Section_20_Bill_Resolution_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Bill Resolution (Section 20)

Central Bill Process

Bill Resolution (PWS Section 20)

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 Resolution - DFEC

51.1 Bill Resolution Overview - DFEC

51.2 Bill Resolution Business Process Description - DFEC

81.3 Bill Resolution Business Process Flow - DFEC

Bill Resolution - DEEOIC

92.1 Bill Resolution Overview - DEEOIC

92.2 Bill Resolution Business Process Description - DEEOIC

122.3 Bill Resolution Business Process Flow - DEEOIC

Bill Resolution - DCMWC

133.1 Bill Resolution Overview - DCMWC

133.2 Bill Resolution Business Process Description - DCMWC

153.3 Bill Resolution Business Process Flow - DCMWC

Bill Resolution Business Requirements

164.1 Functional Requirements

174.2 Business Rules

Bill Resolution Supporting Functional Components

255.1 Initial Data Migration

255.2 Interfaces

265.3 Reports

285.4 Letters

Constraints

296.1 Assumptions

296.2 Dependencies

296.3 Issues/Open Items

Appendices

307.1 Terms & Definitions

1 Bill Resolution - DFEC

1.1 Bill Resolution Overview - DFEC

Most bills will be automatically adjudicated through CBP based on the implemented business rules. The CBP Bill Resolution process provides a program-specific process for those bills that require manual intervention to complete processing.

Bills will suspend as a result of the adjudication process and will need to have a workflow in place to track their progress. The rules and policies for the individual OWCP programs: DCMWC, DEEOIC, and DFEC will be accommodated by the CBP. The bills that require manual review will suspend to the Contractor CBP automated work queues for processing by bill resolution specialists and medical review examiners in accordance with Government-approved Bill Resolution procedures. The inclusion of qualified specialists to make decisions on those medical bills that deviate from the automated process will ensure that suspended bills are resolved quickly and accurately, with knowledge and experience. Further, in cases where a medical bill has been identified as deficient and verified by Contractor personnel, the CBP will process a Return to Provider (RTP)/ Return to Claimant (RTC) notifying the provider/claimant of the missing or incorrect data on the bill. These deficient bills will be returned within 5 business days of receipt. For any bills that fail processing, the Contractor will clearly identify and communicate all specific deficiencies of the returned bill that prevent payment to the recipient.

1.2 Bill Resolution Business Process Description - DFEC

The CBP will utilize customized workflows so that bills are properly suspended for manual resolution by trained bill resolution specialists. These workflows will accept bills based on specific edit criteria as well as permit manual pricing and the manual selection of appropriate EOBs. Automated workflows and queues will be configured to redirect certain suspended bills and their attachments to authorized Government personnel for viewing and, as needed, for making final resolution decisions. All bill resolution actions will be logged by the system to create a permanent record of who did what to a bill and when. CBP will automatically apply the appropriate edits and pricing methodologies to all bills released from suspension back into the bill processing mainline upon completion of manual resolution.

The necessary tools in the form of manuals and reference materials for the correct resolution of each specific edit, for each bill type and for each provider type will be made available to all bill resolution staff. The manuals and reference material will be made available electronically and in hardcopy, and be organized by each program and contain all the necessary instructions to ensure that the manual bill resolution is performed correctly and consistently among all the bill resolution specialists. The reference materials will include all the EOB codes that are appropriate for each program, bill type, and for each specific edit.

The Contractor will process all suspended bills according to Government-approved, program-specific guidelines and time constraints. The Contractor will use procedures, reference materials and desk-top aids, all of which will be made available electronically and in hardcopy, after DOL has reviewed and validated that the processing guidelines meet their expectations for bill processing. The Contractor will update the medical bill procedures manual to reflect all current resolution procedures approved by DOL. The Contractor will provide program specific Bill Resolution work volumes and accuracy statistics via standard reports and dashboards as directed by the Government.

The CBP will automatically apply the appropriate pricing based on the guidelines and fee schedules supplied by DOL. The systematic pricing routines occur on every bill processing through the system, including those that have had an action taken by a resolution specialist or medical reviewer, except for those bills or bill lines that have been manually priced according to DOL guidelines and denied bills or denied bill lines.

