the RTP/RTC staff person agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted and output to a letter generation software package used in the CBP Central Mailroom. The formatted data will be used to populate the RTP/RTC letter.

All non-PPA related bills that do not meet DOL-supplied criteria for processing will be returned as RTP/RTC. All PPA-related bills that do not meet Government-supplied criteria for processing will be forwarded to the correct District Office (DO) for further processing. Upon receipt of the corrected bill from the DO, the bill will be date stamped with a new date of receipt and processed according to the program-specific PPA rules.

The Contractor’s automated mailroom software will ensure the prompt identification of deficient bills. As a result, the Contractor will return all deficient bills to the provider/claimant within 5 business days of receipt, accompanied by an RTP/RTC letter that includes the unique bill identifier, identifies all the specific deficiencies, and advisement to resubmit the completed/corrected bill form. The scanned images of the returned bills and images of the rejection letters generated by the letter generation software will be stored in the image repository, viewable to authorized users.

The Contractor’s workflow for the RTP/RTC process ensures that at least two separate individuals review the missing data from a bill submission before an RTP/RTC letter is generated. The Contractor’s technical services staff will perform regular checks to ensure that all software is functioning properly. The Contractor’s supervisory staff will conduct regular audits from a random sample of RTP/RTC letters generated to ensure that staff is following the correct procedures.

3.3 Return To Provider/Return To Claimant Business Process Flow - DCMWC The following diagram captures the DCMWC Return To Provider/Return To Claimant Business Process flow.

4 Return To Provider/Return To Claimant Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 12 – Return To Provider/Return To Claimant of the PWS. For requirements traceability purposes, IDs have been assigned to each functional requirement and business rule. The first two digits of each ID represent the PWS Section, followed by a system component identifier (IDM01=Core/DFEC; IDM02=DEEOIC; IDM03=DCMWC), followed by a 4 digit sequentially assigned number within each PWS Section and system identifier. 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.

4.1 Functional Requirements

PWS

Req # Functional

Req ID

R0420

R0421

R0423

R0015

Core

R0424

R0425

B1-12-BR003

B1-12-BR004

DFEC

R0424

R0425

B2-12-BR003

B1-12-BR004

DEEOIC

R0424

R0425

B3-12-BR003

B1-12-BR004

B3-12-BR008

DCMWC

R0425

R0428

R0425

R0428

R0425

R0428

R0422

R0429

B2-12-BR009

B3-12-BR009

Core

4.2 Business Rules

· Images and data captured during image scan software’s normal processing steps will feed the Contractor’s letter generation software package, to populate the RTP/RTC letter in an automated manner for mail-out. The image scan application will be used to automate the bill classification and routing. Image scan application will be configured to use pre-defined tables and rule sets to determine the following in order to electronically remove the document for RTP/RTC verification and processing:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is there sufficient information to process the bill? (see Appendix 7.2 and 7.3 below for RTP/RTC Criteria)

· Does the bill fall under the PPA processing requirements?

· Is the bill for a claimant or provider (to determine which RTP/RTC letter should be or will be generated)?

Core

· CMS 1500/OWCP 1500

· UB04/UB92 Inpatient, Outpatient

· OWCP 915 Claimant Reimbursement (Medical)

· OWCP 915 Claimant Reimbursement (Drug/Pharmacy)

· OWCP 957 Travel Form

· ADA Dental Form

· NCPDP Universal Pharmacy Billing Form

· NALC 200 Carrier Reimbursement Form Core

· See PWS Section 7 RSD Appendix 7.4 for Proof of Payment Criteria and Appendix 7.5 for Proof of Purchase Criteria

· See PWS Section 23 RSD Appendix 7.2 for Adjustment Request Template Core

· See Appendix 7.2 below for Non-PPA RTP/RTC Criteria below

· See PWS Section 7 RSD Appendix 7.4 for Proof of Payment Criteria and Appendix 7.5 for Proof of Purchase Criteria

· If the required information is missing from the NALC 200 form (i.e., when a third-party carrier seeks reimbursement for services they paid for a covered claimant), the Contractor will RTP the form back to the carrier (see Appendix 7.2).

DEEOIC

· See PWS Section 7 RSD Appendix 7.4 for Proof of Payment Criteria and Appendix 7.5 for Proof of Purchase Criteria

DCMWC

· If the DFEC PPA bill is returned to the District Office, the date that the PPA Bill re-entered the Contractor’s mailroom facility should be used.

