Section_18_Bill_Pricing_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Bill Pricing (Section 18)

Central Bill Process

Bill Pricing (PWS Section 18)

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 Bill Pricing – DFEC

51.1 Bill Pricing Overview – DFEC

61.2 Bill Pricing Business Process Description – DFEC

81.3 Bill Pricing Business Process Flow – DFEC

81.3.1 1500 Bill Pricing Flow

91.3.2 Inpatient UB Pricing Flow

101.3.3 Outpatient UB Pricing Flow

111.3.4 Travel Pricing Flow

Bill Pricing – DEEOIC

122.1 Bill Pricing Overview – DEEOIC

132.2 Bill Pricing Business Process Description – DEEOIC

152.3 Bill Pricing Business Process Flow – DEEOIC

152.3.1

162.3.2

172.3.3

182.3.4 Travel Pricing Flow: POV Mileage and Airfare

192.3.5 Travel Pricing Flow: Lodging and Incidentals

Bill Pricing – DCMWC

203.1 Bill Pricing Overview – DCMWC

213.2 Bill Pricing Business Process Description – DCMWC

233.3 Bill Pricing Business Process Flow – DCMWC

233.3.1

243.3.2

253.3.3

263.3.4 Treatment Travel Pricing Flow: POV Mileage

273.3.5 Treatment Travel Pricing Flow: Lodging and Incidentals

Bill Pricing Business Requirements

284.1 Functional Requirements

294.2 Business Rules

Bill Pricing Supporting Functional Components

385.1 Initial Data Migration

405.2 Interfaces

455.3 Reports

455.4 Letters

Constraints

466.1 Assumptions

466.2 Dependencies

466.3 Issues/Open Items

Appendices

477.1 Terms & Definitions

527.2 File Maintenance Schedule

1 Bill Pricing – DFEC

1.1 Bill Pricing Overview – DFEC

Bill Pricing processes will use Government-approved fee schedules based on national and industry standards. Fee schedules will be used to ensure that billed services are priced based on both valid procedure and modifier codes, including adjustments for geographic factors where appropriate.

Pricing logic may be unique to the OWCP programs, while some will depend on the type of bill, such as Inpatient vs. Outpatient bills. Bill Pricing also includes the capability to override a fee schedule based on provider-specific data, such as specific types of facilities which are designated “pay as billed”. When no provider-specific fee override data is identified, the standard evaluation is followed. Bill Pricing is dependent on the delivered service and supports both automated and manual pricing of bills. If there is no fee schedule defined, then payment will be up to the maximum amount allowed by the Government.

Bills will price according to their respective fee schedules based on the date of service. To support historical bills, the CBP will maintain historical Fee Schedule files from 1974 through the period of performance of this contract.

CBP will also support Rental vs. Purchase policies by following government policies and utilizing appropriate reference files. Personal appliances (devices) are considered purchase items since they are not reusable, whereas non-personal appliances (equipment) are considered reusable and conducive to allowing rental.

The Contractor will develop and implement all Government-approved pricing mechanisms and algorithms to include RVU, DRG, CCR, OPPS, AWP, Claimant Travel based on Government-approved rates, and Prompt Pay Services based on contract-set maximums.

1.2 Bill Pricing Business Process Description – DFEC

The Contractor will develop and implement all Government-approved pricing mechanisms and algorithms to include RVU, DRG, CCR, OPPS, AWP, Claimant Travel based on Government-approved rates, and Prompt Pay Services based on contract-set maximums.

A combination of factors/criteria determines the pricing to be used on each bill as it is processed, with the ability to override each bill price based on provider specific data. When no provider exceptions exist to cause an override the pricing will default to the appropriate fee schedule.

Bill pricing methodologies will be implemented that address professional services using the RVU scale (RBRVS) pricing with geographic adjustment factors based on regional factors taking into account place of service and modifiers; outpatient services using OPPS; inpatient services using DRG and CCR pricing for DFEC and DEEOIC; AWP plus dispensing fee method for pharmacy services. In addition, pricing can support flat rate, percent of billed, per diems, ASC, pay as billed, contract set maximums, claimant travel at Government approved rates, and other bill pricing scenarios.

Industry standard code sets to be implemented include ICD-9/10, CPT-4, HCPCS, DRG codes, NDC codes, Anesthesia Codes, and RCC CODES. Additionally, the Contractor will configure the fee schedule tables to support Prompt Pay pricing at contract-set maximums. Prompt Pay bills will be identified as their own bill type in CBP, and processing will drive these bills to their respective fee schedules to price at contract-set maximums. If modifier logic is applicable, and if the bill contains a modifier that affects pricing, the payment will be adjusted accordingly.

