Section_7_Claimant_Bill_Development_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Claimant Bill Development (Section 7)

Central Bill Process

Claimant Bill Development (PWS Section 7) Requirements Specification Document

(LEGACY DRAFT)

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 Claimant Bill Development – DFEC

61.1 Claimant Bill Development Overview - DFEC

61.2 Claimant Bill Development Business Process Description - DFEC

81.3 Claimant Bill Development Business Process Flow - DFEC

81.3.1 Claimant Bill Development - DFEC

Claimant Bill Development – DEEOIC

92.1 Claimant Bill Development Overview - DEEOIC

92.2 Claimant Bill Development Business Process Description - DEEOIC

122.3 Claimant Bill Development Business Process Flow - DEEOIC

122.3.1 Claimant Bill Development - DEEOIC

Claimant Bill Development – DCMWC

133.1 Claimant Bill Development Overview - DCMWC

133.2 Claimant Bill Development Business Process Description - DCMWC

163.3 Claimant Bill Development Business Process Flow - DCMWC

163.3.1 Claimant Bill Development - DCMWC

Claimant Bill Development Business Requirements

174.1 Functional Requirements

194.2 Business Rules

Claimant Bill Development Supporting Functional Components

235.1 Initial Data Migration

235.2 Interfaces

245.3 Reports

255.4 Letters

Constraints

266.1 Assumptions

266.2 Dependencies

266.3 Issues/Open Items

Appendices

277.1 Terms & Definitions

297.2 DFEC Return to Claimant (RTC) Criteria

327.3 DFEC Acceptable Claimant Billing Forms

337.4 DFEC Proof of Payment Criteria

347.5 DFEC Proof of Purchase Criteria

367.6 DEEOIC Return to Claimant (RTC) Criteria

377.7 DEEOIC Acceptable Claimant Billing Forms

387.8 DEEOIC Proof of Payment Criteria

397.9 DEEOIC Proof of Purchase Criteria

417.10 DCMWC Return to Claimant (RTC) Criteria

447.11 DCMWC Acceptable Claimant Billing Forms

457.12 DCMWC Proof of Payment Criteria

467.13 DCMWC Proof of Purchase Criteria

1 Claimant Bill Development – DFEC

1.1 Claimant Bill Development Overview - DFEC

Communication with claimants who submit deficient bills is a critical component of the claimant bill development process. The Contractor will provide clear explanations of deficient bill submissions, identify all supporting documentation required to process a request for reimbursement and provide clear instructions on resubmission requirements. A key component of the Claimant Bill Development process is the actual development of the bill (i.e. manual coding of ICD9/10 and Procedure codes).

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

The CBP Central Mailroom and Workflow will be used to identify proof of payment and capture the data required to process a claimant submitted bill through the CBP. The Central Mailroom’s imaging system used for image and data capture will process all bill forms, including but not limited to OWCP-915, OWCP-957, CMS/OWCP-1500 and UB forms with attachments.

All claimant-submitted bills will be processed in the Contractor’s Central Mailroom. All bills will be opened, prepared, scanned, and indexed within 1 business day of receipt. Claimant-submitted bills, including the envelopes, will be processed as documents and scanned using the imaging software application and high-speed scanners. All scanned documents will be submitted to the imaging software for automated classification and routing, and will have a DCN associated with each bill and its attachments. Imaging software then enhances the images to improve the OCR recognition. This is not a second pass at scanning, but rather automated post-scan processing. The imaging software application will classify the bills as claimant-submitted and will recognize the form types. Imaging software is then used to assign DCNs and scan documents into images for further processing. Once this task is accomplished, the images are sent to the relevant workflow in the imaging system.

Expected form types will be CMS/OWCP-1500, UB04/UB92, OWCP-915 and OWCP-957. Using predefined tables and rule sets, the software will determine the following:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill?

· Is proof of payment supplied?

· Are designated documents signed?

The imaging software will be trained to recognize each claimant-submitted bill form and classify them appropriately. The imaging software will also recognize pages that follow the bill form as attachments. Rules will be configured within the imaging software to force these specific documents (and attachments) to be reviewed by an operator. The operator will be presented with the image of the bill and will be asked to verify that one of the attachments is “proof of payment”. Once confirmed by the operator, the specific attachment will be identified as “Proof of Payment,” allowing the bill and attachments to proceed for further processing.