DFEC

· The PPA1 and PPA2 bills will contain the PROMPT PAY stamp and CE signature and date. The PPA Date for Prompt Pay bills submitted for the DEEOIC Program is located in block 11 of the HCFA 1500 or OWCP-1500. PPA 2 bills for reimbursement of diagnostic bills and claimant travel related to second opinion and referee examinations will not have a PPA date. The PPA date of these bills is based on the date received in the mail room. Travel Prompt Pay bills are identified as PPA2 bills and will not have a PPA date.

· If the DEEOIC Travel Prompt Pay bill (PPA2 bill) is returned to the District Office, the date that the PPA Bill re-entered the Contractor’s mailroom facility should be used.

DEEOIC

· If the DCMWC PPA bill is returned to the District Office, the original PPA date is used.

DCMWC

· Image of the bill and attachment returned to the Provider and/or Claimant, along with corresponding RTP/RTC letter, must be available and retrievable from the Contractor’s Medical Bill Imaging system. It is not required to be reflected in the IFEC’s imaging system.

DFEC

B2-12-BR009

Image of returned bills and respective letter

· All RTP/RTC images should be electronically accessible and viewable within a monthly average of 2 business days.

· Image of the bill and attachment returned to the Provider and/or Claimant, along with corresponding RTP/RTC letter, must be available and retrievable from the Contractor’s Medical Bill Imaging system.

DEEOIC

· Image of the bill and attachment returned to the Provider and/or Claimant, along with corresponding RTP/RTC letter, must be available and retrievable from the Contractor’s Medical Bill Imaging system.

· NOTE: The claimant receives the original bill for RTC, not the image.

DCMWC

5 Return To Provider/Return To Claimant Supporting Functional Components The following functional components serve as inputs or outputs to the Return To Provider/Return To Claimant process.

5.1 Initial Data Migration

The following table identifies the initial data migration required by the Return To Provider/Return To Claimant process. Specific details (i.e., file layout, business rules, etc.) of each data migration will be outlined under a separate document, Detailed Design Specifications. For requirements traceability purposes, Initial Data Migration IDs have been assigned to each Initial Data Migration requirement. The first two digits represent the PWS Section, followed by a system component identifier (IDM01=DFEC; IDM02=DEEOIC; IDM03=DCMWC; IDM99=Misc/Global), followed by a 3 digit sequentially assigned number within each PWS Section and system identifier.

Data Migration

ID

Source

System Target

System Description

05-IDM01_001

05-IDM02_001

05-IDM03_001

5.2 Interfaces

The following table identifies the interfaces required by the Return To Provider/Return To Claimant process. Specific details (i.e., file layout, business rules, etc.) of each interface will be outlined under a separate document, Detailed Design Specifications. For requirements traceability purposes, Interface IDs have been assigned to each interface requirement. The first two digits represent the PWS Section, followed by a system component identifier (INTF01=DFEC; INTF02=DEEOIC; INTF03=DCMWC; INTF99=Misc/Global), followed by a 3-digit sequentially assigned number within each PWS Section and system identifier.

Future State Interface ID Source

System Target

System

05-INTF01-002

05-INTF02_002

05-INTF03_002

5.3 Reports

The following table identifies the reports required by the Return To Provider/Return To Claimant process. Specific details (i.e., report templates, data elements, business rules, etc.) of each report will be outlined under a separate document, Detailed Design Specifications. For requirements traceability purposes, Report IDs have been assigned to each report requirement. The first two digits represent the PWS Section, followed by a system component identifier (RPT01=DFEC; RPT02=DEEOIC; RPT03=DCMWC; RPT99=Misc/Global), followed by a 3-digit sequentially assigned number within each PWS Section and system identifier.

