Section_13_Edits_and_Audits_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Edits & Audits (Section 13)

Central Bill Process

Edits & Audits (PWS Section 13)

Requirements Specifications Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor

Office of Worker’s Compensation Programs

Prepared by:

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 Edits & Audits – DFEC

61.1 Edits & Audits Overview – DFEC

81.2 Edits & Audits Business Process Description – DFEC

81.2.1 Components of Edits and Audits Process

81.2.1.1 Invoking Edits and Audits in Bill Processing

101.2.1.2 Dispositions in Edits and Audits

101.2.1.3 EOBs

111.2.1.4 Bill Types

111.2.1.5 Error Location

121.2.2 Bills Submission Process

121.2.3 Bills Load Process

121.2.4 Bills Adjudication Process

141.3 Edits & Audits Business Process Flow – DFEC

141.3.1 Edits and Audits Overview Workflow

151.3.2 Edits and Audits in Bill Processing Workflow

Edits & Audits – DEEOIC

182.1 Edits & Audits Overview – DEEOIC

202.2 Edits & Audits Business Process Description – DEEOIC

202.2.1

202.2.1.1

222.2.1.2

222.2.1.3

232.2.1.4

232.2.1.5

242.2.2

242.2.3

242.2.4

262.3 Edits & Audits Business Process Flow - DEEOIC

262.3.1

272.3.2

Edits & Audits – DCMWC

303.1 Edits & Audits Overview – DCMWC

323.2 Edits & Audits Business Process Description – DCMWC

323.2.1

323.2.1.1

343.2.1.2

343.2.1.3

353.2.1.4

353.2.1.5

353.2.2

363.2.3

363.2.4

383.3 Edits & Audits Business Process Flow - DCMWC

383.3.1

393.3.2

Edits & Audits Business Requirements

424.1 Functional Requirements

434.2 Business Rules

Edits & Audits Supporting Functional Components

525.1 Initial Data Migration

525.2 Interfaces

535.3 Reports

535.4 Letters

Constraints

556.1 Assumptions

556.2 Dependencies

556.3 Issues/Open Items

Appendices

567.1 Terms & Definitions

597.2 DFEC Edits & Audits Posting Criteria

797.3 EOB Messages for DFEC Edits and Audits

907.4 UR Limitation Criteria for DFEC Edits

957.5 Error Location of DFEC Edits and Audits

1227.6 DFEC Duplicate Check Criteria

1237.7 DEEOIC Edits & Audits Posting Criteria

1407.8 EOB Messages for DEEOIC Edits and Audits

1577.9 UR Limitation Criteria for DEEOIC Edits

1597.10 Error Disposition of DEEOIC Edits and Audits

1987.11 DEEOIC Duplicate Check Criteria

1997.12 DCMWC Edits & Audits Posting Criteria

2147.13 EOB Messages for DCMWC Edits and Audits

2307.14 UR Limitation Criteria for DCMWC Edits

2357.15 Error Disposition of DCMWC Edits and Audits

2927.16 DCMWC Duplicate Check Criteria

1 Edits & Audits – DFEC

1.1 Edits & Audits Overview – DFEC

The CBP includes a comprehensive series of automated edits and audits that act as control points to dictate the ultimate disposition of the bill (approved, denied, or pended). The CBP will provide greatly increased throughput of bills with bill data being validated at multiple points in the adjudication process. These multiple validations include validation at the EDI gateway, Front End Process (Mailroom), Web Portal, duplicate identification across bill types and procedural categories within the CBP. Bills that should not be approved for payment, which do not meet the policies as set forth and depicted in the defined disposition criteria of each edit/audit, will be edited out quickly. Bills that pass all policies set forth in the edit/audit disposition hierarchical flow will be processed automatically for payment, or denial. Bills that do not pass the edit/audit policy dispositions will be suspended and dispersed to assigned work queues based on defined disposition criteria for each edit/audit as designed for each DOL program.

Each of the three DOL programs requires specific edits and audits to determine when a bill should be denied or suspended (pended) for manual review. The CBP will provide automated routing of bills to work queues, which will improve timeliness and reduce rework while providing tailored Explanation of Benefit (EOB) messages.

The edit process is applied to an individual bill while the audit process is applied across bill history and other applicable data such as authorizations. Bills with a pend status will be automatically re-adjudicated once the items causing the pend status have been resolved. The DOL programs require bill editing functions including but not limited to: provider and claimant eligibility, validity of submitted procedure (including NDC) and diagnosis codes, accepted eligible condition to both the billed diagnosis and billed procedures, authorizations, service limitations (accumulators), duplicate bill identification and category, fee schedule limitations, and other configurable dollar limitations (dollar limit accumulators), CCI edits and audits for more than140,000 sets of comprehensive-component and mutually exclusive code pairings, as well as other edits and audits supported by configurable rules and setup options inherent in the CBP.