Specialty bill edits that require review by either DOL-CBP personnel or regional or national office personnel, will automatically be routed to the appropriate work queues and will be accessible via the secure CBP Web Portal by authorized Government personnel to perform the specialized resolution functions.

The CBP system will include reports that provide Bill Resolution work volume and accuracy statistics for each program. The system also will have processing logs that capture every event that occurs on each processed bill including the edits that were applied, the pricing algorithms that were employed, and every action that was taken by a bill resolution examiner. From these logs the system will provide the capability to produce reports that describe every action taken by the system and the bill resolution actions that have been taken by each of the bill resolution and medical review examiners. These reports will be useful for providing specifics for different types of resolution and to research any processing anomalies if necessary.

Authorized Contractor staff will have immediate access to all suspended bills and resolution activity to facilitate answering provider and claimant inquiries regarding Bill Resolution.

The following are instances where bills will be routed to DOL personnel or CBP Bill Resolution staff for review. This will be further detailed in the Bill Resolution Manual.

Bills over $30,000 but less than $50,000

· Any bill with a reimbursement amount over $30,000 but less than $50,000 will suspend for edit 391 and be routed to CBP Bill Resolution staff for review and resolution.

Bills equal to or over $50,000 but less than $1,000,000

· Any bill with a reimbursement amount equal to or over $50,000 but less than $1,000,000 will suspend for Edit 497 and be routed to a DOL workflow queue for District Office review and work instructions.

Bills equal to or over $1,000,000

· Any bill with a reimbursement amount greater than $1,000,000 will suspend for edit 380 and be routed to the National Office for review. The National Office will communicate resolution instructions via the workflow .

Durable Medical Equipment

· For DFEC, all DME’s for unlisted procedures or exceeding $2000 must be prior authorized by the District Office Claims Examiner (CE). Requests for motorized wheel chair will be reviewed by DMA at the request of the CE during the authorization process.

· If the prior authorization does not match, the bill will be denied by the system on the appropriate authorization edit and not be routed to the District Office for bill resolution.

Travel (DFEC Program)

· Travel Procedure Codes A0080 and A0090 are set for mileage validations. This means that if the mileage is less than 200 miles, these procedures are level-1 procedures. If any of these procedures is billed and is equal to or greater than 200 miles, the system will automatically flip the authorization level for the procedure to a level-3 -- an authorization is required.

· If a travel bill is submitted by the claimant and is equal to or greater than 200 miles on one day, one way or round trip, and there is no auth on file for these services, then the bill should suspend and authorization request be routed to the CE through the workflow (CE does not resolve the actual bill, the Contractor will resolve it based on CE's response to authorization request).

· For any of the transportation and travel codes, if the travel bill is submitted by a provider and is equal to or exceeds 200 miles (quantity block 24e on HCFA) and there is no authorization on file, the bill should deny for authorization edits.

· Procedure codes A0100, A0110, A0120, A0130, A0140, and A0170 are set for a receipt of a dollar amount. These procedures are level 1 procedures as long as the amount billed is under $75.00. If the provider bills an amount for any of these procedures which is equal to or greater than $75.00, the procedure will automatically flip to a level-3 and an authorization will be required.

· If a travel bill is submitted by the claimant and is equal to or greater than $75 for services billed in Block F and there is no auth on file for these services, then the bill should suspend and an authorization request will be routed to the CE through the workflow tool ( the Contractor will resolve the bill based on the CE Response).

· If the travel bill is submitted by a provider and is equal to or exceeds $75 (Block 24d on HCFA) and there is no authorization on file, the bill should deny for authorization edits.

· For any transportation and travel codes submitted, if the travel services are submitted by a claimant and exceed the required dollar amounts and/or mileage requirements, the request will be routed through the workflow to the District Office. If the request is submitted by the provider, and there is not an authorization on file, the request should be denied for authorization.