Future State

Report ID Current State

Report ID

12-RPT01_001

12-RPT02_001

12-RPT03_001

Data Elements:

OWCP Program ID

Claimant Submitted Medical (RTC)

Claimant Pay Pharmacy (RTC)

Dental (RTP/RTC)

OWCP-1500 (RTP/RTC)

OWCP-957 (RTC)

Pharmacy (RTP/RTC)

UB-04 (RTP/RTC)

Gross Bill Volume

# Rejected

# returned as RTP/RTC Total Number of Rejected and returned as RTP/RTC Date Bill Received

Date Bill Returned

12-RPT02_002

Data Elements:

Claimant Medical Pay Claimant Pay Pharmacy

Dental

HCFA

OWCP 957

Pharmacy

UB

12-RPT03_002

Data Elements:

Claimant Medical Pay

Claimant Pay Pharmacy

HCFA

OWCP 957

Pharmacy

UB

5.4 Letters

The following table identifies the letters required by the Return To Provider/Return To Claimant process. Specific details (i.e., letter templates, data elements, business rules, etc.) of each letter will be outlined under a separate document, Detailed Design Specifications. For requirements traceability purposes, Letter IDs have been assigned to each letter requirement. The first two digits represent the PWS Section, followed by a system component identifier (LTR01=DFEC; LTR02=DEEOIC; LTR03=DCMWC; LTR99=Misc/Global), followed by a 3-digit sequentially assigned number within each PWS Section and system identifier.

Future State

Letter ID Current State

Rpt ID

12-LTR01_001

12-LTR02_001

12-LTR03_001

Return To Provider (RTP) letter that includes the bill’s unique identifier, identifies all specific deficiencies, and advises resubmission of the completed/corrected bill form

12-LTR01_002

12-LTR02_002

12-LTR03_002

Return To Claimant (RTC) letter that includes the bill’s unique identifier, identifies all specific deficiencies, and advises resubmission of the completed/corrected bill form

12-LTR01_003

12-LTR02_003

12-LTR03_003

N/A

Deficient PPA Check List to the appropriate District Office, detailing the reason for return

6 Constraints

6.1 Assumptions

· N/A

6.2 Dependencies

· N/A

6.3 Issues/Open Items

Section Issue/

Resolution

Resolved

Resolution: N/A

7 Appendices

7.1 Terms & Definitions

Program administered by the Division of Coal Mine Workers’ Compensation (DCMWC) that provides compensation benefits to eligible coal miners and their families and medical benefits to eligible coal miners in the event of total disability or death due to pneumoconiosis. These benefits are financed through direct Federal appropriations, earmarked tax revenues, and legislatively mandated private sector liability insurance arrangements.

A medical bill processing operation that processes bills for three OWCP programs: DFEC; BLBA under DCMWC and DEEOIC using one centralized process, but with customized business rules for each program.

Administers The Black Lung Benefits Act (BLBA) and provides compensation benefits to eligible coal miners and their families and medical benefits to eligible coal miners in the event of total disability or death due to pneumoconiosis. These benefits are financed through direct Federal appropriations, earmarked tax revenues, and legislatively mandated private sector liability insurance arrangements.

Provides benefits to employees or survivors of employees of the Department of Energy (DOE), its Contractors, and subcontractors, companies that provided beryllium to DOE and atomic weapons employers who suffer from a radiation-related cancer, beryllium-related disease, chronic silicosis, or exposures to other toxic substances resulting in occupational illnesses. The program also covers certain uranium workers who suffer from radiation-related illnesses as a result of their work in producing or testing nuclear weapons.

Act/program that provides wage replacement and medical benefits to civilian employees of the Federal Government who were injured at work and to certain designated groups.

Note: Based on the approach taken in identifying CBP Functional Requirements as requested by DOL, Functional Requirements, in the context of Section 4.1 of this document, cover both system and operational requirements.

Disability compensation programs, administered under the Department of Labor (DOL), which mitigate, through the provision of wage replacement and cash benefits, medical treatment, vocational rehabilitation, and other benefits, the financial burden on certain workers, or their dependents or survivors, resulting from work-related injury, disease, or death.

7.2 Non-PPA RTP/RTC Criteria

OWCP-1500

· SSN missing/invalid or SSN/name mismatch

· Signature or acceptable forms of a signature missing

· Diagnosis Codes Missing/Invalid

· Procedure Codes missing/invalid

· Missing Place of Service

· Line Item Charges missing/invalid

· Date of Service missing/invalid/or is a future date

· Missing Facility name/address

· No Active Provider Number on file or Provider number missing

· Physicians signature is missing

· Submitted provider number does not match tax id

OWCP-1500 - DCMWC

· SSN missing/invalid or SSN/name mismatch

· Signature or approved wording missing

· Diagnosis codes missing or all codes present are invalid

· Procedure Codes missing/invalid

· Missing Place of Service

· Line Item Charges missing/invalid

· Date of Service missing/invalid/or is a future date

· No Active Provider Number on file or Provider number missing in box 33 of a HCFA or box 51 of a UB