Each program will have its own set of edits and audits, edits and audits flow, and allowance for multiple EOB remarks per edit and audit, each with their own corresponding bill disposition messages. The EOB messages will be configured during implementation to provide specific text, and will be easily configured during the operations phase, at DOL’s request. The edits and audits will be easily configurable as well, and will be assigned an outcome of suspend, auto deny, or auto pay to render specific bill dispositions per each Program’s requirements. It will also ensure that for all edits/audits set to auto deny, the Resolution Specialist will have the capability of changing the status to “Override the decision”, or for edits/audits set to auto pay, the Resolution Specialist will have the capability to “Manually Deny” the edit/audit to change the decision from a “Pay” when a bill is posted with a suspended edit at appropriate header or line level. For all edit/audits set to suspend, the Resolution Specialist will have the capability in this category to “Pay” or “Deny” the edit using an assigned indicator “Force” (F), “Deny” (D)”.

The CBP solution will provide the flexibility necessary to implement improvements in distinguishing duplicates (e.g., exact, potential, possible conflict). The Contractor will perform continual analysis on all editing, and recommend to DOL criteria be added or removed from the duplicate editing/auditing process as observed from billing analysis. The Contractor will disposition all edits/audits, including duplicates, per Government direction, and in the event of bills suspended for manual review, implement Government approved disposition processing of these bills. The Contractor’s duplicate edit solution will also address multiple bills within a medical provider group practice that have the same case, diagnosis, and dates of service. The Contractorwill ensure that the edit/audit routines are established at the appropriate granular level to accurately detect duplicates in this scenario. The Contractorwill also ensure that the same services are not being billed by physician and outpatient facilities by crosschecking duplicates between HCFAs and UB04s (e.g., RCCs billed that crosswalk to a CPT/HCPCS).

The CBP solution and all of its components will be fully integrated to support all aspects of medical bill processing, from data entry to transmission of payment files, and all functionality in between. The Contractorwill configure the CBP, specifically its step engine process, to ensure all processing routines are coordinated with other functions (e.g., data entry, transmission of payment files, authorization of services, and other appropriate functions), to yield efficient, accurate bill disposition.

To support the edit and audit process, the Contractorwill also apply external files (e.g., Programs and validation tables) at DOL’s direction, using automated loader utilities of the CBP to efficiently and accurately load data. The Contractorwill run these updates through its configuration management process, ensuring they are fully tested and meet DOL’s expectations prior to loading to Production. The Contractorwill use this flexible setup to configure DOL specific requirements (e.g., bill/bill type, service type, provider type, etc.) with date driven assignments of various values and rules providing high granularity and specificity of the edits and audits. The sets of CBP edits and audits will be modified over time, maintaining the history, but also updating any other system components that use this template, providing easy, fast and inexpensive global maintenance.

As part of overall continuous improvement, the Contractorwill study operational trends and billing patterns, examining edit/audit posting frequencies, and recommend to DOL changes to the edit/audit routine that will further automate and make efficient the bill processing function. The Contractor will also update the edit and audit processes to keep current with modified business practices, and provide recommendations to DOL on practices that would enhance the accuracy, timeliness, and cost effectiveness of medical bill processing.

The CBP will automatically populate work queues as appropriate based on the edit/audit assignment in the hierarchical flow, as well as the disposition indicator set for each edit. On the basis of security roles and privileges, the Contractor’sOperations staff will access work queues in the CBP to process such items as bills, provider enrollments, and authorizations. On the basis of security roles and privileges, external users, such as DOL, will directly access work queues via the CBP Web Portal.

1.2 Edits & Audits Business Process Description – DFEC

1.2.1 Components of Edits and Audits Process

1.2.1.1 Invoking Edits and Audits in Bill Processing

Edits and audits are used to implement each program’s business rules during the prepayment bill adjudication cycle. Edits/audits and their specific posting criteria are implemented at the program level, enabling customized EOBs and edit dispositions for each OWCP program. The edit/audit algorithms are organized so that edits and audits fire in a logical sequence ensuring efficient and cost-effective automated processing. For example, an edit/audit algorithm may check data validity first (including timely submission and inclusion of required attachments), followed by claimant and provider eligibility, then validation of procedure/diagnosis, treatment suites, authorizations, fee schedule, CCI, duplicate check and utilization review. Bills that fail the initial validity check (e.g., claimant or provider not eligible, invalid procedure code, etc.) are automatically denied and follow the appropriate RTP or RTC process.

Categories of edits and audits that will be supported in CBP include:

· Claimant Eligibility

· Provider Eligibility

· Duplicate checks across all bill types (e.g., HCFA-1500 and UB-04 outpatient facility bills)

· Data validity checks against diagnosis and procedure (including NDC) codes

· Authorizations – required as designated for the service being billed

· Treatment Suites – to ensure that services billed are appropriate for diagnosis/accepted condition

· Service Limitations – controls the number of times a given service is payable over a specific period of time

· Medicare CCI – edits utilizing Medicare reference files to prevent improper payment when incorrect code combinations are used; check for comprehensive versus component codes, as well as mutually exclusive codes

· Edits to check for add-on codes to ensure a base/parent code is present when an add-on code is billed

· Age and/or gender edits will be applied against all reference codes to ensure consistency between the service billed and the claimants gender

· Fee schedule edits

· Other dollar limitations (e.g., Global Surgical Cut-backs, Multiple Surgical Cut-backs, and Unit of Services Cut-backs).

