Section_9_Bill_Processing_Legacy__version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Bill Processing (Section 9)

Central Bill Process

Bill Processing (PWS Section 9)

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 Processing - DFEC

61.1 Bill Processing Overview - DFEC

61.2 Bill Processing Business Process Description - DFEC

61.2.1 Workflow Management

71.2.2 Bill Entry Process

71.2.2.1 Mailroom Bill Entry

81.2.2.2 On-Line Portal Entry

81.2.2.3 Electronic Entry of COP Nurse Bills

91.2.2.4 Pharmacy POS Bills

91.2.2.5 EDI Bills

101.2.3 Fee Schedule Appeals

101.2.4 Adjustments

111.2.5 Authorizations

121.2.6 Provider Eligibility

131.2.7 Claimant Eligibility

151.2.8 Treatment Suites

161.2.9 Edits & Audits

171.2.10 Bill Resolution

181.2.11 Bill Pricing

181.2.12 Payment Process

191.2.13 Reporting

191.2.14 Data Inquiry

201.3 Bill Processing Business Process Flow - DFEC

Bill Processing - DEEOIC

212.1 Bill Processing Overview - DEEOIC

212.2 Bill Processing Business Process Description - DEEOIC

212.2.1

222.2.2

222.2.2.1

232.2.2.2

232.2.2.3

242.2.2.4

242.2.3 Fee Schedule Appeals

252.2.4

252.2.5

262.2.6

272.2.7

282.2.8

302.2.9

312.2.10

312.2.11

322.2.12

322.2.13

322.2.14

342.3 Bill Processing Overview Workflow – DEEOIC

Bill Processing – DCMWC

353.1 Bill Processing Overview - DCMWC

353.2 Bill Processing Business Process Description - DCMWC

353.2.1

363.2.2

363.2.2.1

373.2.2.2

373.2.2.3

383.2.2.4

383.2.3

393.2.4

393.2.5

403.2.6

413.2.7

423.2.8

433.2.9

433.2.10

443.2.11

453.2.12

453.2.13

463.3 Bill Processing Overview Workflow – DCMWC

Bill Processing Business Requirements

474.1 Functional Requirements

494.2 Business Rules

Bill Processing Supporting Functional Components

785.1 Initial Data Migration

805.2 Interfaces

815.3 Reports

885.4 Letters

Constraints

906.1 Assumptions

906.2 Dependencies

906.3 Issues/Open Items

Appendices

917.1 Terms & Definitions

1007.2 Pulmonary Rehab CMN Codes – DCMWC

1027.3 Home Nursing CMN Codes – DCMWC

1037.4 DME Codes – DCMWC

1 Bill Processing - DFEC

1.1 Bill Processing Overview - DFEC

Bill Processing encompasses most of the functionality of the CBP system. The process begins with the submission of bills from multiple sources, continues through successful adjudication and pricing, and then ultimately generates payments to the providers and/or claimants. Workflow management is one of the most important components of the system design, directing the flow of bills through the entire process, including interfaces, communications and data management for all phases of the bill process. Workflow encompasses all activities designed to support the rules and policies established by the OWCP for processing bills.

Bill Processing includes editing, both at the point of entry, and throughout the adjudication function. Key editing verifies both provider and claimant eligibility, confirms that all procedure codes are valid and that the services billed are appropriate for the claimant’s injury. Edits also ensure that prior authorizations exist where required, cut-backs in procedure pricing and units are performed when applicable, limits are not exceeded, CCI editing is enforced, adjustments are processed appropriately, and exact duplicate bills are never paid in the system, except only in certain circumstances based on a manual review. Those bills that are suspended due to errors being posted are resolved by following established procedures, defined for both Government and contractor personnel.

Bills that are successfully adjudicated are priced according to Government approved Fee Schedules to pay CPT and HCPC Codes, DRG and CCR calculations to pay Inpatient Bills where applicable, OPPS to pay Outpatient Bills, and AWP to pay Pharmacy Bills in accordance with set policies, and in conjunction with industry standards. Payment processing will support all requirements for both EFT and check payments until March 2013 for current providers and claimants who have not converted to the mandated EFT Process, and maintain payment history with information returned from the U.S. Treasury. All information relative to submitted bills will be accessible for inquiry, including adjudication and payment status and also viewing documents attached to the bills.

1.2 Bill Processing Business Process Description - DFEC

1.2.1 Workflow Management

Bill Processing will be driven by a Workflow design which supports the Government approved rules and processes for every functional area in the CBP. Workflows will appropriately guide each bill from its receipt through scanning, editing, resolution of issues, pricing and payment by the Treasury Dept.

· Workflows must ensure compliance with all defined procedures established by the Government.

· Workflow management will be implemented to control submissions of electronic transactions such as Pharmacy POS, EDI files, and entries initiated on the Web Portal, as well as paper bill submissions.