The Imaging software will route all bills passing this initial check to the data capture entry point for further processing. All captured data will be properly formatted for submission to the Contractor bill processing software for processing using manual coding for diagnoses (ICD-9/10), procedure codes (CPT-4/HCPCS), and NDCs. The Contractor will ensure that staff familiar with the required coding schemas handle these bills to make certain the correct interpretation and coding occurs.

As detailed in the Section 12 Return To Provider RSD, if a bill is submitted on an unapproved form, the original bill and its attachments must be returned to the claimant (RTC) with clear instructions for correct submission. The Contractor will perform cursory checks for completeness in the mailroom. All claimant submitted bills will be scanned and the images placed in image repository. A transaction will be sent for each bill to the workflow tool, which will queue the bills for review/development by staff located in the development facility. Bills that do not have a case number and/or signature will have an indicator designating them as requiring the RTC process. The bill development staff will review each deficient bill, identify all missing information, create the RTC letter using a letter utility contained in the workflow software and re-queue a transaction to the mailroom. The mailroom staff will print the RTC letter; match it to the original bill and attachments, and mail the complete bill and letter back to the submitter. Bills identified as deficient by the developers for other reasons (e.g. missing receipts/proof of payment, missing critical data elements such as date of service, etc.) will be handled in the same manner. The RTC letter will be created by the bill development staff, a transaction re-queued to the mailroom, the letter printed and matched to the originals and the complete bill and letter mailed back to the submitter. Bills that are complete and have all required documentation (including inpatient/outpatient bills paid by the claimant) will be keyed directly into bill processing software by the bill development staff.

If any of the described conditions are not met, the bill will be electronically removed from the workflow and routed to mailroom staff responsible for the return of deficient bills to claimants. The imaging software will generate a reject report in DCN order, which will be used to retrieve the original bill. The images will be used as the basis to develop the return to claimant letter. Using the DOL supplied return to provider (RTP) template as the basis; the imaging software will populate relevant captured data such as claimant name and address. The mailroom staff will review the images, and if they agree that the reject is not valid, the bills will be re-routed to the imaging system for data capture and further processing. If the mailroom staff agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted to generate and print a letter using the Contractor’s letter generation software package.

For claimant bills not meeting Government-supplied criteria, the Contractor’s automated document processing solution will identify, reject from the workflow, and return all deficient original bill documentation (e.g., missing attachments or required documentation such as proof of payment) to the claimant without further processing. The RTC will contain a letter explaining the reason for rejection and instructions on how to correctly resubmit the original bill. The letter will contain language to the effect that:

· If the claimant resubmits the bill they must submit the original bill (indicating the original imprinted DCN to assist in identification)

· Without the required identifying information and/or attachments, future resubmission will result in a returned bill

· Even with submission of the required identifying information and/or attachments, future resubmission may not result in a paid bill

DFEC Required Bill Types for Claimant Submitted Bills, and bills that will be processed with disbursements paid directly to the claimant, are listed in Appendix 7.3.

1.3 Claimant Bill Development Business Process Flow - DFEC

The following diagram captures the DFEC Claimant Bill Development Business Process flow.

1.3.1 Claimant Bill Development - DFEC

SHAPE \* MERGEFORMAT

2 Claimant Bill Development – DEEOIC

2.1 Claimant Bill Development Overview - DEEOIC

The Contractor should understand the importance of supporting claimants and providing reimbursement for their out-of-pocket expenses in a timely manner. Communication with claimants who submit deficient bills is a critical component of the claimant bill development process. The Contractor will provide clear explanations of deficient bill submissions, identify all supporting documentation required to process a request for reimbursement and provide clear instructions on resubmission requirements. A key component of the Claimant Bill Development process is the actual development of the bill (i.e., manual coding of ICD9/10 and Procedure codes).

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

The CBP Central Mailroom and Workflow will be used to identify proof of payment and capture the data required to process claimant submitted bills through the CBP. The Central Mailroom’s imaging system used for image and data capture will process all bill forms, including the DEEOIC-accepted forms OWCP-915 and OWCP-957 and all associated attachments.