As part of the pricing process, the Contractor will include effective from and through dates on all fee schedules and codes to validate against the date of service on the bill to ensure accurate processing.

Manual pricing is also supported in CBP, allowing manual entry of the price on the bill line itself. Manual pricing of procedures will be documented in the Bill Resolution Procedure Manual to be developed for the CBP medical bill suspense processing.

Further, the pricing methodologies that CBP will operate include professional services using the RVU scale (RBRVS) pricing with geographic adjustment factors (GAFs) that link the provider’s zip codes to metropolitan statistical areas (MSA). Professional fee schedules will also take into account place of service and modifier differentials as approved by the government.

Both historical data and current data will be imported using existing utility tools. These same tools will be used going forward and will include any structural changes needed to meet future requirements. Additionally, the system will automatically drive to a default fee schedule assignment in the absence of other determining factors (provider specific scenarios).

The entire pricing process takes place as part of the adjudication processing, which includes the edit/audit process and is automatic with the option to pend or deny based on specific criteria determined by the system configuration. Bills determined to not be valid, based on claimant eligibility and covered services, are not priced. The result is bill pricing against components that are appropriate for the date of service of the bill, ensuring that as things change over time, you can maintain historical results and also easily perform maintenance and updates to the applicable components. The specific criteria to drive to the appropriate fee schedule for a provider include, but are not limited to, provider (hospital or individual provider), specific provider ID, provider network level, provider type and specialty, and user configurable criteria, which are defined objects in the database. Fee schedules may also be uniquely driven based on type of service, modifier, place of service, and zip code. CBP will support payment up to a maximum allowable amount in the event fee schedules are not defined for such medical services as home health, prosthetics, orthotics, dental, and claimant travel. The system can also automatically drive to a pay as billed fee schedules for bills that meet specific Government-approved criteria.

Through rules-based configurations, the Contractor will ensure that for the DFEC and DEEOIC programs, only Inpatient services billed by acute care hospitals are subjected to Medicare PPS/DRG pricing via the 3M Grouper/Pricer. Prior to calling the 3M Grouper/Pricer, CBP will validate that the acute care hospital is not a Federal facility. If it is a Federal facility, the bill will not be sent to the 3M Grouper/Pricer and will be priced using the “pay as billed” fee schedule. If it is determined that the acute care hospital is not a Federal facility, the 3M Grouper/Pricer will be invoked in a real-time call. CBP will pass the 3M Grouper/Pricer information including, but not limited to, the Medicare number, date of service, diagnosis, and surgical procedure codes from the bill. This information is used to determine the DRG code and the appropriate schedule to price the bill. If a schedule is found, and a DRG is obtained, CBP will price the bill incorporating Government-specified reimbursement formulae, capping the DRG price at 120 percent of the billed amount. The Contractor will also implement and operate the cost-to-charge ratio (CCR) pricing methodology for inpatient hospital facilities exempt from the DRG methodology. Additionally, the Contractor will “pay as billed” specific facilities without subjecting them to DRG and/or CCR pricing, including Maryland and Federal hospitals, skilled nursing/intermediate care/assisted living facilities, boarding homes and nursing homes. It is known that not all Maryland hospitals are subject to pay as billed. The Contractor will work with DOL to identify those regulated by the Maryland Health Services Cost Review Commission that has negotiated a facility-specific cost-based rate with HHS and they are consequently paid as billed.

Starting with CBP go-live, all outpatient bills received on a UB-04 should be submitted through OPPS. For historical bills, CBP will perform a crosswalk of medical treatment procedure codes submitted on a UB-04 bill (RCC) to a CPT or HCPC code including modifiers. Where appropriate, the Contractor will price based on RVU and dollar conversion factors during the submission of adjustments for historical bills. The Contractor will implement and integrate OPPS with the default configurations and algorithms as part of Build 1 functionality. The Contractor will work with DOL to customize and implement the configurations and algorithms throughout SIT. As the configurations and algorithms are finalized, the appropriate documentation (RSDs and pricing exhibits) will be updated.

As part of the fee schedule maintenance process, the Contractor will obtain updates as they become available from outside sources including but not limited to CMS fee schedules, 3M DRG Grouper/Pricer, AMA Procedure file and drug reference files (TC, NDC, GCN), and will apply update files to the CBP relational database only upon approval of the Government.