· It will be used to track documents through specific processes such as imaging. The Central Mailroom will implement workflow management to track bills from the time of receipt through the scanning/imaging process. Details of this process will be in technical specifications of the Mailroom/imaging software process.

· A workflow capability will be used to both generate and monitor communications between the CBP interfaces and Government locations as necessary, such as requests to District Offices for authorizations.

· Workflow processes will support payment and denial policies based on edit dispositions, and provide the capability for bill resolution procedures to allow manual intervention.

· Bills will be routed to appropriate areas and/or personnel through use of work queues and messaging (i.e. web services between system applications).

1.2.2 Bill Entry Process

CBP requires a variety of bill entry methods, described in the following sections. Common to all are preliminary edits to validate key fields on each bill before being delivered to the CBP. Additionally, each bill is assigned a unique identifier that classifies the type of bill/transaction to be adjudicated through the CBP. The unique identifier will be a 12-character Control Number schema that consists of the year, Julian Date, bill type, source, and sequence. This number will serve to uniquely identify each bill across all programs and bill types through the entire adjudication process, including payment and bill history.

1.2.2.1 Mailroom Bill Entry

The CBP Mailroom will receive bills and adjustments for medical services, in addition to bill attachments and other documents related to the bills and adjustments received including claimant’s medical records. The mailroom will incorporate standardized processes for the receipt, identification, and preparation of documents for further processing:

· All documents will be sorted by OWCP program, based largely on the PO Boxes receiving the envelopes.

· All documents will be scanned to produce electronic images of the document. During the imaging process a document control number (DCN) is assigned to each document and its attachments, and then imprinted on the physical documents.

· After scanning, the images are routed to a process for automated classification, such as provider bills, claimant bills, Prompt Pay bills, authorizations, provider enrollments, etc.

· All Pharmacy Bills submitted by paper to the mailroom will be routed for manual entry into the Pharmacy system for adjudication.

· Foreign Bills are recognized and routed to the National Office (NO) for processing and payment by the Government, including conversion to US dollars. Once paid, the NO will create and submit the bill to the mailroom, clearly identified by batch headers and instructions for entry. The bills will have Homegrown procedure codes (FORGN, SPPAY, PANAC, PANAM), and all but the PANAM bills will be keyed as “History Only” bills in the Key Data Entry Unit and routed to Operations.

· All non-Foreign bill documents and attachments will be recognized and routed to the appropriate workflow for data capture and bill processing activities.

· Bills should be submitted on Government approved forms such as HCFA-1500/OWCP-1500, UB-04, OWCP-915, OWCP-957, ADA Dental, NCPDP, and the NALC Carrier form. All bills not submitted on a Government approved form will be returned to the provider (RTP) or claimant (RTC) depending on who submitted the bill.

· Preliminary data checking will be completed by analyzing data fields (depending on the bill form submitted) to ensure that required fields contain appropriate data.

· Key data elements have been identified and will be specifically verified to insure that each bill is acceptable to the CBP process. Edits will vary based on the bill form and whether it was submitted by a provider or claimant, but a bill must always be identified by a valid case number. Other edits check for valid/active providers, as well as excluded providers, date formats, SSN/Case Number, diagnosis and procedures, etc. Invalid critical data elements will result in the RTP/RTC of the bill, with explanation of the issues, and a request for correction and resubmission. If Prompt Pay bills are identified as having any issues, the bill is returned to the District Office responsible for its submission.

· All provider-submitted bills successfully imaged and verified will be routed for data capture and submission to the CBP adjudication system.

· Claimant-submitted bills (typically 957 for Travel & 915 for Medical, but can also be 1500 & UB-04) will be further processed in the mailroom, routed to specific personnel trained to manually develop the bills, including providing diagnoses and procedure codes as needed. In addition to the edits on critical fields, claimants must supply proof of payment before bill entry can continue. The Claimant Development Group will only be verifying the claimant submitted bill for the appropriate “Proof of Payment”. For inpatient bills, the claimant submitted UB will be keyed into the system, and rolled up into a single “Room Charge” line. Since the claimant does not have a Medicare number, the claimant’s submitted UB-04 will pay based on the Cost to Charge Ratio (CCR). If the amount in the reimbursement field as derived from the CCR calculation is higher than the amount that claimant has paid as referenced on the proof of payment, the contractor will pay the amount as paid by the claimant and referenced on the proof of payment. If the amount in the reimbursement field as derived from the CCR calculation is less than the amount as referenced on the claimant’s proof of payment, the contractor will pay the amount as derived by the CCR calculation. As with provider bills, keyed data will be captured to generate an electronic file for submission to the CBP for adjudication and payment.

1.2.2.2 On-Line Portal Entry

Bill entry utilizing the Web Portal will have real-time editing performed as the bills are entered. On line entry forms will be designed in the exact image of Government approved forms (ex. HCFA-1500 and UB-04) to facilitate entry by those already familiar with current paper submissions. In addition, Voc Rehab and Contract Nurse bills will be designed for on-line entry and identified as Prompt Pay bills, and presented in the HCFA-1500/OWCP-1500 format. Claimants will not have the ability to enter bills on-line via Web Portal entry.