All claimant-submitted bills will be processed in the Contractor’s Central Mailroom. All bills will be opened, prepared, scanned, and indexed within 1 business day of receipt. Claimant-submitted bills, including the envelopes, will be processed as documents and scanned using the imaging software application and high-speed scanners. All scanned documents will be submitted to the imaging software for automated classification and routing, and will have a DCN associated with each bill and its attachments. The imaging application then enhances the images to improve the OCR recognition. This is not a second pass at scanning, but rather automated post-scan processing. The The imaging software application will classify the bills as claimant-submitted and will recognize the form types. Imaging software is then used to assign DCNs and scan documents into images for further processing. Once this task is accomplished, the images are sent to the relevant workflow in the imaging system.

For DEEOIC, the only expected form types will be OWCP-915 and OWCP-957. Using predefined tables and rule sets, the software will determine the following:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill?

· Is proof of payment supplied?

· Are designated documents signed?

The imaging software will be trained to recognize each claimant-submitted bill form and classify them appropriately. The imaging software will also recognize pages that follow the bill form as attachments. Rules will be configured within the imaging software to force these specific documents (and attachments) to be reviewed by an operator. The operator will be presented with the image of the bill and will be asked to verify that one of the attachments is “proof of payment”. Once confirmed by the operator, the specific attachment will be identified as “Proof of Payment,” allowing the bill and attachments to proceed for further processing.

The imaging software will route all bills passing this initial check to the data capture entry point for further processing. All captured data will be properly formatted for submission to the the Contractor’s Medical Bill Processing System (MBPS) for processing using manual coding for diagnoses (ICD-9/10), procedure codes (CPT-4/HCPCS), and NDCs. The Contractor will ensure that staff familiar with the required coding schemas handle these bills to make certain the correct interpretation and coding occurs.

As detailed in the Section 12 Return To Provider (RTP) RSD, if a bill is submitted on an unapproved form, the original bill and its attachments must be returned to the claimant (RTC) with clear instructions for correct submission. The Contractor will perform cursory checks for completeness in the mailroom. All claimant submitted bills will be scanned and the images placed in the image repository. A transaction will be sent for each bill to the workflow , which will queue the bills for review/development by staff located in the development facility. Bills that do not have an SSN and/or signature will have an indicator designating them as requiring the RTC process. The bill development staff will review each deficient bill, identify all missing information, create the RTC letter using a letter utility contained in the workflow software and re-queue a transaction to the mailroom. The mailroom staff will print the RTC letter; match it to the original bill and attachments, and mail the complete bill and letter back to the submitter. Bills identified as deficient by the developers for other reasons (e.g. missing receipts/proof of payment, missing critical data elements such as date of service, etc.) will be handled in the same manner. The RTC letter will be created by the bill development staff, a transaction re-queued to the mailroom, the letter printed and matched to the originals and the complete bill and letter mailed back to the submitter. Bills that are complete and have all required documentation (including inpatient/outpatient bills paid by the claimant) will be keyed directly into bill processing software by the bill development staff.

If any of the described conditions are not met, the bill will be electronically removed from the workflow and routed to mailroom staff responsible for the return of deficient bills to claimants. The imaging software will generate a reject report in DCN order, which will be used to retrieve the original bill. The images will be used as the basis to develop the return to claimant letter. Using the DOL supplied return to provider (RTP) template as the basis; the imaging software will populate relevant captured data such as claimant name and address. The mailroom staff will review the images, and if they agree that the reject is not valid, the bills will be re-routed to the imaging system for data capture and further processing. If the mailroom staff agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted to generate and print a letter using the Contractor’s letter generation software package.

For claimant bills not meeting Government-supplied criteria, the Contractor’s automated document processing solution will identify, reject from the workflow, and return all deficient original bill documentation (e.g., missing attachments or required documentation such as proof of payment) to the claimant without further processing. The RTC will contain a letter explaining the reason for rejection and instructions on how to correctly resubmit the original bill. The letter will contain language to the effect that:

· If the claimant resubmits the bill they must submit the original bill (indicating the original imprinted DCN to assist in identification)

· Without the required identifying information and/or attachments, future resubmission will result in a returned bill

· Even with submission of the required identifying information and/or attachments, future resubmission may not result in a paid bill

DEEOIC Required Bill Types for Claimant Submitted Bills, and bills that will be processed with disbursements paid directly to the claimant, are listed in Appendix 7.7.

2.3 Claimant Bill Development Business Process Flow - DEEOIC

The following diagram captures the DEEOIC Claimant Bill Development Business Process flow.