The edit and audit routines in CBP are defined by each program’s Edit/Audit Exhibit. In addition to dispositioning at the program level, edit and audit dispositions will be based on the specific bill type (i.e., Professional, Inpatient, Outpatient, Prompt Pay, Pharmacy, Travel and Dental,). With DOL approval, CBP will implement greater granularity for edits/audits, for example, editing at the NPI/Taxonomy level and/or better distinction between group/individual providers to support accurate duplicate checking. The NPI will be required for all providers’ enrolling as a “Group” as well as required for all providers within the group. The NPI for group providers will be used in the editing of duplicate edits across bill types where applicable. The Contractorwill ensure that the group provider’s are required to bill with the NPI of the provider who performed the services, and referenced in Block-J of the OWCP-1500/HCFA-1500 billing form. If the provider billing is a group provider, and there is no NPI referenced in Block-J, the bill will be denied.

Edit and audit routines will be implemented as approved by the Government; the Contractor will not consolidate multiple edit routines into single edits without Government approval.

The following table is a summary of the DFEC edit groups and number of edits that apply to each group. These edits ensure that bills that do not meet Government business rules or policy are denied and bills that are not in conflict with policy proceed through bill processing activities.

Edits and audits are mechanisms used to implement business rules during the adjudication cycle. Below is the summary of edits and audits belonging to different groups with their counts as identified for the DFEC program. These edits help prevent bills with data that are in conflict with DOL’s policy into entering financials for payment. The list of edits along with DOL specific posting criteria are stated in appendix 7.2

To ensure continued bill processing accuracy, CBP will receive updated files from outside sources such as AMA/CPT, HCPCS, and ICD9/10. Updates may be received via subscription. When updates are received via subscription the Contractorwill compare current procedures and codes and compile the list of changes and maintenance required and forward to DOL for approval. The compare process is not dependent on the subscription, rather the completeness of the file received. DOL will review the submission and provide needed data elements. End-dates for deleted procedures should already be included in file sent to DOL for review. End dates for new procedures are expected to be programmed default settings (99/99/9999). After implementing updates to all affected tables, and upon completion of DOL and the Contractor testing, changes will be promoted to the production CBP environment.

Some updates are scheduled (yearly, bi-annually), others are by request. Updates can be full file updates (such as the yearly CPT load), or midyear changes (such as HCPCS added in the spring after the annual load). All updates will follow the CBP Change Management process, and once loaded will ensure proper bill disposition based on the latest approved procedure and diagnosis codes as the edit and audit routines match billed procedures and diagnosis against the latest file updates. The Contractorwill maintain reference files on old codes per effective date to ensure that edit and audit routines are applied correctly against date of service.

1.2.1.2 Dispositions in Edits and Audits

After bills process through edits and audits, the system assigns a status known as the disposition. The disposition is determined by the edits and audits posted against the bill and their outcome. Bills that are suspended for review and resolution may initially receive a disposition value of 1, but if conflicts are resolved and the bill successfully continues through processing to payment it will ultimately be assigned a disposition value of 4. If a bill is suspended for an edit that contains a “Super Suspend” disposition, which is resolved by a Resolution Specialist and the bill successfully continues through processing to payment, the edit will not re-suspend unless there are other issues with the bill, and the next edit in the hierarchical flow is also equal to a disposition of “1” (Super Suspend). If this is not the case, and based on other edits/audits for which the bill has posted, will result in the resolution systematically of one of the other disposition values 2, 3, 4, or 5. Below are the applicable disposition values:

Current

Disposition Value Current

Disposition Definition Current

Disposition Description Future

Disposition

Definition

Pay

1.2.1.3 EOBs

When a bill is denied or a reduction in payment occurs, all edits and audits that posted against the bill have a corresponding Explanation of Benefit (EOB) message that provides the provider/claimant/CBP staff with details explaining the reason for the denial/cut-back. Multiple EOBs may be assigned to each edit and audit, as required, to provide additional clarification regarding bill conflicts/errors. Each Edit/Audit will have an assigned EOB message that is systematically generated concurrently if the Edit/Audit is denied, or services are cut-back as well as other limitations in payment. However, in addition to the assigned EOB messages for each edit/audit, the Resolution Specialist will have access to the other EOB messages that can be utilized or selected to provide the provider/claimant with additional information for which the assigned EOB message to the edit/audit may not fully disseminate. Authorized users will have access to EOB messages displayed through the portal and claimants and providers will also receive EOBs on their remittance voucher. In addition, EOBs will be presented to Bill Resolution staff through work queues to assist in timely resolution of pended bills.