While valid key data fields will be assured as part of the Portal entry (case number, claimant and provider eligibility, procedure codes, etc.), electronic bill data files will be generated for submission into the CBP system for all other functions of the adjudication process: editing, Treatment Suites, authorizations, pricing and payment.

1.2.2.3 Electronic Entry of COP Nurse Bills

Bills for COP Nurse Services are a specific type of Prompt Pay bill submitted to the CBP system on an electronic XML file, generated directly from the IFECS system. The triggers for the process are controlled entirely by IFECS, with supporting case status and eligibility information to be provided on the daily eligibility file.

The IFECS file, consisting of a header record followed by individual records, must be subjected to an intermediate loading process, designed to validate the file entries against a specific list of edits (ex. Case number, provider, etc.). An error file will be generated for those entries failing the edits, and an Acknowledgement file must also be returned to IFECS identifying both those entries accepted and rejected.

Valid transactions will be formatted into an electronic file suitable for entry into the CBP system, using the same XML format as for bills from the Mailroom and Portal. Due to the nature of the COP Nurse entries, multiple fields will be populated with a common value for all transactions and presented to medical bill process in the HCFA-1500/OWCP-1500 format:

Diagnosis Code = 999.99

Procedure Code = COPTN

Billed Amount = $100.00

Billed Units = 1

Bill Type = N (Prompt Pay)

1.2.2.4 Pharmacy POS Bills

The Pharmacy bill processapplication will be the sole source of entry for the Pharmacy POS bills. As with medical bills entered on the Portal, they will be subject to real-time editing. Though Pharmacy POS will ultimately be entering the CBP system as fully adjudicated bills (introduced at the point of the payment cycle processing), they will have followed all Government guidelines for capturing and editing the bill data, including most processes defined for medical bills:

· Verification of all key elements, with access to up-to-date claimant and provider eligibility information. This includes recognizing special claimant eligibility scenarios, such as CA-16 and SFC. Dates of service that fall within the CA-16 date span are subject to specific therapeutic classes that are payable within the full CA-16 period.

· Successfully passing standard editing procedures, some specially designed for Pharmacy bills (ex. duplicate bills, verification of NDC codes, dosage limitations, compound drugs, etc.).

· Access Treatment Suites (after translating the NDC into Therapeutic Class Code) to confirm that drugs are valid for claimant’s accepted condition and date of service is valid.

· Verify that appropriate pre-authorizations exist and that authorized limits are not exceeded.

· Account for Short Form Closure restrictions, recognizing the $1500 limit that applies to a combination of both pharmacy and medical bills.

· Provide the capability to record credits and reversals (In-cycle and Out-of Cycle) transactions.

Pharmacy bills will be paid as part of the normal payment cycle process and will become part of the bill history maintained in the system of record, available for inquiry and appropriate reporting.

1.2.2.5 EDI Bills

Some providers will contract to have their bills submitted through a clearinghouse to the CBP systemThose bills will be subjected to the same preliminary edits for critical data fields as the previously mentioned sources of bill entry, with failures returned to the clearinghouse to manage their correction and resubmission. Acceptable bill entries will be received into the CBP, and will follow all standard processes through adjudication and payment to the providers. For DOL, 837P (Professional) and 837I (Institutional) bills will be supported Contractor will capture through the Provider Enrollment application if the provider is interested in billing electronically. If they are, a notification is sent to the electronic clearinghouse to work with that Provider to set them up with EDI. EDI bill submission will be compliant with the 5010 transaction. This will specifically support the entry of up to 12 diagnosis codes on Professional bills, and 25 Diagnosis and Surgical codes on Institutional bills.

1.2.3 Fee Schedule Appeals

Fee Schedule Appeals are a mechanism made available to CBP providers to request a reevaluation of the rate at which a bill was paid. These appeals are received in the mailroom then routed for manual review. The request and all attached documentation are examined to determine whether one of three specific criteria is met:

· An incorrect procedure code was used on the bill originally

· A severe or concomitant medical condition existed which made treatment especially difficult

· The provider possesses an “unusual qualification”

If the request satisfies any of the above criteria, workflow will forward the request to the appropriate District Office for review and final decision, at which time Contractor will send an "Appeals Criteria Letter to the provider/claimant informing them that the appeal was forwarded to the District Office. If the request warrants an adjustment, specific instructions are returned from the District Office to Operations for entry of that adjustment.

If the criteria for a Fee Schedule Appeal are not met, and it is confirmed that the bill had been properly entered, the provider will be notified using the "Appeals Criteria” letter.

Providers will be required to submit with their letter of appeal a "Fee Schedule Appeal Template," checking and referencing one of the criteria for submitting the appeal.