2.3.1 Claimant Bill Development - DEEOIC

3 Claimant Bill Development – DCMWC

3.1 Claimant Bill Development Overview - DCMWC

The Contractor should understand the importance of supporting claimants and providing reimbursement for their out-of-pocket expenses in a timely manner. Communication with claimants who submit deficient bills is a critical component of the claimant bill development process. The Contractor will provide clear explanations of deficient bill submissions, identify all supporting documentation required to process a request for reimbursement and provide clear instructions on resubmission requirements. A key component of the Claimant Bill Development process is the actual development of the bill (i.e., manual coding of ICD9/10 and Procedure codes).

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

The Contractor’s Central Mailroom and Workflow will be used to identify proof of payment and capture the data required to process a claimant submitted bill through the CBP. The Central Mailroom’s imaging system used for image and data capture will process all bill forms, including the DCMWC-accepted forms OWCP-915 and OWCP-957 and all associated attachments.

All claimant-submitted bills will be processed in the Contractor’s Central Mailroom. All bills will be opened, prepared, scanned, and indexed within 1 business day of receipt. Claimant-submitted bills, including the envelopes, will be processed as documents and scanned using the imaging application and high-speed scanners. All scanned documents will be submitted to the imaging software for automated classification and routing, and will have a DCN associated with each bill and its attachments. Imaging then enhances the images to improve the OCR recognition. This is not a second pass at scanning, but rather automated post-scan processing. The imaging software application will classify the bills as claimant-submitted and will recognize the form types. Imaging software is then used to assign DCNs and scan documents into images for further processing. Once this task is accomplished, the images are sent to the relevant workflow in the imaging system.

For DCMWC, the expected form types will be OWCP-1500, UB-04 (formerly UB-92), OWCP-915 and OWCP-957. Using predefined tables and rule sets, the software will determine the following:

· Are the documents on acceptable forms?

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill?

· Is proof of payment supplied?

· Are designated documents signed?

The imaging software will be trained to recognize each claimant-submitted bill form and classify them appropriately. The imaging software will also recognize pages that follow the bill form as attachments. Rules will be configured within the imaging software to force these specific documents (and attachments) to be reviewed by an operator. The operator will be presented with the image of the bill and will be asked to verify that one of the attachments is “proof of payment”. Once confirmed by the operator, the specific attachment will be identified as “Proof of Payment,” allowing the bill and attachments to proceed for further processing.

The imaging software will route all bills passing this initial check to the data capture entry point for further processing. All captured data will be properly formatted for submission to the the Contractor’s Medical Bill Processing System (MBPS) for processing using manual coding for diagnoses (ICD-9/10), procedure codes (CPT-4/HCPCS), and NDCs. The Contractor will ensure that staff familiar with the required coding schemas handle these bills to make certain the correct interpretation and coding occurs.

As detailed in the Section 12 Return To Provider/Claimant (RTP/RTC) RSD, if a bill is submitted on an unapproved form, the original bill and its attachments must be returned to the claimant (RTC) with clear instructions for correct submission. The Contractor will perform cursory checks for completeness in the mailroom. All claimant submitted bills will be scanned and the images placed in image repository. A transaction will be sent for each bill to the workflow , which will queue the bills for review/development by staff located in the development facility. Bills that do not have an SSN and/or signature will have an indicator designating them as requiring the RTC process. The bill development staff will review each deficient bill, identify all missing information, create the RTC letter using a letter utility contained in the workflow software and re-queue a transaction to the mailroom. The mailroom staff will print the RTC letter; match it to the original bill and attachments, and mail the complete bill and letter back to the submitter. Bills identified as deficient by the developers for other reasons (e.g. missing receipts/proof of payment, missing critical data elements such as date of service, etc.) will be handled in the same manner. The RTC letter will be created by the bill development staff, a transaction re-queued to the mailroom, the letter printed and matched to the originals and the complete bill and letter mailed back to the submitter. Bills that are complete and have all required documentation (including inpatient/outpatient bills paid by the claimant) will be keyed directly into bill processing software by the bill development staff.

If any of the described conditions are not met, the bill will be electronically removed from the workflow and routed to mailroom staff responsible for the return of deficient bills to claimants. The imaging software will generate a reject report in DCN order, which will be used to retrieve the original bill. The images will be used as the basis to develop the return to claimant letter. Using the DOL supplied return to claimant (RTC) template as the basis; the imaging software will populate relevant captured data such as claimant name and address. The mailroom staff will review the images, and if they agree that the reject is not valid, the bills will be re-routed to the imaging system for data capture and further processing. If the mailroom staff agrees the bill is a valid reject, they will select the applicable reason for rejection from a drop-down menu. The resulting data file will be formatted to generate and print a letter using the Contractor’s letter generation software package.