CBP provides flexibility with regard to modifying EOB verbiage, which will be done upon request and approval from the Government. Additional EOBs or modifications to existing EOBs will be handled through the CBP Change Management Process. Updates include, but are not limited to:

· Modify/Add Edit/Audit

· Modify/Add EOB

· Modify/Add Edit/Audit Disposition

The Contractorwill maintain an audit trail of EOB changes to show who, what, and when EOB changes were made. The CBP system will not only maintain the internal logs of individuals that made the changes to the system, but also maintain an audit trail of who (OWCP staff) requested and approved the EOB change, or any changes to the system. All system changes should follow the change management process, as approved by DOL.

1.2.1.4 Bill Types

Edit/audit routines will be based on program rules and also be applied based on the bill type. The CBP system will recognize the seven current bill types as follows:

PPA1

PPA2

1.2.1.5 Error Location

Error location is the level at which Edits/Audits are posted on the bill. This can be at the header, line or both header/line levels. This criterion is determined based on the location of the bill data in the respective bill types. The error location value for the DFEC edits with respect to bill type and disposition are captured in Appendix 7.5

1.2.2 Bills Submission Process

Medical, Pharmacy Bills for OWCP are submitted to the CBP system through various formats (i.e., paper forms, scanned image, HIPAA) and input sources (Mailroom, Call Center, Web Portal, EDI). Provider scanned bills are captured via OCR and processed as a batch file submission to the system. Paper forms undergo Key from Image process. Certain real time validation edits are invoked to prohibit invalid data capture during the bill submission process.

1.2.3 Bills Load Process

All bills, including adjustment and void/credit, entering the Central Bill Processing system will undergo data and business rules validation. Exception handling at the file level load process will occur real-time, through the acknowledgement response. Bills entered into the system through Key From Image process will also be subjected to real-time front end edits. Bills that are missing any mandatory information will be returned to the provider. The data insertion of bills in the CBP database will be driven by business as well as mapping rules. A unique bill number called TCN (Transaction Control Number) will be generated for each bill that gets successfully loaded into the system. Bills may have pre-validation edits posted on them on completion of the load process and will be ready to be transmitted for batch processing.

1.2.4 Bills Adjudication Process

Bill adjudication is a batch process. The process picks up all eligible bills in the appropriate status. All program specific edits are invoked based on edits group and hierarchy. Below are a few rules of disposition hierarchy:

· Header level super suspension disposition supersedes the header level auto denial and suspend disposition.

· Line level super suspension disposition supersedes the line level auto denial and suspend disposition.

· Post and pay disposition is mutually exclusive to auto denial disposition.

· If the Header level contains an edit/audit, and the disposition is equal to an auto denial disposition, and there is also an edit in the Header level and the disposition is equal to a “3” or “1”, although the header contains an auto deny edit/audit disposition (2), the bill still needs to Super-Suspend or Suspend so that the Resolution Specialist can review the bill and make changes/corrections if applicable that would potentially clear the “Auto Denied Edit/Audit during the next batch cycle.

· If the Line Level contains an edit/audit, and the disposition is equal to an auto denial disposition, and there is also an edit in the same Line Level and the disposition is equal to a “3” or “1”, although the line contains an auto deny edit/audit (2), the bill still needs to Super-Suspend or Suspend so that the Resolution Specialist can review the bill and make changes/corrections if applicable that would potentially clear the “Auto Denied Edit/Audit during the next batch cycle.

Processing rules for each of the programs are not the same (refer to bills processing and reference section for processing logic details). Post adjudication will produce a bill in a paid, denied or suspended status.

The Resolution/Adjustment Specialist is responsible for processing all bills that are in a suspend status. Based upon edit and bill type, the edits from suspended bills will be assigned to various locations. The Resolution /Adjustment Specialists will work on these edits by 1) correcting the bill data found as a result of incorrect data entry process, 2) Manual pricing the bill, 3) Forcing/Denying/Releasing applicable edits. Release of edits can be at line or header level. Once the edits are worked, the bill will go through the batch process to adjudicate into either a paid or denied status. The bill will go through the batch process to adjudicate into either a “paid”, “denied”, “re-suspended” status. The paid/denied/suspended bill lines will appear on the remittance voucher of the subsequent payment cycle.

Duplicate check through edits 101 to 105 is one of the important groups in edits and audits. This affects the following bill types:

· Inpatient – UB-04

· Prompt Pay – OWCP-1500

· Physician – OWCP-1500

· Outpatient – UB-04

· Pharmacy – (Is real-time and only subjected to exact duplicate denials)

· Dental

· Travel

This process will take into consideration the following and will be specific in the validation criteria for each bill type as stated in OWCP-DFEC DUPLICATE VALIDATION PROCESSING 032211.doc:

· Claimants Case Number (s)

· Provider Number

· Group Providers based on the NPI number referenced in Block 24J of the HCFA- 1500/OWCP-1500

· Dates of Services

· CPT/HCPC Procedure Codes, NDC, and RCC codes

· Modifiers (in all applicable positions)

· Billed Diagnosis codes and assigned pointers (where applicable per specific bill type)

· Billed Amounts (a single or each line item billed compared to a history, or within the same bill)

· Identification across bill types (Outpatient, and Physician) billings which uses CPT/HCPC coding to generate pricing criteria.