1.3 Bill Pricing Business Process Flow – DFEC

The following diagrams capture the DFEC Bill Pricing Business Process flow:

1.3.1 1500 Bill Pricing Flow

1.3.2 Inpatient UB Pricing Flow

1.3.3 Outpatient UB Pricing Flow

1.3.4 Travel Pricing Flow

2 Bill Pricing – DEEOIC

2.1 Bill Pricing Overview – DEEOIC

Bill Pricing processes use Government-approved fee schedules based on national and industry standards. Fee schedules will be used to ensure that billed services are priced based on both valid procedure and modifier codes, including adjustments for geographic factors where appropriate.

Pricing logic may be unique to the OWCP programs, while some will depend on the type of bill, such as Inpatient vs. Outpatient bills. Bill Pricing also includes the capability to override a fee schedule based on provider-specific data, such as specific types of facilities which are designated “pay as billed”. When no provider-specific fee override data is identified, the standard evaluation is followed. Bill Pricing is dependent on the delivered service and supports both automated and manual pricing of bills. If there is no fee schedule defined, then payment will be up to the maximum amount allowed by the Government.

Bills will price according to their respective fee schedules based on the date of service. To support historical bills, the CBP will maintain historical Fee Schedule files from 1974 through the period of performance of this contract.

CBP will also support Rental vs. Purchase policies by following government policies and utilizing appropriate reference files. Personal appliances (devices) are considered purchase items since they are not reusable, whereas non-personal appliances (equipment) are considered reusable and conducive to allowing rental.

The Contractor will develop and implement all Government-approved pricing mechanisms and algorithms to include RVU, DRG, CCR, OPPS, AWP, Claimant Travel based on Government-approved rates, and Prompt Pay Services based on contract-set maximums.

2.2 Bill Pricing Business Process Description – DEEOIC

The Contractor will develop and implement all Government-approved pricing mechanisms and algorithms to include RVU, DRG, CCR, OPPS, AWP, Claimant Travel based on Government-approved rates, and Prompt Pay Services based on contract-set maximums.

A combination of factors/criteria determines the pricing to be used on each bill as it is processed, with the ability to override each bill price based on provider specific data. When no provider exceptions exist to cause an override the pricing will default to the appropriate fee schedule.

Bill pricing methodologies will be implemented that address professional services using the RVU scale (RBRVS) pricing with geographic adjustment factors based on regional factors taking into account place of service and modifiers; outpatient services using OPPS; inpatient services using DRG and CCR pricing for DEEOIC; AWP plus dispensing fee method for pharmacy services. In addition, pricing can support flat rate, percent of billed, per diems, ASC, pay as billed, contract set maximums, claimant travel at Government approved rates, and other bill pricing scenarios.

Industry standard code sets to be implemented include ICD-9/10, CPT-4, HCPCS, DRG codes, NDC codes, Anesthesia Codes, and RCC CODES. Additionally, the Contractor will configure the fee schedule tables to support Prompt Pay pricing at contract-set maximums. Prompt Pay bills will be identified as their own bill type in CBP, and processing will drive these bills to their respective fee schedules to price at contract-set maximums. If modifier logic is applicable, and if the bill contains a modifier that affects pricing, the payment will be adjusted accordingly.

As part of the pricing process, the Contractor will include effective from and through dates on all fee schedules and codes to validate against the date of service on the bill to ensure accurate processing.

Manual pricing is also supported in CBP, allowing manual entry of the price on the bill line itself. Manual pricing of procedures will be documented in the Bill Resolution Procedure Manual to be developed for the CBP medical bill suspense processing.

Further, the pricing methodologies that CBP will operate include professional services using the RVU scale (RBRVS) pricing with geographic adjustment factors (GAFs) that link the provider’s zip codes to metropolitan statistical areas (MSA). Professional fee schedules will also take into account place of service and modifier differentials as approved by the government.

Both historical data and current data will be imported using existing utility tools. These same tools will be used going forward and will include any structural changes needed to meet future requirements. Additionally, the system will automatically drive to a default fee schedule assignment in the absence of other determining factors (provider specific scenarios).

The entire pricing process takes place as part of the adjudication processing, which includes the edit/audit process and is automatic with the option to pend or deny based on specific criteria determined by the system configuration. Bills determined to not be valid, based on claimant eligibility and covered services, are not priced. The result is bill pricing against components that are appropriate for the date of service of the bill, ensuring that as things change over time, you can maintain historical results and also easily perform maintenance and updates to the applicable components. The specific criteria to drive to the appropriate fee schedule for a provider include, but are not limited to, provider (hospital or individual provider), specific provider ID, provider network level, provider type and specialty, and user configurable criteria, which are defined objects in the database. Fee schedules may also be uniquely driven based on type of service, modifier, place of service, and zip code. CBP will support payment up to a maximum allowable amount in the event fee schedules are not defined for such medical services as home health, prosthetics, orthotics, dental, and claimant travel. The system can also automatically drive to a pay as billed fee schedules for bills that meet specific Government-approved criteria.