For claimant bills not meeting Government-supplied criteria, the Contractors automated document processing solution will identify, reject from the workflow, and return all deficient original bill documentation (e.g., missing attachments or required documentation such as proof of payment) to the claimant without further processing. The RTC will contain a letter explaining the reason for rejection and instructions on how to correctly resubmit the original bill. The letter will contain language to the effect that:

· If the claimant resubmits the bill they must submit the original bill (indicating the original imprinted DCN to assist in identification)

· Without the required identifying information and/or attachments, future resubmission will result in a returned bill

· Even with submission of the required identifying information and/or attachments, future resubmission may not result in a paid bill

DCMWC Required Bill Types for Claimant Submitted Bills, and bills that will be processed with disbursements paid directly to the claimant, are listed in Appendix 7.8.

3.3 Claimant Bill Development Business Process Flow - DCMWC

The following diagram captures the DCMWC Claimant Bill Development Business Process flow.

3.3.1 Claimant Bill Development - DCMWC

4 Claimant Bill Development Business Requirements

The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 7 – Claimant Bill Development 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, (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

R0296

R0299

R0300

B2-07-BR001

B3-07-BR001

Core

(B1-06-FR002/ B1-06-BR004) &

Section 08

(B1-08-FR009/ B1-08-BR011)

RSD

Core

R0296 R0015

B1-07-BR002

B2-07-BR002

B3-07-BR002

Core

R0296

B3-07-BR001

B2-07-BR002

B1-07-BR004

Core

R0296

R0303

R0304

R0305

R0310

R0296

R0298

R0303

R0304

R0305

R0311

R0296

R0298

R0303

R0305

R0306

R0307

R0308

R0309

R0310

B1-07-BR005

Core

(B1-06-FR003/ B1-06-BR005)

Section 08

(B1-08-FR005/ B1-08-BR007) RSD

Core

R0296

R0300

B2-07-BR006

B3-07-BR006

Core

R0296

R0301

B2-07-BR007

B3-07-BR007

Core

B2-07-BR007

B3-07-BR007

Core

4.2 Business Rules

B1-07-BR001

· CMS 1500/OWCP 1500

· UB04/UB92 Inpatient, Outpatient

· OWCP 915 Claimant Reimbursement (Medical)

· OWCP 915 Claimant Reimbursement (Drug/Pharmacy)

· OWCP 957 Travel Form

DFEC

B2-07-BR001

· OWCP 915 Claimant Reimbursement (Medical)

· OWCP 915 Claimant Reimbursement (Drug/Pharmacy)

· OWCP 957 Travel Form

DEEOIC

B3-07-BR001

· CMS 1500/OWCP 1500

· UB04/UB92 Inpatient, Outpatient

· OWCP 915 Claimant Reimbursement (Medical)

· OWCP 915 Claimant Reimbursement (Drug/Pharmacy)

· OWCP 957 Travel Form

DCMWC

B1-07-BR002

B3-07-BR002

B1-07-BR003

· Identify all missing information

· Include all DOL approved reasons for return of a claimant submitted bill (see Appendix 7.2 RTP/RTC Criteria)

· State that claimant must resubmit the original bill

· State that without the required identifying information and/or attachments, future resubmission results in a returned bill

· State that even with the required identifying information and/or attachments, future resubmission may not result in a paid bill Core

B1-07-BR006

· For DFEC, claimant submitted UB-04 billing forms where the claimant has paid the charges in full, will be submitted directly through Bill processing software, and the bill should be set to pay based on the Cost to Charge Ratio (CCR). If the resulting CCR is greater than what the claimant has paid, the claimant should be paid what he paid as referenced in the appropriate block of the UB-04. If the CCR is less than what the claimant has paid, the claimant should be paid based on the CCR final equation. If the claimant submitted UB-04 is submitted for the reimbursement of Co-Pay charges, this is the point in which the charged will be transferred onto the 915, and processed using home-grown code "COPAY.