Limits related edits are implemented through service limitation edits. The criteria details for each edit are compiled in Appendix 7.4 Prompt Pay bills will be subjected to specific business rules. The disposition of most of the edits applicable to prompt pay is set to “5” which enables the system to adjudicate such bills in a short cycle. Bills loaded into the system as “History only” will not be processed through normal bill processing logic. They are prepaid bills and come into the system as history records. The payment cycle will generate zero payments for these kinds of bills. Once these bills reach the finalized stage, the payment cycle process is the same as for other bills.

1.3 Edits & Audits Business Process Flow – DFEC

The following diagrams capture the DFEC Edits & Audits Business Process flow.

1.3.1 Edits and Audits Overview Workflow

This diagram provides the details on how edits and audits from different groups get invoked during bill processing. Edits and audits are associated with the processes marked with highlighted text in Green.

1.3.2 Edits and Audits in Bill Processing Workflow

This diagram provides a general understanding of edits and audits in the adjudication cycle.

NOTE: The details of the inpatient and outpatient processing flows have been captured in Process Flow 3.2 and 3.3 of Section 18 (Bill Pricing) RSD. All Inpatient bills will be subjected to the DRG grouper. Only Inpatient bills submitted by an acute hospital will price DRG, and require a Medicare number on file in order to price. For all other inpatient bills submitted, they will obtain a DRG using a 'dummy' Medicare schedule that allows these bills to obtain a DRG code, but will not render a DRG price. These bills will price either pay as billed or CCR, based on the type of provider they are.

2 Edits & Audits – DEEOIC

2.1 Edits & Audits Overview – DEEOIC

The CBP includes a comprehensive series of automated edits and audits that act as control points to dictate the ultimate disposition of the bill (approved, denied, or pended). The CBP will provide greatly increased throughput of bills with bill data being validated at multiple points in the adjudication process. These multiple validations include validation at the EDI gateway, Front End Process (Mailroom), Web Portal, duplicate identification across bill types and procedural categories within the CBP. Bills that should not be approved for payment which do not meet the policies as set forth in the defined disposition criteria of each edit/audit will be edited out quickly,. Bills that pass all policies set forth in the edit/audit disposition hierarchical flow will be processed automatically for payment, or denial. Bills that do not pass the edit/audit policy dispositions will be suspended and dispersed to assigned work queues based on defined disposition criteria for each edit/audit as designed for each DOL program.

Each of the three DOL programs requires specific edits and audits to determine when a bill should be denied or suspended (pended) for manual review. The CBP will provide automated routing of bills to work queues, which will improve timeliness and reduce rework while providing tailored Explanation of Benefit (EOB) messages.

The edit process is applied to an individual bill while the audit process is applied across bill history and other applicable data such as authorizations. Bills with a pend status will be automatically re-adjudicated once the items causing the pend status have been resolved. The DOL programs require bill editing functions including but not limited to: provider and claimant eligibility, validity of submitted procedure (including NDC) and diagnosis codes, accepted eligible condition to both the billed diagnosis and billed procedures, authorizations, service limitations (accumulators), duplicate bill identification and category, fee schedule limitations, and other configurable dollar limitations (dollar limit accumulators), CCI edits and audits for more than 140,000 sets of comprehensive-component and mutually exclusive code pairings, as well as other edits and audits supported by configurable rules and setup options inherent in the CBP.

Each program will have its own set of edits and audits, edits and audits flow, and allowance for multiple EOB remarks per edit and audit, each with their own corresponding bill disposition messages. The EOB messages will be configured during implementation to provide specific text, and will be easily configured during the operations phase, at DOL’s request. The edits and audits will be easily configurable as well, and will be assigned an outcome of suspend, auto deny, or auto pay to render specific bill dispositions per each Program’s requirements. It will also ensure that for all edits/audits set to auto deny, the Resolution Specialist will have the capability of changing the status to “Override the decision”, or for edits/audits set to auto pay, the Resolution Specialist will have the capability to “Manually Deny” the edit/audit to change the decision from a “Pay” when a bill is posted with a suspended edit at appropriate header or line level. For all edit/audits set to suspend, the Resolution Specialist will have the capability in this category to “Pay” or “Deny” the edit using an assigned indicator “Force” (F), “Deny” (D)”.