Through rules-based configurations, the Contractor will ensure that for the DEEOIC program, only Inpatient services billed by acute care hospitals are subjected to Medicare PPS/DRG pricing via the 3M Grouper/Pricer. Prior to calling the 3M Grouper/Pricer, CBP will validate that the acute care hospital is not a Federal facility. If it is a Federal facility, the bill will not be sent to the 3M Grouper/Pricer and will be priced using the “pay as billed” fee schedule. If it is determined that the acute care hospital is not a Federal facility, the 3M Grouper/Pricer will be invoked in a real-time call. CBP will pass the 3M Grouper/Pricer information including, but not limited to, the Medicare number, date of service, diagnosis, and surgical procedure codes from the bill. This information is used to determine the DRG code and the appropriate schedule to price the bill. If a schedule is found, and a DRG is obtained, CBP will price the bill incorporating Government-specified reimbursement formulae, capping the DRG price at 120 percent of the billed amount. The Contractor will also implement and operate the cost-to-charge ratio (CCR) pricing methodology for inpatient hospital facilities exempt from the DRG methodology. Additionally, the Contractor will “pay as billed” specific facilities without subjecting them to DRG and/or CCR pricing, including Maryland, Cancer, Federal hospitals, skilled nursing/intermediate care/assisted living facilities, boarding homes and nursing homes. It is known that not all Maryland hospitals are subject to pay as billed. The Contractor will work with DOL to identify those regulated by the Maryland Health Services Cost Review Commission that has negotiated a facility-specific cost-based rate with HHS and they are consequently paid as billed.

Starting with CBP go-live, all outpatient bills received on a UB-04 should be submitted through OPPS. For historical bills, CBP will perform a crosswalk of medical treatment procedure codes submitted on a UB-04 bill (RCC) to a CPT or HCPC code including modifiers. Where appropriate, the Contractor will price based on RVU and dollar conversion factors during the submission of adjustments for historical bills. The Contractor will implement and integrate OPPS with the default configurations and algorithms as part of Build 1 functionality. The Contractor will work with DOL to customize and implement the configurations and algorithms throughout SIT. As the configurations and algorithms are finalized, the appropriate documentation (RSDs and pricing exhibits) will be updated.

As part of the fee schedule maintenance process, the Contractor will obtain updates as they become available from outside sources including but not limited to CMS fee schedules, 3M DRG Grouper/Pricer, AMA Procedure file and drug reference files (TC, NDC, GCN), and will apply update files to the CBP relational database only upon approval of the Government.

2.3 Bill Pricing Business Process Flow – DEEOIC

The following diagrams capture the DEEOIC Bill Pricing Business Process flow:

2.3.1 1500 Bill Pricing Flow

2.3.2 Inpatient UB Pricing Flow

2.3.3 Outpatient UB Pricing Flow

2.3.4 Travel Pricing Flow: POV Mileage and Airfare

2.3.5 Travel Pricing Flow: Lodging and Incidentals

3 Bill Pricing – DCMWC

3.1 Bill Pricing Overview – DCMWC

Bill Pricing processes use Government-approved fee schedules based on national and industry standards. Fee schedules will be used to ensure that billed services are priced based on both valid procedure and modifier codes, including adjustments for geographic factors where appropriate.

Pricing logic may be unique to the OWCP programs, while some will depend on the type of bill, such as Inpatient vs. Outpatient bills. Bill Pricing also includes the capability to override a fee schedule based on provider-specific data, such as specific types of facilities which are designated “pay as billed”. When no provider-specific fee override data is identified, the standard evaluation is followed. Bill Pricing is dependent on the delivered service and supports both automated and manual pricing of bills.

Bills will price according to their respective fee schedules based on the date of service. To support historical bills, the CBP will maintain historical Fee Schedule files from 1974 through the period of performance of this contract.

CBP will also support DCMWC specific pricing rules such as ‘I’ Logic, by following government policies and utilizing appropriate reference files.

3.2 Bill Pricing Business Process Description – DCMWC

The Contractor will develop and implement all Government-approved pricing mechanisms and algorithms to include ‘I’ (inpatient) Logic, OPPS, AWP, Claimant Travel based on Government-approved rates, Prompt Pay Services, and professional services based upon DCMWC fee schedules.