DFEC

B2-07-BR006

· If the itemized bill is a UB-04 for inpatient services, the claimant should be subject to the fee schedule. Due to the lack of a Medicare number for a claimant-submitted bill, the bill will price and reimburse according to the CCR logic using the State identified from the address of where the service was rendered, not the claimant home address.

· If the claimant submitted bill is submitted for the reimbursement of Co-Pay charges, it will be processed using the home-grown code "COPAY”.

DEEOIC

B3-07-BR006

· For DCMWC, claimants submitted UB-04 billing forms where the claimant has paid the charges in full, should be keyed and processed as a provider-submitted inpatient bill and utilize the inpatient logic table. Lines of the bill should not be rolled up into a single "room charge" line.

DCMWC

· DOL approved guidelines should be satisfied

· Are the documents on acceptable forms? (see Appendix 7.3 for DFEC Acceptable Claimant Billing Forms)

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill? (see Appendix 7.2 below for RTC criteria by form)

· Is proof of payment/purchase supplied? (see Appendix 7.4 below for DFEC Proof of Payment Criteria; see Appendix 7.5 below for DFEC Proof of Purchase Criteria)

· Are the designated documents signed?

· Claimant bill development should be completed in 5 days. DOL approved response letters should be included, as appropriate, when bills are returned to claimants.

DFEC

B2-07-BR007

· DOL approved guidelines should be satisfied

· Are the documents on acceptable forms? (see Appendix 7 for Acceptable Claimant Billing Forms)

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill? (see Appendix 7 for RTC criteria by form)

· Is proof of payment/purchase supplied? (see Appendix 7 for Proof of Payment Criteria and Proof of Purchase Criteria)

· Are the designated documents signed?

· Claimant bill development should be completed in 5 days. DOL approved response letters should be included, as appropriate, when bills are returned to claimants.

DEEOIC

B3-07-BR007

· DOL approved guidelines should be satisfied

· Are the documents on acceptable forms? (see Appendix 7 for Acceptable Claimant Billing Forms)

· Are all required forms present?

· Is the predefined minimum information sufficient to process the bill? (see Appendix 7 for RTC criteria by form)

· Is proof of payment/purchase supplied? (see Appendix 7 for Proof of Payment Criteria and Proof of Purchase Criteria)

· Are the designated documents signed?

· Claimant bill development should be completed in 5 days. DOL approved response letters should be included, as appropriate, when bills are returned to claimants.

DCMWC

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

5.1 Initial Data Migration

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

Data Migration

ID

Source

System Target

System Description

05-IDM01_001

05-IDM02_001

05-IDM03_001

5.2 Interfaces

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

Future State Interface ID Source

System Target

System

05-INTF01-002

05-INTF02-002

05-INTF03-002

05-INTF01-003

05-INTF02-003

05-INTF03-003

5.3 Reports

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

Future State

Report ID Current State

Report ID

12-RPT01_001

12-RPT03_001

Monthly/

On-Demand

(Standard) OWCP Cumulative RTP/RTC Statistical Report (By Program, and Bill Type)

Data Elements:

OWCP Program ID

Claimant Submitted Medical (RTC)

Claimant Pay Pharmacy (RTC)

Dental (RTP/RTC)

OWCP-1500 (RTP/RTC)

OWCP-957 (RTC)

Pharmacy (RTP/RTC)

UB-04 (RTP/RTC)

Gross Bill Volume

# Rejected

# RTP’d/RTC’d

Total Number of Rejected and RTP’d/RTC’d

12-RPT02_001

Monthly/

On-Demand

(Standard) OWCP Cumulative RTP/RTC Statistical Report (By Program, and Bill Type)

Data Elements:

OWCP Program ID

Claimant Submitted Medical (RTC)

Claimant Pay Pharmacy (RTC)

Dental (RTP/RTC)

OWCP-1500 (RTP/RTC)

OWCP-957 (RTC)

Pharmacy (RTP/RTC)

Gross Bill Volume

# Rejected

# RTP’d/RTC’d

Total Number of Rejected and RTP’d/RTC’d

5.4 Letters

The following table identifies the letters required by the Claimant Bill Development. 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 Claimant Bill Development. 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

12-LTR01_002

12-LTR02_002

12-LTR03_002

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

6 Constraints

6.1 Assumptions

· N/A

6.2 Dependencies

· N/A

6.3 Issues/Open Items

· N/A 7 Appendices

7.1 Terms & Definitions

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

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

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

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

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

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

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

7.2 DFEC Return to Claimant (RTC) Criteria

OWCP-915

(Treatment)