Claimants are not required to submit a "Fee Schedule Appeal Template,” or an Adjustment Request Form, and will not be returned as RTC for this action.

1.2.4 Adjustments

Adjustments can be submitted by claimants and providers to request additional payment or a decrement to an existing debt. They are also initiated by the Government in response to requests or due to issues identified in their accounting and eligibility systems. The scenarios generating adjustments can vary, from procedural rate changes, procedure changes, diagnosis changes, errors in processing, Fee Schedule Appeals, that all can result in the creation of a History Adjustment (No additional Monies Paid), AR1 (Debt Creation), or AR2 (Payment of additional monies). Within the scope of adjustment processing, the CBP will provide the ability to process several types of adjustments including, but not limited to:

· Adjustments on bills incorrectly adjudicated

· Void and credit transactions against previously paid or denied bills

· Single bill and Mass adjustments

· History Only adjustments, which do not affect any payments

Workflow will be utilized to direct the communication of adjustment requests and decisions from the Government to CBP, as in the case of Fee Schedule Appeals described above. All reference files and fee schedules will be available for processing adjustments, to perform all appropriate edits and re-pricing, based on the date of service, and suspending or denying the adjusted bill in the same manner that the original bill would have been adjudicated. As part of that process, the system must allow for manual overrides to insure that only specific parts of a bill are affected by the adjustments applied. CBP will maintain the capability for online access to the complete history of adjusted bills, including all associated transactions.

A critical element of the adjustment process is to support an Accounts Receivable function, in which balances are established for providers who were overpaid. An overpayment is a potential outcome of adjustment processing, and may be identified by either CBP or by processes controlled by the Government accounting system. In either case, interface files are used to communicate A/R transactions between the 2 systems:

· Notification to the Government that an overpayment exists for a provider, or notification from the Government that a payment was returned from the provider due to overpayment

· Acknowledgement received from the Government to create a debt

· Instruction from the Government to begin recoupment of the debt from the provider

· Payments received or recouped as full or partial payment of the debt

· Notification from the Government that a debt is paid in full

· Notification from the Government to write-off a debt (AR3)

· Notification from DOL to cancel a Check (36)

CBP cannot initiate a recoupment of any part of a Medical debt owed by a provider unless directed by the Government. However, if thereare pharmacy debts recorded on the provider file Payee Credit Balance screen, CBP will perform an automatic recoupment from a provider for the same claimant for which the debt was created. If a debt is on file for a pharmacy provider, and a bill comes in for the same claimant case number for which the original debt occurred, CBP will deduct either the entire amount or a partial amount up to the amount that satisfies the debt. If a pharmacy debt has been on file for 120 days with no action of a recoupment, CBP will systematically send a letter to the pharmacy provider on the 121st day to state that they have 30 days to send in the money or be reported to Treasury, at which time CBP will close the debt and send the closed debt to IFECs. IFECs will receive the debt and place the debt in a preliminary status, upgrade the debt to Final Determination and report the provider to Treasury.

The process of decrementing a debt on file can only begin after IFECs or CBP has created an AR1 which actually sets up a debt. If a debt is on file, the debt started out as an AR1, as monies are received (whether in full to satisfy the entire debt or partial payment which does not satisfy the debt), IFECS will send CBP an AR2 record. If the AR2 record sent satisfies the entire debt, the debt is closed in IFECS, and CBP will close the debt, record the debit record which can be identified by a unique debit TCN (Provider Returned the money) and applied to the provider’s 1099. If the provider sends only partial payments which do not satisfy the debt, IFECs will send CBP an AR2 record in order to decrement the debt on file. The debt will not be closed until the last AR2 record is sent to CBP from IFECS, which will satisfy and close the debt. If IFECS decides to write-off the remainder of the debt (Principal, or Interest), IFECs will send CBP a transaction “WD or WI,” which is translated into an AR3 transaction and CBP will create a “History Transaction,” reflecting “Principal Write-off, or Interest Write-off” which is not applied to the provider’s 1099. This process should be detailed further in PWS Section 23 (Adjustment Processing) RSD.

1.2.5 Authorizations

In order to pay for medical services billed on behalf of claimants, the Government requires that the service is related to their accepted conditions or diagnosis or a complication of the claimant accepted condition. In addition, depending on the specific service to be rendered, a pre-authorization is often required, and providers will request approval for an authorization prior to performing the service, to insure that the claimant is covered.