A combination of factors/criteria determine the pricing to be used on each bill as it is processed, with the ability to override each bill price based on provider specific data. When no provider exceptions exist to cause an override the pricing will default to the appropriate fee schedule.

Bill pricing methodologies will be implemented that address professional services using fee schedules derived from the Philadelphia MSA, and taking into account modifiers; outpatient services using OPPS; inpatient services using ‘I’ Logic ;and AWP plus dispensing fee method for pharmacy services. In addition, pricing can support claimant travel at Government approved rates, prompt pay fee schedules, and other bill pricing scenarios.

Industry standard code sets to be implemented include ICD-9/10, CPT-4, HCPCS, GCN codes, and RCC CODES. Additionally, the Contractor will configure the fee schedule tables to support Prompt Pay pricing. Prompt Pay bills will be identified as their own bill type in CBP, and processing will drive these bills to their respective fee schedules to price based upon DCMWC policies. If modifier logic is applicable, and if the bill contains a modifier that affects pricing, the payment will be adjusted accordingly.

As part of the pricing process, the Contractor will include effective from and through dates on all fee schedules and codes to validate against the date of service on the bill to ensure accurate processing.

Manual pricing is also supported in CBP, allowing manual entry of the price on the bill line itself. Manual pricing of procedures will be documented in the Bill Resolution Procedure Manual to be developed for the CBP medical bill suspense processing.

Both historical data and current data will be imported using existing utility tools. These same tools will be used going forward and will include any structural changes needed to meet future requirements. Additionally, the system will automatically drive to a default fee schedule assignment in the absence of other determining factors (provider specific scenarios/pay as billed overrides).

The entire pricing process takes place as part of the adjudication processing, which includes the edit/audit process and is automatic with the option to pend or deny based on specific criteria determined by the system configuration. Bills determined to not be valid, based on claimant eligibility and covered services, are not priced. The result is bill pricing against components that are appropriate for the date of service of the bill, ensuring that as things change over time, you can maintain historical results and also easily perform maintenance and updates to the applicable components. The specific criteria to drive to the appropriate fee schedule for a provider include, but are not limited to, provider (hospital or individual provider), specific provider ID, provider network level, provider type and specialty, and user configurable criteria, which are defined objects in the database. DCMWC fee schedules may also be uniquely driven based on type of service or modifier. The system can also automatically drive to a pay as billed fee schedules for bills that meet specific Government-approved criteria.

DCMWC Inpatient bills are processed through specific ‘I’ Logic. Diagnosis codes are read to determine if they are in a ‘payable’ category. In addition, surgical procedures are evaluated to determine if covered. The result is a combination of the categories of diagnosis codes, and the surgical coverage indicators. Each possible combination has been assigned a disposition in the logic table.

Inpatient bills will pay in full (as billed) minus non-covered charges (PRCC), pay obligate charges (POOT), or deny (DENY). Bills with diagnoses’ covered by the logic are analyzed line-by-line by RCC to determine if the line should be paid or denied. If the billed diagnosis is not covered, each line is analyzed by the RCC to determine the appropriate denial message.

Starting with CBP go-live, all outpatient bills received on a UB-04 should be submitted through OPPS. For historical bills, CBP can perform a crosswalk of medical treatment procedure codes submitted on a UB-04 bill (RCC) to a CPT or HCPC code including modifiers. Where appropriate, the Contractor will price based on RVU and dollar conversion factors during the submission of adjustments for historical bills. DCMWC will not process any outpatient bill through the crosswalk after the implementation of OPPS. DCMWC will do a complete cut over to OPPS.

As part of the fee schedule maintenance process, the Contractor will obtain updates as they become available from outside sources including but not limited to CMS fee schedules, 3M OPPS Grouper/Pricer, AMA Procedure file and drug reference files (TC, NDC, GCN), and will apply update files to the CBP relational database only upon approval of the Government.

3.3 Bill Pricing Business Process Flow – DCMWC

The following diagrams capture the DCMWC Bill Pricing Business Process flow:

3.3.1 1500 Bill Pricing Flow

3.3.2 Inpatient UB Pricing Flow

3.3.3 Outpatient UB Pricing Flow

Proposed Outpatient UB pricing flow.

3.3.4 Treatment Travel Pricing Flow: POV Mileage

3.3.5 Treatment Travel Pricing Flow: Lodging and Incidentals

4 Bill Pricing Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 18 – Bill Pricing 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.