· Physicians signature is missing

· Diagnosis code pointer is blank and more than one diagnosis code Is present

UB-04/UB 92

· SSN number missing/invalid or SSN number name mismatch

· Principle diagnosis missing code is missing/invalid

· Line Item Charges missing

· No Active Provider Number on file or Provider number missing

· Physicians signature is missing

· Type of bill missing/invalid

· Revenue Center Code (s) missing/invalid

· Medicare # missing for Provider type 01 on UB Bill Type 111

· Incorrect Form

UB-04/UB 92 - DCMWC

· SSN number missing/invalid or SSN number name mismatch

· No Active Provider Number on file or Provider number missing in box 33 of a HCFA or box 51 of a UB

· Physicians signature is missing

· Type of bill missing

· Statement covers period is missing/invalid/future

· Revenue Center Code (s) missing/invalid

· Principal diagnosis code is missing/invalid or diagnoses handwritten

· Admission date is missing/invalid/future

· Line item charges missing or invalid

Pharmacy

· SSN number missing/invalid or SSN number name mismatch

· Detail Line charges missing

· Date of Service missing/invalid/or is a future date

· NCPDP missing/invalid

· Authorized pharmacy representative signature missing

· NDC missing

· Quantity missing

· Prescription Number Missing/Invalid

Pharmacy - DCMWC

· SSN number missing/invalid or SSN number name mismatch

· NCPDP missing/invalid

· Authorized pharmacy representative signature missing

· NDC missing

· Quantity missing

· Prescription Number Missing/Invalid

· Date of Service missing/invalid/or is a future date

· Patient signature missing

· Detail Line charges missing

OWCP-957

· SSN missing/invalid or SSN/name mismatch

· Claimant Signature missing

· Travel Expense Missing

· Travel From/To Missing

· Date of Travel is missing

· Medical Facility Address Missing/Invalid in Block-E

· Physician signature missing

· Date Care Rendered Missing/invalid

· Mileage Missing/invalid (which would only be valid if there were no submitted options in block f)

· Receipts/Proof of payments missing (which would be valid if any of the items referenced in block “f” equals or exceeds $75.00) Receipts not required if charges in block “f” are less than $75.00.

OWCP-957 – DEEOIC

· SSN missing/invalid or SSN/name mismatch

· Claimant Signature missing

· Travel Expense Missing

· Travel From/To Missing

· Date of Travel is missing

· Medical Facility or Pharmacy Address Missing/Invalid in Block-E

· Physician signature missing

· Date Care Rendered Missing/invalid

· Mileage Missing/invalid (which would only be valid if there were no submitted options in block f)

· Receipts/Proof of payments missing (which would be valid if any of the items referenced in block “f” equals or exceeds $75.00) Receipts not required if charges in block “f” are less than $75.00.

· Diagnosis Code Missing/Invalid

· Medical Facility or Pharmacy Name and address missing/invalid (Block E)

· Receipts are required for all Lodging (including companion), Airfare (including companion), Rental Cars, and Rental Car Gas regardless of the amount.

OWCP-957 - DCMWC

· SSN missing/invalid or SSN/name mismatch

· Date of Travel is missing

· One way/round trip missing

· Travel From/To Missing

· Mileage Missing

· Claimant Signature missing

· Travel Expense Missing

· Physician signature missing

· Date Care Rendered Missing/invalid

· Diagnosis Code Missing/Invalid

· Medical Facility and Address Missing/Invalid

OWCP-915 Medical

· SSN missing/invalid or SSN/name mismatch

· Claimant signature and date missing

· Procedure codes missing/invalid

· Amount Paid by the Claimant missing

· Date of Service missing

· Receipts/Proof of Payment missing

· Diagnosis Code Missing/Invalid

OWCP-915 Medical – DEEOIC

All data elements in black text are Core.