The CBP solution will provide the flexibility necessary to implement improvements in distinguishing duplicates (e.g., exact, potential, possible conflict). The Contractor will perform continual analysis on all editing, and recommend to DOL criteria be added or removed from the duplicate editing/auditing process as observed from billing analysis. The Contractor will disposition all edits/audits, including duplicates, per Government direction, and in the event of bills suspended for manual review, implement Government approved disposition processing of these bills. The Contractor’s duplicate edit solution will also address multiple bills within a medical provider group practice that have the same case, diagnosis, and dates of service. The Contractor will ensure that the edit/audit routines are established at the appropriate granular level to accurately detect duplicates in this scenario. The Contractor will also ensure that the same services are not being billed by both physician and outpatient facilities by crosschecking duplicates between HCFAs and UB04s (e.g., RCCs billed that crosswalk to a CPT/HCPCS).

The CBP solution and all of its components will be fully integrated to support all aspects of medical bill processing, from data entry to transmission of payment files, and all functionality in between. The Contractor will configure the CBP, specifically its step engine process, to ensure all processing routines are coordinated with other functions (e.g., data entry, transmission of payment files, authorization of services, and other appropriate functions), to yield efficient, accurate bill disposition.

To support the edit and audit process, the Contractor will also apply external files (e.g., Programs and validation tables) at DOL’s direction, using automated loader utilities of the CBP to efficiently and accurately load data. The Contractor will run these updates through its configuration management process, ensuring they are fully tested and meet DOL’s expectations prior to loading to Production. The Contractor will use this flexible setup to configure DOL specific requirements (e.g., bill/bill type, service type, provider type, etc.) with date driven assignments of various values and rules providing high granularity and specificity of the edits and audits. The sets of CBP edits and audits will be modified over time, maintaining the history, but also updating any other system components that use this template, providing easy, fast and inexpensive global maintenance.

As part of overall continuous improvement, the Contractor will study operational trends and billing patterns, examining edit/audit posting frequencies, and recommend to DOL changes to the edit/audit routine that will further automate and make efficient the bill processing function. The Contractor will also update the edit and audit processes to keep current with modified business practices, and provide guidance to DOL on practices that would enhance the accuracy, timeliness, and cost effectiveness of processing.

The CBP will automatically populate work queues as appropriate based on the edit/audit assignment in the hierarchical flow, as well as the disposition indicator set for each edit. On the basis of security roles and privileges, the Contractor’s Operations staff will access work queues in the CBP to process such items as bills, provider enrollments, and authorizations. On the basis of security roles and privileges, external users, such as DOL, will directly access work queues via the CBP Web Portal.

2.2 Edits & Audits Business Process Description – DEEOIC

2.2.1 Components of Edits and Audits Process

2.2.1.1 Invoking Edits and Audits in Bill Processing

Edits and audits are used to implement each program’s business rules during the prepayment bill adjudication cycle. Edits/audits and their specific posting criteria are implemented at the program level, enabling customized EOBs and edit dispositions for each OWCP program. The edit/audit algorithms will be organized so that edits and audits fire in a logical sequence ensuring efficient and cost-effective automated processing. For example, an edit/audit algorithm may check data validity first (including timely submission and inclusion of required attachments), followed by claimant and provider eligibility, then validation of procedure/diagnosis, treatment suites, authorizations, fee schedule, CCI, duplicate check and utilization review. Bills that fail the initial validity check (e.g., claimant or provider not eligible, invalid procedure code, etc.) are automatically denied and follow the appropriate RTP or RTC process.

Categories of edits and audits that are supported in CBP include:

· Claimant Eligibility

· Provider Eligibility

· Duplicate checks across all bill types (e.g., HCFA-1500 and UB-04 outpatient facility bills)

· Data validity checks against diagnosis and procedure (including NDC) codes

· Authorizations – required as designated for the service being billed

· Treatment Suites – to ensure that services billed are appropriate for diagnosis/accepted condition

· Service Limitations – controls the number of times a given service is payable over a specific period of time

· Medicare CCI – edits utilizing Medicare reference files to prevent improper payment when incorrect code combinations are used; check for comprehensive versus component codes, as well as mutually exclusive codes

· Edits to check for add-on codes to ensure a base/parent code is present when an add-on code is billed

· Age and/or gender edits will be applied against all reference codes to ensure consistency between the service billed and the claimants gender

· Fee schedule edits

· Other dollar limitations (e.g., Global Surgical Cut-backs, Multiple Surgical Cut-backs, and Unit of Services Cut-backs).

The edit and audit routines in CBP are defined by each program’s Edit/Audit Exhibit. In addition to dispositioning at the program level, edit and audit dispositions will be based on the specific bill type (i.e., Professional, Inpatient, Outpatient, Prompt Pay, Pharmacy, Travel and Dental,). With DOL approval, CBP will implement greater granularity for edits/audits, for example, editing at the NPI/Taxonomy level and/or better distinction between group/individual providers to support accurate duplicate checking. The NPI will be required for all providers’ enrolling as a “Group” as well as required for all providers within the group. The NPI for group providers will be used in the editing of duplicate bills across bill types where applicable. The Contractor will ensure that the group provider’s are required to bill with the NPI of the provider who performed the services, and referenced in Block-J of the OWCP-1500/HCFA-1500 billing form. If the provider billing is a group provider, and there is no NPI referenced in Block-J, the bill will be denied.