4.1 Functional Requirements

PWS

Req # Functional

Req ID

R0668

R0669 R0015

R0670

R0674

R0676

B1-18-BR003

B1-18-BR004

B3-18-BR026

Core

R0670

R0680

R0681

R0682

R0683

R0684

B3-18-BR005

B1-18-BR006

B1-18-BR015

B3-18-BR015

B1-18-BR016

B3-18-BR016

B1-18-BR024

B3-18-BR024

Core

R0670

R0674

R0670

R0674

B3-18-BR008

Core

R0671

R0672

B1-18-BR023

B3-18-BR023

Core

R0674

R0675

R0676

R0678

R0684

B2-18-BR025

B1-18-BR012

B3-18-BR012

B1-18-BR013

B3-18-BR013

B1-18-BR014

B3-18-BR014

B1-18-BR015

B3-18-BR015

B1-18-BR016

B3-18-BR016

B1-18-BR017

B1-18-BR023

Core

R0677

B3-18-BR018

Core

R0686

R0687

B1-18-BR021

Core

R0688

R0689

4.2 Business Rules

B1-18-BR001

B3-18-BR001

· Must locate the correct fee schedule Core

· Apply modifier percentage to calculated price Core

· Apply non-facility RVU in calculation

· Apply any modifier percentage to the calculated price Core

· Apply facility RVU in calculation

· Apply ASC multiplier

· Apply any modifier percentage to the calculated price Core

· Maryland Hospital with a Negotiated Rate to pay as billed

· Federal Hospital

· Skilled Nursing Facility

· Intermediate Care Facility

· Nursing Home

· Assisted Living Facility

· Boarding Home

· Hospice

· Cancer Hospitals

· Price using DRG fee schedule

· Bills will be processed through the 3MGrouper/Pricer

· The pricer returned ‘Medicare Allowed Amount’ is multiplied by an OWCP specific formula to determine the total bill reimbursement

· If the calculated DRG price (Medicare pricer amount + OWCP formula applied) is greater than the billed amount, only pay up to 120% of the billed amount

· If the bill cannot price DRG, it should price using Cost to Charge (CCR). See B1-18-BR016 below for formula.

· Inpatient bills with valid locator codes (“Type of Bill”) submitted by Acute Care Hospitals (identified by provider type) with valid Medicare numbers should be reimbursed according to Medicare PPS and DRG.

· Inpatient Rehab and Psych bills (identified by Provider type) should be priced according to CCR.

· Acute care hospitals covered under the CMS PPS with a last date of service outside the Medicare pricing schedule window should be priced CCR. Current Medicare pricer only supports the last 5 years of pricing schedules.

· Acute care hospitals covered the CMS PPS should be priced CCR when the DRG Pricer is unable to return a Medicare price for that bill or the calculated DRG price is zero.

Core

· Maryland Hospital with a Negotiated Rate to pay as billed

· Federal Hospital

· Cancer Hospitals

· Price using ‘I’ (inpatient) logic.

· The Bill Pricing process for the DCMWC Program requires a systematic comparison of covered diagnoses to non-covered conditions and services. There are tables to be systematically reviewed when processing inpatient bills.

· Covered and Non-covered Diagnosis Table – This table assigns a value to each billed diagnosis.

· Covered and Non-covered Procedure Table – This table assigns a value to each billed ICD surgical procedure code.

· The category for each diagnosis when doing diagnosis edits is stored in the tables. The covered Government categories are acute conditions (A0, A1, and A2) and chronic conditions (B0, B1, B2, C0, and D0). The non-covered categories are H0, I0, J0, and K0.

· Each bill line RCC is checked against the pay/deny table to determine final disposition. This can result in PRCC, POOT, or DENY.

DCMWC

· Maryland Hospital with a Negotiated Rate to pay as billed

· Federal Hospital

· Skilled Nursing Facility

· Intermediate Care Facility

· Nursing Home

· Assisted Living Facility

· Boarding Home

· Hospice

· Cancer Hospitals

· Per diem rates are applied by the District Office (New York, and Seattle), and will be forwarded to the Contractor for processing as a “Prompt Pay Travel Bill”

· The District Office Medical Scheduler will make the reservations for the claimant. The invoice for the travel (air) services will be forwarded by the provider to the National Office Fiscal Officer and paid via government credit card. The Fiscal Officer or designee will complete the OWCP-957 form indicating the appropriate procedure code, and will apply the amount paid based on the per diem. The completed OWCP-957 will be sent to the Contractor and "keyed as a history only" bill.