Authorization requests are submitted to CBP by way of the mailroom, fax, Call Center and Portal. Authorization requests will not be requested via the IVR system,. As with all processes in CBP, workflow plays an integral part, directing the requests through editing and transmitting requests and associated documents to and from Government locations as required to support the rules of the authorization process. Many of the edits are similar to those for bills, including eligibility edits for both the claimants and providers. Treatment Suites are also accessed, validating at least 2 diagnosis codes or less submitted on the authorization form with the claimant’s accepted condition to determine coverage of the requested procedure(s) and to identify the authorization level required for the requested procedure(s). That level will also determine the steps required to approve the authorization request:

· Level 1 - no authorization is required

· Level 2 - services that require review by contractor personnel for approval, based on Government guidelines

· Level 3 - services that require review by Government personnel, including the Level 2 services that cannot be resolved by the contractor and systematically escalated to a Level 3. There are circumstances when the authorization level returned from Treatment Suites has to be systematically escalated from a Level 1 to a Level 3. For example, if on a claimant travel bill, the total dollar amount is equal to or greater than $75.00 (procedure codes A0100, A0110, A0120, A0130, and A0140, A0170), the authorization level must default to Level 3. The authorization must be systematically requested from the District Office, if not already in the system. The same rule applies to a mileage total that is equal to or greater than 200 miles (procedure codes A0080, A0090).

For procedures that require a prior authorization, the existence of the authorization will be confirmed before the adjudication / payment of a bill can be completed. Authorization requests also include specific quantities to be approved, in terms of units or dollar value. Authorization limits will be maintained appropriately through the payment and adjustment processes to ensure that services are not paid beyond what was authorized, as well as decremented appropriately for adjustments resulting in an AR1 or AR2 transaction.

1.2.6 Provider Eligibility

CBP will process bills using provider eligibility rules defined by the Government. The goal is to reimburse only qualified, active providers that comply with policies of the OWCP programs. Provider eligibility will be supported as a function of multiple areas of the system:

· Provider Enrollment will insure that all providers are properly identified by Government accepted identification, such as Medicare Number (mandatory for acute care hospitals), Provider Type, Provider Category of Service (Type of Service Modifier), NPI and Taxonomy. The NPI number will be collected for all providers, and used in editing duplicate services for Group Providers.

· All providers will undergo review for proper certification and state licensure, except for non-medical providers.

· Providers will be classified to allow editing for type of service being rendered and billed using the Category of Service Processes.

· Government files will be regularly processed to maintain providers in terms of identifying excluded providers and those on the IRS levy file.

· Providers may be placed “on review” or deactivated based on Government evaluation or other specific criteria, such as inactivity for 2 years.

All bills will be subject to Provider eligibility edits to restrict payment to active providers only:

· Bills for invalid, excluded and non-active providers will be returned as RTP in the mailroom.

· Several edits performed as part of adjudication are designed to deny or suspend a bill based on provider-related information, such as ineligible category of service, type of service, or ineligible date of service.

· If a bill is successfully adjudicated for a provider not on the excluded provider list, payment will still be denied if the provider is subsequently identified as excluded prior to execution of the payment cycle process.

· If a provider is on the IRS Levy file, the bill will be paid, but the payment will go directly to the IRS.

· If a provider has been released from the IRS Levy, the provider will be released from the levy in the system upon receipt of notification from the Government to release the provider.

Bill Processing will notify Providers of reasons for non-payment by way of Remittance Vouchers generated as part of the Payment cycle process.

1.2.7 Claimant Eligibility

Claimant eligibility data will be transmitted from DOL to CBP for each OWCP program on a daily basis via interface data files. Only new cases or those with updated eligibility information will be included on the interface file, which will be subjected to validity edits and checks for presence of key data elements (ex. Name, DOB, SSN, Address, Date of Injury, etc.). Records with fatal errors will be returned to the appropriate Case Management system, designated by program and recorded in the Claimants Eligibility Error Report by District Office. For valid records, the philosophy is that information on an updated eligibility file can overlay the data already existing in the eligibility “system of record.” In terms of identifying a case as payable, the eligibility status information on each file must be carefully evaluated to establish valid time spans for each claimant during which a billed service can be accepted for CBP. All databases accessed as part of any function in Bill Processing must be appropriately updated with new eligibility data in a timely manner such as: CBP System of Record, Claimant Eligibility Record, Eligibility Records in Pharmacy bill system, Eligibility Records in Medical bill process, Eligibility Records Interface to AQS, and Eligibility Records Interface to CQS.

Claimants may have multiple cases within the DFEC program for different work related injuries and referenced in the system with different injury dates. A DFEC claimant having multiple cases will have a separate eligibility record established within CBP for each unique case number. For both DCMWC and DEEOIC claimants, only one eligibility record will exist, identified by the claimant’s SSN.

Claimant eligibility information must be available to some degree in all areas of CBP. For example:

· All bills must be associated with a claimant case number/SSN. Regardless of medium, all incoming bills must be matched to an existing case number/SSN.

· Claimant eligibility data is used to identify valid periods of time for which a service can be billed for any claimant, based on case status and associated effective date spans.

· Accepted Conditions recorded as part of eligibility information are required to be verified with the billed diagnosis and services being billed for a claimant to ensure appropriateness for their injury or illness.