Home Grown Procedure Code

· The only bills for which the District Office will resolve the edits online are those over $50,000. If a bill is suspended for Homegrown procedure codes, in which an authorization is not on file for the Homegrown procedure code, that bill will be placed in a “work location” that sends the appropriate District Office notification of the bill information through the work-flow and receive the resolution instructions provided by the District Office.

· If a bill suspends for a Homegrown procedure code that also requires a Level 3 Prior Authorization, it should have already been prior authorized by the DO. If it is a PPA bill and the Prior Authorization does not match, it should be suspended for an authorization request to be routed via workflow to the DO Representative to update the authorization. If it is not a PPA bill and there is no matching authorization on file, the bill should be denied on the appropriate authorization edit. The DO does not directly resolve these bills; the Contractor will resolve the bills based on the CE Response.

Airfare

· All claims for airfare (A0140) must be prior-authorized by the DO. If a Non-PPA bill is received with no matching authorization in place, the bill will be denied on the appropriate edit by the contractor. If it is a PPA bill, the bill will be suspended for an authorization request to be routed to the appropriate DO via the workflow prior to bill resolution by the Contractor.

· The Medical Scheduler in the District Office will make the reservations for the claimant, and the Airport will send sends the invoices to the National Office, at which time a check is cut to the Travel Facility, a 957 is completed with the procedure code "A0140", amount paid to the facility on behalf of the claimant, stamped Prompt Pay "History Only", and sent to the Contractor facility for scanning and keying. When the National Office submits the airfare bill for claimant travel, it will be keyed by the Contractor as "History Only".

1.3 Bill Resolution Business Process Flow - DFEC

The following diagram captures the DFEC Bill Resolution Business Process flow.

2 Bill Resolution - DEEOIC

2.1 Bill Resolution Overview - DEEOIC

Most bills will automatically be adjudicated through CBP based on the business rules implemented. The CBP Bill Resolution process provides a program-specific process for those bills that require manual intervention to complete processing.

Bills will suspend as a result of the adjudication process and will need to have a workflow in place to track their progress. The rules and policies for the individual OWCP programs: DCMWC, DEEOIC, and DFEC will be accommodated by the CBP. The bills that require manual review will suspend to the CBP automated work queues for processing by bill resolution specialists and medical review examiners in accordance with Government-approved Bill Resolution procedures. The inclusion of qualified specialists to make decisions on those medical bills that deviate from the automated process will ensure that suspended bills are resolved quickly and accurately, with knowledge and experience. Further, in cases where a medical bill has been identified as deficient and verified by the Contractor personnel, the Contractor will process a Return to Provider (RTP)/ Return to Claimant (RTC) notifying the provider/claimant of the missing or incorrect data on the bill. These deficient bills will be returned within 5 business days of receipt. For any bills that fail processing, the Contractor will clearly identify and communicate all specific deficiencies of the returned bill that prevent payment to the recipient.

2.2 Bill Resolution Business Process Description - DEEOIC

The CBP will utilize customized workflows so that bills are properly suspended for manual resolution by trained bill resolution specialists. These workflows will accept bills based on specific edit criteria as well as permit manual pricing and the manual selection of appropriate EOBs. Automated workflows and queues will be configured to redirect certain suspended bills and their attachments to authorized Government personnel for viewing and, as needed, for making final resolution decisions. All bill resolution actions will be logged by the system to create a permanent record of who did what to a bill and when. CBP will automatically apply the appropriate edits and pricing methodologies to all bills released from suspension back into the bill processing mainline upon manual resolution.

The necessary tools in the form of manuals and reference materials for the correct resolution of each specific edit, for each bill type and for each provider type will be made available to all bill resolution staff. The manuals and reference material will be made available electronically and in hardcopy, and be organized by each program containing all the necessary instructions to ensure that the manual bill resolution is performed correctly and consistently among all the bill resolution specialists. The reference materials will include all the EOB codes that are appropriate for each program, bill type, and for each specific edit.

The Contractorwill process all suspended bills according to Government-approved, program-specific guidelines and time constraints. The Contractor will use procedures, reference materials and desk-top aids, all of which will be made available electronically and in hardcopy, after DOL has reviewed and validated that the processing guidelines meet their expectations for bill processing. The Contractor will update the medical bill procedures manual to reflect all current resolution procedures approved by DOL. The Contractor will provide program specific Bill Resolution work volumes and accuracy statistics via standard reports and dashboards as directed by the Government.