· SSN missing/invalid or SSN/name mismatch

· Procedure codes missing/invalid or Description of Services Missing (itemized bill or statement must be attached)

· Amount Paid by the Claimant missing

· Date of Service missing

· Receipts/Proof of Payment missing

· Diagnosis Code Missing/Invalid or Reason for Visit Missing

OWCP-915 Medical - DCMWC

· SSN missing/invalid or SSN/name mismatch

· Procedure codes missing/invalid

· Amount Paid by the Claimant missing

· Date of Service/purchase missing

· Receipts/Proof of Payment missing

· Diagnosis Code Missing/Invalid or Reason for Visit Missing

OWCP-915

(Drug/Pharmacy)

· SSN missing/invalid or SSN/name mismatch

· Amount paid by the claimant missing

· Date of Service/Dispense date missing

· NDC Missing

· Drug Quantity missing

· Receipts/Proof of payment missing

· Prescription number missing

Dental (ADA)

· SSN missing/invalid or SSN/name mismatch

· Procedure codes missing/invalid

· Line Item Charges missing

· Date of Service missing/invalid/or is a future date

· Provider Identification number is missing/invalid

· Physicians signature is missing

· Submitted provider number does not match tax id

· Case file number on the template missing/invalid (C1)

· Claimant Name (Last, First, Initial) missing/invalid (C2)

· Explanation for adjustment required (E1)

· Provider Number on template (Block #3) is missing/invalid (P1)

· Provider Number on the TCN to be adjusted not equal to Adjustment Provider (P2)

· TCN in Block #1 of the template was not found/not valid or not legible (T0)

· TCN in Block #1 of the template currently being adjusted or in process. (Please allow (10) business days for complete adjudication) (T3)

· TCN Adjustment Request is for a Claimant-Pay Bill (T5)

· Reprocess under correct Program (T6)

· Pharmacy TCN (X2)

· SSN missing/invalid or SSN name mismatch

· Provider not type 95 (Third Party/Other Carrier)

· Provider missing/invalid (block 4)

· Date of Service (From/To) missing/invalid (Block 6),

· Place of Service Code missing (Block 6B),

· Procedure/Revenue Code Missing/Invalid (Block 6C)

· Diagnosis Code missing/invalid (Block 6D)

· No charges Present (Block 6F)

· No signature on bill (Block 8)

· Facility zip code missing

7.3 District Office Prompt Pay Verification Checklist

· Block - #2, Patient’s name

· Block - #11, Case number

· Block - #21, Diagnosis - 999.99

· Block - #24 A, Dates of Service

· Block - #24 D, Procedure – Homegrown code - IMPAR

· Block - #25 Federal Tax I.D. Number

· Block - #28, Total Charge

· Block - #30, Balance Due

· Block - #31, Dr’s signature and date

· Block - #32 Name & address of Facility

· Block - #33, Billing provider info & PH #

· Block - #33A, PIN

· Check attachments for a bill for Diagnostic Services (process as PPA1)

· Block - #2, Patient’s name

· Block - #1a or #11, Insured I.D., number/case number

· Block - #21, Diagnosis - 999.99

· Block - #24 A, Dates of Service

· Block - #24 D, Procedure – Homegrown code - CNSLT

· Block - #25 Federal Tax I.D. Number

· Block - #28, Total Charge

· Block - #31, Dr’s signature and date

· Block - #33A, PIN

· Original provider’s invoice stamped as PROMPT PAY or maybe on a HCFA-1500

· Case number

· Dates of Service

· Procedure – Homegrown code

· Federal Tax I.D. Number

· PIN

· Total Charge

· Rehab Specialist signature and/or initials verifying “OK to pay”

· Claimant’s name

· Social Security Number

· Case number

· Address

· Description of Charge – CLMMT or other Homegrown code

· Date of Service or Purchase

· Total amount paid by Claimant

· Rehab Specialist signature and date

· Stamped as PROMPT PAY

· Block - #2, Patient’s name

· Block - #11, Case number

· Block - #21, Diagnosis - 999.99

· Block - #24 A, Dates of Service

· Block - #24 D, Procedure – SECOP or other Homegrown code or diagnostic code

· Block - #25 Federal Tax I.D. Number

· Block - #28, Total Charge

· Block - #30, Balance Due

· Block - #31, Physician or facility name and date

· Block - #32 Name & address of Facility

· Block - #33, Billing provider info & phone number

· Block - #33A, PIN

· Check attachments for a bill for Diagnostic Services (process as PPA1)

7.4 Prompt Pay Bills Missing Required Information – DEEOIC

<<Bill Contractor Name, Address, phone, fax>>

PROMPT PAY BILLS

MISSING REQUIRED INFORMATION

District Office (Select One)

Date: _________________

The following required information is missing from the attached prompt pay bill(s). Please correct the bill by providing the necessary information and resubmit to <<_____>> for processing.

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