DFEC

DCMWC

· DCMWC Fee Schedule from 1974 through period of performance

· DFEC Fee Schedule from 1980 through period of performance

· Energy Fee Schedule from 2001 through period of performance

· Fee schedule design must allow for updates and changes to pricing methods Core

· Date ranges cannot overlap

· The appropriate span to utilize in pricing is determined by the date of service on the bill Core

· GAF values will be applied to all RVUs

· GAF link zip codes to metropolitan statistical areas (MSA) Core

B1-18-BR013

· GAF values will be applied to all RVUs

· GAF link zip codes to metropolitan statistical areas (MSA) Core

B3-18-BR013

· Time units are derived by dividing the minutes reported in block 24G of OWCP-1500 by 15 Core

· (3M Medicare Allowable Amount * 1.33333) + DOL provided dollar amount Core

· This is the current CCR formula, subject to changes.

Core

manual pricing

· Pay as billed fee schedules will be created as instructed by DOL and can apply to any bill type

· Bills will be manually priced as instructed by DOL

· Bills will be priced 'pay as billed' based on the following scenarios:

· OWCP fee schedule has procedure set to pay as billed (RVU values are set to zero)

· Provider has a 'Pay as Bill' fee schedule override set, in which any procedure submitted by that provider will pay as billed

· Manually price a bill to pay as bill as instructed by DOL

· OWCP fee schedule that is set to "Pay as Billed", will also have a "Pay Factor Code of "B" concurrently with the RVU's set to zeros

· Providers identified on the legacy Provider file with a 'PAYASBIL' override should not be subjected to the DRG/CCR pricing and priced pay as billed Core

· Operational procedures as specified by DOL (OWCP fee schedule) will instruct pricing up to a specified maximum amount for services including:

· Home Health (if any procedure has an RVU value, it should be paid with the RVU and conversion factor rather than the max)

· Prosthetics

· Orthotics

· Dental

· Claimant Travel

· Provider Travel Services (these services are submitted on a OWCP-1500 billing form by provider type 44) Core

· Claimant is eligible for dates of service

· Services are covered

· The bill adjudication process should ensure that all bills are subjected to the appropriate edits and audits (data validity, claimant eligibility, provider eligibility, reference editing, etc.) prior to entering the Bill Pricing process.

Core

· If OPPS does not group to an APC, services price based upon the fee schedule for the CPT/HCPCS procedure (RBRVS), including modifiers

· If CPT/HCPCS is missing, bill will deny for edit 172 Core

· If OPPS does not group to an APC, services price based upon the fee schedule for the CPT/HCPCS procedure (RBRVS), including modifiers Core

· Updates from the following sources must be obtained as information is published by the respective organization:

· CMS Fee Schedule

· 3M Grouper/Pricer (DRG)

· AMA Procedure File

· First Data Bank (TC, NDC, GCNs)

· All reference updates, once obtained, must be submitted to DOL (changes only) for review and approval with recommended configuration settings.

· Reference updates must be implemented in the test environment, and upon receiving DOL approval, implemented in production.

· All reference updates (Fee Schedules, Codes - Procedure, Diagnosis, Therapeutic Class, NDC, GCN, DRG, RCC, HCPCS, CPT, ICD Surgical, and OPPS) must be administered through the CBP change management process and only implemented with DOL approval.

Core

· Resource-Based Relative Value Scale (RBRVS) and modifiers

· Fee-based procedures

· Per diem

· Flat rates

· Mileage

· All inclusive rates

· Manual pricing

· Time unit pricing

· Drugs grouped by generic code, NDC, or other code sets determined by the Government

· Other pricing methodologies as determined by the Government

· The following fee schedules will be used to support DOL approved pricing methodologies:

· OWCP Fee Schedule

· Anesthesia Fee Schedule (only applies to DFEC and DEEOIC, does not apply to DCMWC)

· Contract Nurse & Voc Rehab Fee Schedule (only applies to DFEC, does not apply to DEEOIC or DCMWC)

· Travel Fee Schedule (mileage and per diem based on GSA)

· 3M Medicare PPS

· 3M Medicare OPPS

· Pharmacy AWP pricing or equivalent

· Fee schedules will differ between programs.

Core

· Fee-based procedures

· Mileage

· Manual pricing

· Time unit pricing

· Drugs grouped by generic code, NDC, or other code sets determined by the Government

· Inpatient Logic Table Pricing (DCMWC only)

· Other pricing methodologies as determined by the Government

· The following fee schedules will be used to support DOL approved pricing methodologies:

· Anesthesia Fee Schedule (only applies to DFEC and DEEOIC, does not apply to DCMWC)

· Travel Fee Schedule (mileage and per diem based on GSA)

· 3M Medicare OPPS

· Pharmacy AWP pricing or equivalent

· Fee schedules will differ between programs.