The CBP will automatically apply the appropriate pricing based on the guidelines and fee schedules supplied by DOL. The systematic pricing routines occur on every bill processing through the system, including those that have had an action taken by a resolution specialist or medical reviewer; except for those bills or bill lines that have been manually priced according to DOL guidelines and denied bills or denied bill lines.

Specialty bill edits that require review by either DOL-CBP personnel or regional or national office personnel, will automatically be routed to the appropriate work queues and will be accessible via the secure CBP Web Portal by authorized Government personnel to perform the specialized resolution functions.

The CBP system will include reports that provide Bill Resolution work volume and accuracy statistics for each program. The system also will have processing logs that capture every event that occurs on each processed bill including the edits that were applied, the pricing algorithms that were employed, and every action that was taken by a bill resolution examiner. From these logs the system will provide the capability to produce reports that describe every action taken by the system and the bill resolution actions that have been taken by each of the bill resolution and medical review examiners. These reports will be useful for providing specifics for different types of resolution and to research any processing anomalies if necessary.

Authorized Contractor staff will have immediate access to all suspended bills and resolution activity to facilitate answering provider and claimant inquiries regarding Bill Resolution.

The following are instances where bills will be routed to DOL personnel or CBP Bill Resolution staff for review. This will be further detailed in the Bill Resolution Manual.

HCFA/OWCP 1500 Bills Over $30,000

· Any bill with a reimbursement amount over $30,000 will suspend and will be routed to the National Office for review and instructions for resolution. The National Office will communicate resolution instructions via the workflow.

Outpatient Bills Over $30,000

· Any bill with a reimbursement amount over $30,000 will suspend and will be routed to the National Office for review and instructions for resolution. The National Office will communicate resolution instructions via the workflow.

Inpatient Bills Over $75,000

· Any bill with a reimbursement amount greater than $75,000 will suspend and will be routed to the National Office for review. The National Office will communicate resolution instructions via the workflow.

Durable Medical Equipment

· For DEEOIC, all DME exceeding $5000 must be authorized by the District Office. Mobility devices (power wheel chairs and scooters) greater than $5,000, or those purchased within 3 years of last purchase (regardless of price) require prior authorization by the District Office.

· If the prior authorization does not match, the bill will be denied by the system on the appropriate authorization edit and not routed to the District Office for bill resolution.

Unlisted Procedures

· For DEEOIC, most unlisted codes will suspend and are set to Level 3 requiring authorization. All unlisted codes must include supporting documentation for the use of the code such as a report from the physician or facility including time, skill and any necessary specialized equipment necessary to provide the service. A Contractor bill Resolution Specialist will be responsible for determining appropriate code usage, researching authorization, determining possible keying errors, notifying the District Offices through the workflow, and following all processes as referenced in the Resolutions Manual (SOP).

· If the prior authorization does not match, the bill will be denied by the system on the appropriate authorization edit and not routed to the District Office for bill resolution.

Travel (DEEOIC Program)

· For DEEOIC, the following travel-related services require prior authorization:

· Automobile travel greater than 100 miles each way or 200 miles round-trip

· Lodging

· Rental Car and Rental Car Gas

· Companion Travel

If there is no authorization on file for these services, the bill will suspend and the authorization request will be routed to the appropriate District Office via the workflow. The Contractor will resolve the issue based on the District Office’s response to deny or approve the authorization request.

Airfare

· For DEEOIC, air travel requires prior authorization.

· For airfare reimbursement requests, the travel procedure code A0140 is set to level 3.

Meals

· Meals may be covered without prior authorization for travel less than 200 miles round trip where meals are claimed when the destination is to and from a medical facility, such as doctors office, hospital, cancer institution, outpatient hospital facility, or ambulatory surgical center.

· Meals are not covered for travel less than 200 miles round trip when the destination is to and from a pharmacy or DME/Medical Supply facility.