· Edit errors posted, based partly on eligibility information, will dictate whether or not a bill is successfully adjudicated, suspended or denied.

· The OWCP Program District Office number, part of each eligibility record, will control where workflow will direct authorization requests or billing resolution issues that require the attention of District Office personnel.

· Eligibility information will be accessed for inquiries by the Portal, AQS, CQS, medical bill process, and IVR functions.

In addition to the eligibility file data, the CBP will also maintain status indicators to identify a claimant/case “on review,” or a case designated as catastrophic. The requirement to set these indicators will be communicated via a specific request from DOL (DD Exception Process). While the indicator is set, any bills processed for that case will be flagged with a specific error and suspended, requiring manual review. The bill will be routed to a specific work location to be resolved per approved guidelines and instructions such as the following:

· Cases identified as true catastrophic cases (S) will require payment instructions on the eligibility record, as well as a Yearly Prior Authorization to ensure that all medications are paid and no Treatment Suite editing is applied for Pharmacy services.

· Requests to place the claimant on review as an exception should be for specifics (i.e., to pay for specific procedures, or provider’s, for a claimant for a specific date of service or a period of services).

· Exception review requests related to pharmacy medications for a specific medication(s) to be paid for six months or less only will continue to be maintained as it is today utilizing the DD Exception process, and providing a means for tracking these requests over and above the use of a spreadsheet, but generating a standard monthly report which can also be generated on demand by the District Office.

For any bill submitted, the case status is evaluated to confirm that the bill is “payable”. In addition to recognizing normal payable case statuses, CBP must support the identification and handling of cases in specific scenarios which require exceptions to the normal logic flow of adjudication:

· CA-16 – identified by 1 of 2 CA-16 date spans (60 days) on the eligibility record, only a specific list of Procedure Codes, RCC Codes, Therapeutic Classes, and DRG codes are allowable, some payable only within the 1st 15 days, and some payable for the entire 60 day period. As stated in the Authorization RSD 16, the “CA” case status will be utilized in an effort to have accountability on the eligibility file for the 60 day validation. Additionally, there will be instances where an authorization will be checked. Those instances include; If any of the procedures are within the surgical procedure ranges (10000-69999), Medical and Surgical Supplies (A4208-Q4051), Anesthesia (00100-01999), Transportation (A0021-A0999), Specific MS-DRG Codes ranges; as well, for specific DRG code ranges, these services are payable for the first 15 days from the start of the CA-16 period., Contractor will verify if there is an authorization on file for the procedure. If any of these services are performed on the 16th through the 60th day of the CA-16 period, Contractor will verify if there is an authorization on file for the procedure based on the procedures authorization level. (DOL will consider the increase of authorization levels for "Anesthesia,” as well as some Medical and Surgical Supplies). If there is an authorization on file for the procedure, the services will be paid. If there is not an authorization on file for the procedure, the service will be denied for an authorization edit appropriately. Contractor will also take into consideration all of the other procedures that are covered within the entire period of the CA-16.

· Prompt Pay bills – are approved and submitted by the appropriate OWCP Program District Office, clearly identified (bundled and stamped) when received in the mailroom. Other specific Prompt Pay bills are entered on the Portal. Prompt Pay bills submitted via paper submission, and received from the District Office, may include Homegrown codes and/or diagnostic charges in specific situations, in which the diagnostic charges will be identified also as a prompt pay service when applicable as a PPA1 or PPA2, paid based on the calculation as derived from the National Fee Schedule, as well as when to apply interest charges. The procedure codes are validated against a specific Treatment Suite, but the existence of prior authorizations is not required for diagnostic charges.

· Short Form Closure (SFC) – identified by a case status of C1, C2, C4, and a $1500 flag, such a case is payable for a period of 180 days from the start (Date of Injury) of the SFC status. This scenario will allow bills to be paid up to a limit of $1500, including both medical and pharmacy bills. If the $1,500.00 limit is exceeded, a “flip” file is generated, the case status is systematically changed to a “UD” status, and the record is forwarded to the appropriate DFEC District Office for evaluation and update of claimant’s eligibility record.

· UN/UD payable for diagnostics – a case in UN or UD status may still be payable for diagnostic charges, only if DOL has recorded an Accepted Condition of 999.98. If the District Office has placed 999.98 on the claimant’s eligibility file as an accepted condition for a 30 day period, in order to pay for diagnostic services, the diagnostic procedure code is validated against the 999.98 Treatment Suite to see if the diagnostic procedure is present. If the procedure is present, the procedure file will also be checked to see if the diagnostic procedure is covered (not a control code “D,” or an end date towhich the date of service is not prior ). If the diagnostic procedure is not referenced in the 999.98 suite or if the diagnostic procedure code has a control “D” or an end date to which the date of service billed is not prior, the bill will be held in a work queue/location and the District Office will be notified via the workflow tool. Subsequently, the District Office will be required to provide instruction on resolving the situation.