Edit and audit routines will be implemented as approved by the Government; the Contractor will not consolidate multiple edit routines into single edits without Government approval.

The following table is a summary of the DEEOIC edit groups. These edits ensure that bills that do not meet Government business rules or policy are denied and bills that are not in conflict with policy proceed through bill processing activities.

Edits and audits are mechanisms used to implement business rules during the adjudication cycle. Below is the summary of edits and audits belonging to different groups identified for the DEEOIC program. These edits help prevent bills with data that are in conflict with DOL’s policy into entering financials for payment. The list of edits along with DOL specific posting criteria are stated in appendix 7.7 Edit and Audit Groups

DEEOIC DIAGNOSIS

DEEOIC PROCEDURE VALIDITY

DEEOIC SERVICE LIMITATION

CLAIMANT ELIGIBILITY

DEEOIC PROVIDER

DEEOIC DATE OF SERVICE/OTHER DATE VALIDATION

DEEOIC AUTHORIZATION

DEEOIC CCI

DEEOIC TOTAL AND LINE CHARGE

DEEOIC ADJUSTMENT

DEEOIC DENTAL

DEEOIC MODIFIER

DEEOIC DUPLICATE

GLOBAL SURGERY

DEEOIC TIMELY

DEEOIC BILL ATTACHMENT REQUIREMENT

DEEOIC UNITS OF SERVICES

DEEOIC MULTIPLE SURGERY/ANESTHESIA CUTBACK

To ensure continued bill processing accuracy, CBP will receive updated files from outside sources such as AMA/CPT, HCPCS, and ICD9/10. Updates may be received via subscription. When updates are received via subscription the Contractor will compare current procedures and codes and compile the list of changes and maintenance required and forward to DOL for approval. DOL will review the submission and provide needed data elements. End-dates for deleted procedures should already be included in the file sent to DOL for review. End dates for new procedures are expected to be programmed default settings (99/99/9999). After implementing updates to all affected tables, and upon completion of DOL and Contractor testing, changes will be promoted to the production CBP environment.

Some updates are scheduled (yearly, bi-annually), others are by request. Updates can be full file updates (such as the yearly CPT load), or midyear changes (such as HCPCS added in the spring after the annual load). All updates will follow the CBP Change Management process, and once loaded will ensure proper bill disposition based on the latest approved procedure and diagnosis codes as the edit and audit routines match billed procedures and diagnoses against the latest file updates. The Contractor will maintain reference files on old codes per effective date to ensure that edit and audit routines are applied correctly against date of service.

2.2.1.2 Dispositions in Edits and Audits

After bills process through edits and audits, the system assigns a status known as the disposition. Bills that are suspended for review and resolution may initially receive a disposition value of 1, but if conflicts are resolved and the bill successfully continues through processing to payment it will ultimately be assigned a disposition value of 4. If a bill is suspended for an edit that contains a “Super Suspend” disposition, which is resolved by a Resolution Specialist and the bill successfully continues through processing to payment, the edit will not re-suspend unless there are other issues with the bill, and the next edit in the hierarchical flow is also equal to a disposition of “1” (Super Suspend). If this is not the case, and based on other edits/audits for which the bill has posted, it will result in the resolution systematically of one of the other disposition values 2, 3, 4, or 5. Below are the applicable disposition values:

Current

Disposition Value Current

Disposition Definition Current

Disposition Description Future

Disposition

Definition

Pay

2.2.1.3 EOBs

When a bill is denied or a reduction in payment occurs, all edits and audits that posted against the bill have a corresponding Explanation of Benefit (EOB) message that provides the provider/claimant/CBP staff with details explaining the reason for the denial/cut-back. Multiple EOBs may be assigned to each edit and audit, as required, to provide additional clarification regarding bill conflicts/errors. Each Edit/Audit will have an assigned EOB message that is systematically generated if the Edit/Audit is denied, or services are cut-back as well as other limitations in payment. However, in addition to the assigned EOB messages for each edit/audit, the Resolution Specialist will have access to other EOB messages that can be utilized or selected to provide the provider/claimant with additional information which the EOB message assigned to the edit/audit may not fully describe. Authorized users will have access to EOB messages displayed through the portal and claimants and providers will also receive EOBs on their remittance vouchers. In addition, EOBs will be presented to Bill Resolution staff through work queues to assist in timely resolution of pended bills.

CBP will provide flexibility with regard to modifying EOB verbiage--which will be done upon request and approval from the Government. Additional EOBs or modifications to existing EOBs will be handled through the CBP Change Management Process. Updates include, but are not limited to:

· Modify/Add Edit/Audit

· Modify/Add EOB

· Modify/Add Edit/Audit Disposition

The Contractor will maintain an audit trail of EOB changes to show who, what, and when EOB changes were made. The CBP system will not only maintain the internal logs of individuals that made the changes to the system, but also maintain an audit trail of who (OWCP staff) requested and approved the EOB change, or any changes to the system. All system changes should follow the change management process, as approved by DOL.