2.3 Bill Resolution Business Process Flow - DEEOIC

The following diagram captures the DEEOIC Bill Resolution Business Process flow.

3 Bill Resolution - DCMWC

3.1 Bill Resolution Overview - DCMWC

Most bills will automatically be adjudicated through CBP based on the business rules implemented. The CBP Bill Resolution process will provide a program-specific process for those bills that require manual intervention to complete processing.

Bills will suspend as a result of the adjudication process and will need to have a workflow in place to track their progress. The rules and policies for the individual OWCP programs: DCMWC, DEEOIC, and DFEC will be accommodated by the CBP. The bills that require manual review will suspend to the CBP automated work queues for processing by bill resolution specialists and medical review examiners in accordance with Government-approved Bill Resolution procedures. The inclusion of qualified specialists to make decisions on those medical bills that deviate from the automated process will ensure that suspended bills are resolved quickly and accurately, with knowledge and experience. Further, in cases where a medical bill has been identified as deficient and verified by Contractor personnel, the Contractor will process a Return to Provider (RTP)/ Return to Claimant (RTC) notifying the provider/claimant of the missing or incorrect data on the bill. These deficient bills will be returned within 5 business days of receipt. For any bills that fail processing, the Contractor will clearly identify and communicate all specific deficiencies of the returned bill that prevent payment to the recipient.

3.2 Bill Resolution Business Process Description - DCMWC

The CBP will utilize customized workflows so that bills are properly suspended for manual resolution by trained bill resolution specialists. These workflows will accept bills based on specific edit criteria as well as permit manual pricing and the manual selection of appropriate EOBs. Automated workflows and queues will be configured to redirect certain suspended bills and their attachments to authorized Government personnel for viewing and, as needed, for making final resolution decisions. All bill resolution actions will be logged by the system to create a permanent record of who did what to a bill and when. CBP will automatically apply the appropriate edits and pricing methodologies to all bills released from suspension back into the bill processing mainline upon manual resolution.

The necessary tools in the form of manuals and reference materials for the correct resolution of each specific edit, for each bill type and for each provider type will be made available to all bill resolution staff. The manuals and reference material will be made available electronically and in hardcopy, and be organized by each specific program containing all the necessary instructions to ensure that the manual bill resolution is performed correctly and consistently among all the bill resolution specialists. The reference materials will include all the EOB codes that are appropriate for each program, bill type, and for each specific edit.

The Contractor will process all suspended bills according to Government-approved, program-specific guidelines and time constraints. The Contractor will use procedures, reference materials and desk-top aids, all of which will be made available electronically and in hardcopy, after DOL has reviewed and validated that the processing guidelines meet their expectations for bill processing. The Contractor will update the medical bill procedures manual to reflect all current resolution procedures approved by DOL. The Contractor will provide program specific Bill Resolution work volumes and accuracy statistics via standard reports and dashboards as directed by the Government.

The CBP will automatically apply the appropriate pricing based on the guidelines and fee schedules supplied by DOL. The systematic pricing routines occur on every bill processing through the system, including those that have had an action taken by a resolution specialist or medical reviewer, except for those bills or bill lines that have been manually priced according to DOL guidelines and denied bills or denied bill lines.

Specialty bill edits that require review by either DOL-CBP personnel or regional or national office personnel, will automatically be routed to the appropriate work queues and will be accessible via the secure CBP Web Portal by authorized Government personnel to perform the specialized resolution functions.

The CBP system will include report that provide Bill Resolution work volume and accuracy statistics for each program. The system will also have processing logs that capture every event that occurs on each processed bill including the edits that were applied, the pricing algorithms that were employed, and every action that was taken by a bill resolution examiner. From these logs the system will provide the capability to produce reports that describe every action taken by the system and the bill resolution actions that have been taken by each of the bill resolution and medical review examiners. These reports will be useful for providing specifics for different types of resolution and to research any processing anomalies if necessary.

Authorized Contractor staff will have immediate access to all suspended bills and resolution activity to facilitate answering provider and claimant inquires regarding Bill Resolution.