DCMWC

· Resource-Based Relative Value Scale (RBRVS) and modifiers

· Fee-based procedures

· Per diem

· Flat rates

· Mileage

· All inclusive rates

· Manual pricing

· Time unit pricing

· Drugs grouped by generic code, NDC, or other code sets determined by the Government

· Other pricing methodologies as determined by the Government

· The following fee schedules will be used to support DOL approved pricing methodologies:

· OWCP Fee Schedule

· Anesthesia Fee Schedule (only applies to DFEC and DEEOIC, does not apply to DCMWC

· Travel Fee Schedule (mileage and per diem based on GSA)

· 3M Medicare PPS

· 3M Medicare OPPS

· Pharmacy AWP pricing or equivalent

· Fee schedules will differ between programs.

Core

Acute care hospital services covered under the CMS Prospective Pay System (PPS) are paid under the following formulas based on:

A = OWCP maximum allowable payment;

LOS = The claimant's length of stay; and

MA = CMS Medicare allowable amount calculated using the versions of Grouper and Pricer software appropriate to the discharge date.

If LOS is less than or equal to 60 days, A = (MA x 1.33333) + 1,132.00

If LOS is greater than 60 days but less than or equal to 90 days, A = (MA x 1.33333) + 1,132.00 + [(LOS - 60) x 283.00]

If LOS is greater than 90 days, A = (MA x 1.33333) + 9,622.00 + [(LOS - 90) x 5.00]

This is the current formula, subject to changes.

Core

If travel is greater than 100 miles one way or greater than 200 miles round trip, authorization is required. Lodging and meals require authorization. If no authorization on file, the contractor will send notification to the DO requesting authorization.

All airfare travel requires prior authorization from the DO. If a bill is submitted to obtain reimbursement for airfare (no matter the cost) authorization request must be sent to the DO. A0140 is set to a level 3.

DEEOIC

5 Bill Pricing Supporting Functional Components The following functional components serve as inputs or outputs to the Bill Pricing process.

5.1 Initial Data Migration

The following table identifies the initial data migration required by Bill Pricing. 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

DFEC fee schedule from 1980 through period of performance

DEEOIC fee schedule from 2001 through period of performance.

DCMWC fee schedule from 1974 through period of performance.

Current OWCP fee schedule

18-IDM01_002

18-IDM02_002

Anesthesia fee schedule

Contract nurse & voc rehab fee schedule

Travel fee schedule (mileage and per diem based on GSA)

18-IDM99_005

18-IDM02_005

3M Medicare PPS

Inpatient Logic Tables

3M Medicare OPPS

Pharmacy AWP pricing or equivalent

5.2 Interfaces

The following table identifies the interfaces required by Bill Pricing. 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

OWCP Fee Schedule – Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment and upon receiving DOL approval will be implemented in production.

18-INTF01_002

18-INTF02_002

Anesthesia Fee Schedule – Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment, and upon receiving DOL approval, be implemented in production

Contract Nurse & Voc –Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment, and upon receiving DOL approval, be implemented in production

Travel Fee Schedule (Mileage and Per Diem based on GSA) – Updates

All reference updates, once obtained will be submitted to DOL (Changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment, and upon receiving DOL approval, be implemented in production

18-INTF99_005

INFT02_005

3M Medicare PPS – Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment, and upon receiving DOL approval, be implemented in production

3M Medicare OPPS – Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the Test environment, and upon receiving DOL approval, be implemented in production

Pharmacy AWP pricing or equivalent – Updates

All reference updates, once obtained will be submitted to DOL (changes only) for review and approval with recommended configuration settings. Reference updates should be implemented in the test environment, and upon receiving DOL approval, be implemented in production

Diagnoses & Surgical Procedures www.cms.gov/ICD9/10ProviderDiagnosticCodes/07_summarytables.asp

The Contractor initiates change management to download File

OWCP Medical Director sends change management to apply changes.

https://catalog.ama-assn.org/Catalog The Contractor initiates change management to download File

Compare reports run (see below)

DOL responds with any changes

( The Contractor to receive email notification of mid-year updates from CMS listservs)

www.cms.hhs.gov/HCPCSReleaseCodeSets The Contractor initiates change management to download File

Compare reports run

DOL responds with any changes

( The Contractor to receive email notification of mid-year updates from CMS listservs)

The Contractor will check for new revenue codes- this is a new process

The Contractor Provide list of ASC codes(surgical procedure and the ancillary procedures) from CMS http://www.cms.gov/ASCPayment/10_Annual_Policy_files.asp#TopOfPage and provides to DOL in the The Contractor format as requested by the government (pertinent to the…