Although Prompt Pay diagnostics will not be validated through the 999.98 suite, the Prompt Pay diagnostic procedure will be validated through the PPA1 and PPA2 Prompt Pay suites, when applicable, to see if the diagnostic procedure is there. If present, the Prompt Pay diagnostic procedure will also be validated through the procedure file to see if the diagnostic procedure is covered (not a control code “D,” or an end date to which the date of service is not prior). If the diagnostic procedure is not referenced in the applicable PPA1 or PPA2 suite(s) or if the diagnostic procedure code has a control “D” or an end date to which the date of service billed is not prior, the bill will be held in a work queue/location and the District Office will be notified via the workflow tool. At which time, the District Office will be required to provide instruction on resolving the situation.

· Third Party Liability - Third party liability will be indicated on the claimant eligibility file. For any time the TPL flag is on, claimant's bills will be denied for payment by CBP, which will be communicated by an EOB to the claimant. Once the TPL status is removed, bills will process normally.

1.2.8 Treatment Suites

Treatment Suites is an interface designed to ensure that services billed for a claimant are appropriate for their billed diagnosis / accepted condition. It is driven by a database built to reflect Government policies and guidelines as well as industry standards for medical procedures and medical bill processing. Treatment Suites are basically a grouping by diagnosis of all services deemed appropriate for treating an individual with that diagnosis or complications. Included in each Treatment Suite are medical procedures, medications, diagnostic procedures and other services, identified by standard coding structures, including ICD-9/10, CPT, HCPCS, DRG, GCN, RCC, and Therapeutic Class codes. DOL has also included some Homegrown procedures appropriate for specific types of eligibility and/or bills.

In addition to identifying acceptable procedures for a diagnosis, Treatment Suites is also used to record the level of authorization required for each service. The authorization level of a given procedure may change between treatment suites. The authorization level is key to both the approval of new authorization requests submitted and the adjudication of bills, to verify the existence of required pre-authorizations. An inquiry function will be available on the Portal, which will be used to verify to a provider (or pharmacy) whether a claimant is eligible for a specific treatment; that inquiry function will also access Treatment Suites to confirm that eligibility and communicate what prior authorizations are required.

All bill types will be subjected to some degree of Treatment Suite processing, for both Medical and Pharmacy bill processing. The process will be built as a package to be called by both Pharmacy bill processand Medical bill process as part of the adjudication of bills submitted. The logic itself will be determined by the type of bill and / or certain eligibility scenarios:

· Treatment Suites is executed at the line level of each bill, except for Inpatient bills, which is based on the entire bill. An interface with the 3M Grouper will be used to evaluate the bill as a whole, assigning the appropriate DRG code. That DRG is the procedure code that will be verified as acceptable in Treatment Suites for the claimant’s accepted condition(s)

· On Pharmacy bill lines, the NDC code must be translated into a Therapeutic Class code before accessing Treatment Suites based on the claimant’s accepted condition on the eligibility record. Since pharmacy bills do not contain a diagnosis, the treatment suites will utilize only the accepted condition(s). There will be no need to cascade to complications.

· On Outpatient bills, the RCC to CPT crosswalk determines if a treatment suite look-up is based upon the RCC or CPT code. In addition, the move to OPPS will affect pricing of these bills, and the level of acceptable payments with the implementation of this process will be determined by DOL.

· There are exception conditions, such as Prompt Pay bills and eligibility scenarios including CA-16 & SFC, which may force accessing a specific Treatment Suite, or bypassing the validation of authorizations.

Taking into consideration that the process followed depends on exceptions as listed above, the basic Treatment Suite logic is as follows:

· The billed diagnosis code must match 1 of 99 accepted conditions (or their complications) recorded on the claimant’s eligibility record.

· The billed date of service must be within the date range of the matching accepted condition.

· The Treatment Suite for that accepted condition must include the billed procedure code (or DRG or Therapeutic Class).

Treatment Suites edits are assigned specific disposition codes, which may suspend or deny payment of a bill, as with all other edits described below.

1.2.9 Edits & Audits

The CBP will support Government business rules by using approved edits and audits. Depending on the edit, it may be applied against bill lines or against the complete bill. Audits are applied against bill histories and used for duplicate check, utilization review, CCI editing, Global Surgical Cut-backs, Multiple Surgical Cut-backs, Maximum Units Cut-backs, Utilization Review, Pharmacy Polyscriber, and Refill Too Soon editing. The results of the edits performed will return a pre-defined disposition code, which may suspend, reduce payment of a bill line, or deny payment of a bill or bill line.