The following are instances where DCMWC bills will be routed to DOL personnel or CBP Bill Resolution staff for review. This will be further detailed in the Bill Resolution Manual.

· All inpatient bills with a TOTAL PAYABLE amount greater than $75,000

· All Outpatient bills with a TOTAL PAYABLE amount greater than $30,000

· All OWCP-1500 bills with a TOTAL PAYABLE amount greater than $30,000

· Treatment Travel bills greater than 75 miles one way or greater than 150 miles round-trip

· Claimant on Review bills. Bills that require review to price (usually an inpatient bill)

· VA bills

3.3 Bill Resolution Business Process Flow - DCMWC

The following diagram captures the DCMWC Bill Resolution Business Process flow.

4 Bill Resolution Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 20 – Bill Resolution 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

R0723 R0725

R0015

B1-20-FR001

B1-20-BR005

Core

R0723

R0726

R0727

R0729

R0730

B3-20-BR002

Core

B1-20-BR004

B2-20-BR004

B3-20-BR004

Core

R0728

B1-20-FR004

B2-20-BR006

B3-20-BR006

B1-20-BR009

B2-20-BR009

B3-20-BR009

Core

R0731

R0732

R0733

B1-20-FR005

Core

B3-20-BR008

Core

4.2 Business Rules

· Data entry errors (i.e., procedure code, diagnosis code)

· Provider billing errors (i.e., wrong procedure code used, billed for incorrect DOS)

· Policy violations (i.e., failed to obtain a Prior Authorization), Adjustment Review, Claimant on Review, Provider on Review, and Procedure on Review.

· Suspended bills will require manual intervention to complete processing Core

· Bill Resolution SOP that will contain instructions for dispositioning each edit (i.e., when to Force, Deny, Override edits as well as timing for each action taken). It will also include what edits are set to be "bypassed"/ignored by the system with no manual intervention.

· Medical bill procedure manual for each OWCP program which includes step-by-step Bill Resolution instructions for all edits (including multiple EOBs as needed). It should also include the Contractor’s facility processes starting with the Mailroom and ending with the final process of generating the 1099, which comes after the RV generations.

· Electronic and hardcopy desktop aides for Bill Resolution staff to support the resolution of suspended bills such as the following:

· Reference Code Books – AMA/CPT, HCPC, and ICD-9/10. A DRG booklet is not needed for the Resolution Associates, as Inpatient bills will be processed through the system and DRG will be assigned based on the end dates of services systematically. However, they should have access to the 3M Grouper for all periods.

· DOL Program Procedures/Policies

· Necessary changes to the reference materials should be submitted to DOL for approval and subjected to Change Management process.

· Bill Resolution reference materials should be updated as needed to reflect all current resolution procedures approved by the Government.

Core

· Bill Resolution SOP that will contain instructions for dispositioning each edit (i.e., when to Force, Deny, Override edits as well as timing for each action taken). It will also include what edits are set to be "bypassed"/ignored by the system with no manual intervention.

· Medical bill procedure manual for each OWCP program which includes step-by-step Bill Resolution instructions for all edits (including multiple EOBs as needed). It should also include the Contractor’s facility processes starting with the Mailroom and ending with the final process of generating the 1099, which comes after the section of RV generations.

· Electronic and paper desktop aides for Bill Resolution staff to support the resolution of suspended bills such as the following:

· Reference Code Books – AMA/CPT, HCPC, and ICD-9/10.

· DOL Program Procedures/Policies

· Necessary changes to the reference materials should be submitted to DOL for approval and subjected to Change Management process.

· Bill Resolution reference materials should be updated as needed to reflect all current resolution procedures approved by the Government.

DCMWC

Manages the Bill Resolution process and provides guidance to specialists in a variety of duties.

· Resolution Adjustment Specialist

Conducts bill-specific research to resolve outstanding issues Core

· Request additional information needed to complete adjudication of bills.

· Review bills for necessity, limitations, and exclusions based on bill policies and procedures.

· Assist internal associates with bill-related questions and issues.

· Identify reccurring problems and provide feedback to management to affect change.

· Be familiar with medical bill forms, ICD-9/ 10 coding, CPT/ HCPC coding, and other medical coding schemes (certificate desired).