· Case Number missing/invalid or Case Number/name mismatch

· Claimant signature and date missing

· Procedure codes missing/invalid

· Amount Paid by the Claimant missing

· Date of Service missing

· Receipts/Proof of Payment missing

OWCP-915

(Drug/Pharmacy)

· Case Number missing/invalid or Case Number/name mismatch

· Amount paid by the claimant missing

· Date of Service/Dispense date missing

· NDC missing on submitted bill form and/or attached receipt

· Drug Quantity missing on submitted bill form and/or attached receipt

· Receipts/Proof of payment missing

· Prescription number missing on submitted bill form and/or attached receipt

OWCP-1500

This is a valid Claimant Reimbursement request when there is a mechanical stamp or an indication is made by the physician on the OWCP1500 bill form or the attachment that states “PAID IN FULL BY THE CLAIMANT” and blocks 28 (Total Charge” and 29 (Amount Paid) are populated with a dollar amount and block 30 equals zero.

· Case Number missing/invalid or Case Number/name mismatch

· Claimant Signature or acceptable forms of a signature missing

· Diagnosis Codes missing/invalid

· Procedure Codes missing/invalid

· Missing Place of Service and/or facility

· Line Item Charges missing/invalid

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

· Missing Facility name/address

· Proof of Payment or mechanical stamp not present (when blocks 28 and 29 are populated and there is no indication that payment was paid by the claimant)

OWCP-957

(Travel)

· Case Number missing/invalid or Case Number/name mismatch

· Claimant Signature missing

· Travel Expense missing

· Travel From/To missing

· Date of Travel is missing

· Medical Facility Address missing/invalid/incomplete in Block-E (facility name/provider, street number/name, city, state, zip code)

· Physician’s Signature and Date Care Rendered not present in Block-H

· “Other” block checked but no charge or description

· Receipts/Proof of payment missing (applies to services listed in “Block F”; Proof of purchase must be an original receipt and is only required if the services in Block F equal or exceed $75.00)

· Mileage in Block-G if the claimant has indicated a charge for “Parking and Tolls” (A0170) (not applicable when any other forms of transportation is populated in Block F)

UB-04(Inpatient/Outpatient Co-Pay)

Periodically claimants will submit Inpatient Bills where they have only the “Co-Pay”. These types of submissions must be submitted on the OWCP-915 and developed using an OWCP Special Code (Home-grown code) during the development process as opposed to CPT or HCPC code)

· Case Number missing/invalid or Case Number/name mismatch

· Principle ICD-9/10 diagnosis code is missing/invalid

· Amount Paid by the Claimant missing

· Date of Service missing

· Receipts/Proof of Payment is missing

UB-04

(Inpatient Bill:

Patient paid the bill in full)

Inpatient bills that are submitted when the claimant has actually paid the bill in full, (Not an often occurrence), will not require to be developed. These bills are submitted into the system, and all information on the bill is keyed. The bill will be keyed as a claimant submitted Inpatient Bill, and paid under the Cost to Charge Ratio (CCR) as well as subjected to all system edits; treatment suite etc. The system should systematically review the allowed amount derived by the system to be paid, and if the CCR allowed amount is higher than the amount paid by the claimant, the payment disbursed will be the amount paid by the claimant. If the amount allowed is less than the amount paid by the claimant after all system validations, the payment to the claimant should be at the CCR allowed amount as derived by the system.

· Case Number missing/invalid or Case Number/name mismatch

· Principle ICD-9/10 diagnosis code is missing/invalid

· Physicians signature is missing

· Type of bill billing

· Revenue Center Code (s) missing/invalid

· Incorrect Form (only if this claimant attempts to submit these charge on a OWCP-915 and there is no UB-04 accompanied to the form)

· Amount Paid by the Claimant missing

· Receipts/Proof of Payment missing

UB-04

(Outpatient Bill:

Patient paid the bill in full)

Outpatient bills that are submitted when the claimant has actually paid the bill in full, (Not an often occurrence), will not require to be developed. These bills are submitted into the system, and all information on the bill is keyed. The bill will be keyed as a claimant submitted Outpatient bill, and paid in accordance with Outpatient bill processing guidelines as well as subjected to all system edits; treatment suite etc.