Edits are a crucial part of the adjudication process, beginning with the submission of bills, whether by mail, electronic files or on-line entry. Edits have been designed to verify not only the data on the bill itself, but to confirm that all information relative to the bill is acceptable for payment, such as Provider and Claimant eligibility. There are also edits specific to pharmacy bills versus bills for medical services. All edits to ensure that bills are properly adjudicated and priced correctly are based on the date of service, the control codes reference in the procedure record, maximum units, as well as the end date of the procedure which is also referenced on the procedure file recordThe procedure record will also ensure applicable provider types limited for billing the specific procedure, as well as the proper type of service which will be linked to the provider's Category of Service to eliminate improper billing.

In addition to the eligibility checks already mentioned, CBP will support other categories of edits and audits including:

· Duplicate Checks across all bill types

· Data Validity (diagnoses, procedure codes, etc)

· Authorizations required as designated for the service being billed

· Treatment Suites (described in previous section)

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

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

· CCI edits to check for add-on codes - to ensure a 'base/parent code' is present when an add-on code is billed and also check to see if the ‘'base/parent code' has been billed and/or paid. (NOTE: The add-on to "base/parent code" table is not obtained with the commercially available CCI edits tables. The "add-on to base/parent code" was developed by DOL and is maintained by DOL, and as updates are identified, DOL will provide Contractor with any new add on-codes, as well as new base/parent codes to be applied to their programs for editing.)

· Age and gender edits will be applied against all reference codes to ensure consistency between the service billed and the claimant's gender.

· Fee Schedule

· Cutback edits to ensure newly billed procedures are reduced by previous bill payments when pricing should have been adjusted and/or maximum units are exceeded

· Adjustment processing that ensures only appropriate bill lines are re-priced

Any errors identified will follow workflow to appropriate personnel for resolution. Some edits / types of bills will require handling by specific personnel, for example:

· Depending on the reimbursement amount, DFEC bills will be handled as follows:

· Reimbursement amount of $30,000.00 or greater not to exceed $50,000.00 will be processed and adjudicated by Contractor.,

· Reimbursement amount of $50,000.00 or greater not to exceed $1,000.000.00 will be routed via workflow to the appropriate District Office

· Reimbursement amount of $1,000.000.00 or greater will be routed via workflow to the National Office

· Exact duplicates will deny a bill, but possible and probable duplicates require manual review.

· Prompt Pay bills found in error will be returned to the OWCP Program District Office where initiated.

More specific editing criteria are explained in detail in the Edits & Audits RSD 13.

1.2.10 Bill Resolution

Bills are evaluated and dispositioned according to Government approved edits. While the majority of bills will adjudicate successfully through the electronic process, bills that suspend as a result of any issues identified during adjudication will require manual review and must be routed by workflow to Bill Resolution and in some cases, to authorized Government personnel.

Workflow will also be used to communicate requests to OWCP Program District Offices for missing authorizations related to Claimant submitted bills where the procedure/service being requested for reimbursement requires an authorization.

Specialists will follow approved procedures, based on program policies, bill types and provider types.

Any action taken during bill resolution will be traceable, and accessible for view by authorized personnel and for reporting purposes. The resolution process must allow for exception processing, such as manual pricing and overrides of posted edits, sometimes directed specifically by Government personnel. Once errors are resolved, bills will go through the adjudication process again, including a full set of processing edits and application of fee schedules with the exception of those services requested for the performance of ”Manual Pricing,” which could not be re-priced through the normal Fee Schedule process . These Fee Schedule “Manual Pricing” requests will come in as adjustment requests from DOL as a result of an Adjustment or Fee Schedule Appeal.

1.2.11 Bill Pricing

All prior steps in the adjudication process are directed to ensuring that each bill entering Bill Pricing has successfully passed strict editing guidelines, confirming that all services are appropriate for eligible claimants and billed by active providers. 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 systematic adjustments in the billed charges based on the provider’s geographic factors.

Some 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, and the procedure does not contain a control code of “D,” the procedure will be paid as billed. If the procedure does not contain a control of “D,” and the fee schedule for the procedure contains a set/flat fee, then the payment will be up to the maximum amount as referenced on the file and 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.

More specific pricing criteria governing bill pricing methodology is explained in detail in the Bill Pricing RSD.

1.2.12 Payment Process

The Payment Cycle process is run weekly by OWCP program, and generates payments to providers and/or claimants per the rules of each program. Each run of the payment process will generate two files: Check Payments & EFT Payments. . The files are made available to DOL who will review and forward those files to the US Treasury for printing checks and transmitting EFT payments. For the DFEC payment files, payments are generated at the District Office and Provider level. The claimant’s case number and Agency Code are also used in the Charge Back process handled by the Fiscal Operation unit. The US Treasury will assign check numbers and EFT transaction numbers as part of their disbursement process. Those numbers will be returned to the CBP on an Accomplishment file which will be used to update payment history, completing the payment identification loop.

In support of each payment, Remittance Vouchers (RVs) are generated and mailed to the provider/claimant, to account for the detail of all bills , adjustments, debt balances where applicable, and IRS Levy deducted amounts, including reasons for denial of bills, and statistics on bills still remaining to be paid.