· Be familiar with appropriateness of attachments, invoices for Implants, as well as invoices for Voc Rehab Counselors.

DFEC

· Request additional information needed to complete adjudication of bills.

· Review bills for necessity, limitations, and exclusions based on bill policies and procedures.

· Assist internal associates with bill-related questions and issues.

· Identify reccurring problems and provide feedback to management to affect change.

· Be familiar with medical bill forms, ICD-9/10 coding, CPT/ HCPC coding, and other medical coding schemes (certificate desired).

· Be familiar with appropriateness of attachments and invoices.

DEEOIC

· Request additional information needed to complete adjudication of bills.

· Review bills for necessity, limitations, and exclusions based on bill policies and procedures.

· Assist internal associates with bill-related questions and issues.

· Identify reccurring problems and provide feedback to management to affect change.

· Be familiar with medical bill forms, ICD-9/10 coding, CPT/ HCPC coding, and other medical coding schemes (certificate desired).

· Be familiar with appropriateness of attachments.

DCMWC

· The disposition of the edits should be the driver as to whether a bill will suspend and to whom it will be directed for resolution.

· Bill Resolution procedures should describe instructions per edit, which may ultimately address bill type or provider type.

· Each Edit should have its own EOB message.

· EOB messages should also be selectable for a particular edit as needed.

· Per Audit trail functions, the system should capture what, when and by whom a bill resolution action was performed.

· Security should be set up to allow D.O. staff to see only their own bills.

· Inquiries should be authorized per role and security set up.

· Certain edits should be routed to DOL personnel for resolution as part of the workflow defined by the Contractor.

· After bills are resolved, they should go through the adjudication process again with a full set of processing edits, including fee schedule. An exception to this is a manual price override, which would not be re-priced.

· As part of the Bill Resolution process, suspended bills can be manually priced in order to resolve the suspension.

Core

· Suspended bills should be resolved according to DOL-approved Bill Resolution instructions, while adhering to the 28/21 calendar day processing timeframes for the respective bills.

DFEC

· PPA Travel and Diagnostics will be processed within 21 calendar days of receipt.

· Suspended bills should be resolved according to DOL-approved Bill Resolution instructions, while adhering to the 28/21 calendar day processing timeframes for the respective bills.

DEEOIC

· PPA Travel and Diagnostics will be processed within 21 calendar days of receipt.

· Suspended bills should be resolved according to DOL-approved Bill Resolution instructions, while adhering to the 28/21 calendar day processing timeframes for the respective bills.

DCMWC

· On a weekly basis, quality assurance should be performed internally by the Contractor on a sample of bills to ensure processes/procedures are followed and timeframes are adhered to, and at the same time, analyze/track bill resolution trends (i.e., determine spikes in edit postings, determine whether the disposition of an edit is causing unusually high suspension rates, etc.)

· Quality assurance of bills sampling should be reported to DOL in cumulative statistics monthly.

· Recommended changes to the Bill Resolution processes to improve accuracy and timelines should be provided by the Contractor.

Core

· The Call Center staff should also be knowledgeable on:

· Modifier Level Pricing, Anesthesia Pricing, OPPS Pricing and other types of pricing

· Utilization Review/Service Limitation Edits

· Procedure Covered in an ASC Facility

· RCC to Cross-walk/New Category of Service/Type of Service Process

· Automated Adjustment Process etc;

· Multiple Surgical Cut-backs

· Global Surgical Cut-backs

· Maximum Units reduction and pricing

· Processing of Implantable Services and corresponding invoices

· Policy rules and procedures for each program.

· Both CBP portal and IVR should support inquiries from provider and claimant.

Core

· The Call Center staff should also be knowledgeable on:

· Modifier Level Pricing, Anesthesia Pricing, OPPS Pricing and other types of pricing

· Utilization Review/Service Limitation Edits

· Procedure Covered in an ASC Facility

· RCC to Cross-walk/New Category of Service/Type of Service Process

· Adjustment Process

· Multiple Surgical Cut-backs

· Global Surgical Cut-backs

· Maximum Units reduction and pricing

· Processing of Implantable Services and corresponding invoices

· Policy rules and procedures for each program.