2.2.1.4 Bill Types

Edit/audit routines will be based on program rules and also be applied based on the bill type. The CBP system will recognize the seven current bill types as follows:

PPA1

PPA2

2.2.1.5 Error Location

Error location is the level at which Edits/Audits are posted on the bill. This can be at the header, line or both header/line levels. This criterion is determined based on the location of the bill data in the respective bill types. The error location value for the DEEOIC edits with respect to bill type and disposition are captured in Appendix 7.5

2.2.2 Bills Submission Process

Medical and Pharmacy Bills for OWCP are submitted to the CBP system through various formats (i.e., paper forms, scanned image, HIPAA) and input sources (Mailroom, Call Center, Web Portal, EDI). Provider bills are captured via OCR and processed as a batch file submission to the system. Paper forms may also undergo a “Key from Image” process. Certain real time validation edits are invoked to prohibit invalid data capture during the bill submission process.

2.2.3 Bills Load Process

All bills, including adjustment and void/credit, entering the Central Bill Processing system will undergo data and business rules validation. Exception handling at the file level load process will occur real-time, through the acknowledgement response. Bills entered into the system through Key From Image process will also be subjected to real-time front end edits. Bills that are missing any mandatory information will be returned to the provider. The data insertion of bills in the CBP database will be driven by business as well as mapping rules. A unique bill number called TCN (Transaction Control Number) will be generated for each bill that gets successfully loaded into the system. Bills may have pre-validation edits posted on them on completion of the load process and are ready to be transmitted for batch processing.

2.2.4 Bills Adjudication Process

Bill adjudication is a batch process. The process picks up all eligible bills in the appropriate status. All program specific edits are invoked based on edits group and hierarchy. Below are a few rules of disposition hierarchy:

· Header level super suspension disposition supersedes the header level auto denial, and suspend disposition.

· Line level super suspension disposition supersedes the line level auto denial andsuspend disposition.

· If the Header level contains an edit/audit, and the disposition is equal to an auto denial disposition, and there is also an edit in the Header level and the disposition is equal to a “3” or “1”, although the header contains an auto deny edit/audit disposition (2), the bill still needs to Super-Suspend or Suspend so that the Resolution Specialist can review the bill and make changes/corrections if applicable that would potentially clear the “Auto Denied Edit/Audit during the next batch cycle.

· If the Line Level contains an edit/audit, and the disposition is equal to an auto denial disposition, and there is also an edit in the same Line Level and the disposition is equal to a “3” or “1”, although the line contains an auto deny edit/audit (2), the bill still needs to Super-Suspend or Suspend so that the Resolution Specialist can review the bill and make changes/corrections if applicable that would potentially clear the “Auto Denied Edit/Audit during the next batch cycle.

Processing rules for each of the programs are not the same (refer to bills processing and reference section for processing logic details). Post adjudication will produce a bill in a paid, denied or suspended status.

The Resolution/Adjustment Specialist is responsible for processing all bills that are in a suspend status. Based upon edit and bill type, the edits from suspended bills will be assigned to various locations. The Resolution Associates will work on these edits by 1) correcting the bill data found as a result of incorrect data entry process, 2) Manual pricing the bill, 3) Forcing/Denying/Releasing applicable edits. Release of edits can be at line or header level. Once the edits are worked, the bill will go through the batch process to adjudicate into either a “paid”, “denied”, or “re-suspended” status. The paid/denied/suspended bill lines will appear on the remittance voucher of the subsequent payment cycle.

Duplicate check through edits 101 to 105 is one of the most important groups in edits and audits. This affects the following bill types:

· Inpatient – UB-04

· Prompt Pay – OWCP-1500

· Physician – OWCP-1500

· Outpatient – UB-04

· Pharmacy – (Is real-time and only subjected to exact duplicate denials)

· Dental

· Travel

This process will take into consideration the following and be specific in the validation criteria for each bill type.

· Claimants Case Number (s)

· Provider Number

· Group Providers based on the NPI number referenced in Block 24J of the HCFA- 1500/OWCP-1500

· Dates of Services

· CPT/HCPC Procedure Codes, NDC, and RCC codes

· Modifiers (in all applicable positions)

· Billed Diagnosis codes and assigned pointers (where applicable per specific bill type)

· Billed Amounts (a single or each line item billed compared to a history, or within the same bill)

· Identification across bill types (Outpatient, and Physician) billings which uses CPT/HCPC coding to generate pricing criteria.

Limits related edits are implemented through service limitation edits. The criteria details for each edit is compiled in Appendix 7.9 Prompt Pay bills will be subjected to specific business rules. The disposition of most of the edits applicable to prompt pay is set as 5 which enables the system to adjudicate such bills in a short cycle. Bills loaded into the system as “History only” will not be processed through normal bill processing logic. These are prepaid bills and come into the system for records update purposes. The payment cycle will generate zero payments to these kinds of bills.