· Both CBP portal and IVR should support inquiries from provider and claimant.

DCMWC

· Any bill with a reimbursement amount equal to or over $50,000 but less than $1,000,000 will suspend for Edit 497 review and be routed to a DOL workflow queue for District Office review and instructions for resolution.

· Any bill with a reimbursement amount greater than $1,000,000.00 will suspend for edit 380 and be routed to the National Office for review. The National Office will communicate resolution instructions via the workflow.

DFEC

· Outpatient and OWCP/HCFA bills with a reimbursement amount over $30,000 will suspend and will be routed to the National Office for review and instructions for resolution. The National Office will communicate resolution instructions via the workflow.

· Outpatient bills with a reimbursement amount over $30,000 will suspend and will be routed to the DOL National Office for review and instructions for resolution. The National Office will communicate resolution instructions via the workflow.

· Inpatient bills with a reimbursement amount over $75,000.00 will suspend and will be routed to the National Office for review. The National Office will communicate resolution instructions via the workflow.

DEEOIC

· All Outpatient bills with a TOTAL PAYABLE amount greater than $30,000

· All OWCP-1500 bills with a TOTAL PAYABLE amount greater than $30,000

· Travel bills greater than 75 miles one way or greater than 150 miles round-trip

· Claimant on Review bills. Bills that require review to price (usually an inpatient bill)

· VA bills

DCMWC

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

5.1 Initial Data Migration

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

Data Migration

ID

Source

System Target

System Description

20-IDM01-001

20-IDM02-001

20-IDM03_001

5.2 Interfaces

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

Future State Interface ID Source

System Target

System

20-INTF01-001

20-INTF02-001

20-INTF03-001

20-INTF01-002

20-INTF02-002

20-INTF03-002

5.3 Reports

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

Future State

Report ID Current State

Report ID

20-RPT01_001

Monthly (Standard)

10th of every month Bill Resolutions Statistical Report Card

Data Elements:

Number of incoming bills requiring Manual Resolution

Number of incoming Adjustment Request Requiring Adjustment

Number on incoming correspondence requiring Fee Schedule Appeal

Number of Bills worked (Manual Resolution)

Number of Bills worked (Adjustments)

Number of Bills worked (Fee Schedule Appeal)

20-RPT02_001

Monthly (Standard)

10th of every month Bill Resolutions Statistical Report Card

Data Elements:

Number of incoming bills requiring Manual Resolution

Number of incoming Requiring Adjustment

Number on incoming requiring Fee Schedule Appeal

Number of Bills worked (Manual Resolution)

Number of Bills worked (Adjustments)

Number of Bills worked (Fee Schedule Appeal)

Number of Incoming calls received

20-RPT03_001

Monthly (Standard)

10th of every month Bill Resolutions Statistical Report Card

Data Elements:

Number of incoming bills requiring Manual Resolution

Number of incoming Adjustment Request Requiring Adjustment

Number of Bills worked (Manual Resolution)

Number of Bills worked (Adjustments)

20-RPT01_002

20-RPT02_002

20-RPT03_002

Cumulative Quality Assurance Report showing the results of the weekly internal quality control performed on sample bills.

20-RPT01_003

20-RPT02_003

20-RPT03_003

Bill Resolution Trend Analysis & Recommendations identifying patterns and specific edits causing the suspensions, as well as recommendations for improvement.

5.4 Letters

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

**NOTE: All Letters will be distributed electronically or through the Return To Provider / Return to Claimant. Each respective letter will be listed in its respective RSD (e.g., DOL Prior Authorization Letter will be captured in the Authorization RSD).

Future State

Letter ID Current State

Rpt ID

6 Constraints

6.1 Assumptions

· N/A

6.2 Dependencies

· Timely receipt of mail from ACS during the Bill Hold period.

6.3 Issues/Open Items

Resolution

Resolved

7 Appendices

7.1 Terms & Definitions

Approved (A)

Pending (P)

Denied (D)

Further medical review (F)