25_TCRS_Sec_J_Atch_J-17_PCDIS_User_Guide.pdf

Defense Health Services Systems

Purchased Care

Detail Information System

(PCDIS)

User Guide v 5.01.01.0 For questions or concerns regarding this user guide, contact the MHS Help Desk 1-800-

600-9332, or Email EIDS@mhs-helpdesk.com

Attachment J-17, PCDIS User Guide mailto:EIDS@mhs-helpdesk.com

PCDIS User Guide

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TABLE OF CONTENTS

Table of Contents

1. PEPR Overview

1.1. TRICARE

1.2. Defense Health Services Systems Program Office

1.3. What is PEPR

1.4. PEPR Ad Hoc Reporting Tools

1.5. Why PEPR

1.6. How PEPR Is Used

1.7. The PEPR End User Community

1.8. Purchased Care Data in PEPR

1.9. What is a HCSR

1.10. What is a HCPR

1.11. What is a TED Record

1.12. What is a TEPRV

1.13. Data Collection and Processing

2. The PEPR Portal

2.1. Logging Into the PEPR Portal

3. Purchased Care Detail Information System (PCDIS) Application Overview

3.1. PCDIS Description

3.2. Benefits of PCDIS

3.3. PCDIS Data

3.4. Detailed System Overview

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3.5. About this User guide

3.6. Conventions

4. Using the PCDIS System

4.1. PEPR Portal Welcome Screen

4.2. PCDIS Welcome Screen

PEPR Main Menu Bar

News

Search Options

Provider Directory

4.3. PCDIS Navigation

Primary Navigation Bar

Secondary Navigation Bar

4.4. Use PCD1S Search Options

Using Search Screens

Sponsor /Beneficiary Search Screen

Using Sponsor/Beneficiary Name Searches

Provider Search Screen

NAS/MTF

TED/HCSR ICN

Practice Searching

Perform A Provider Search

Perform A Sponsor/Beneficiary Search

Perform A Search Using A Dropdown List

4.5. Navigate Search Results

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Cross Check Search Results

Selecting Records

Profile, Group Summary, and Detail Screens

Profile Screens

Date of Care Search

Group Summary Screens

Provisional and Fully Accepted TED/HCSR Records

Validity Edits

Relational Edits

Provider Detail Screen

4.6. TED/HCSR Detail Records

Overview

Print and Legend Functions

Field Help, Screen Help, and Definition Tables

TED Record/HCSR Detail Screens

Claims-Related Detail Data Screens

Financial and Processing

Beneficiary and Provider

Detail-Institutional Utilization/Revenue

Non-Institutional Utilization

Records with Multiple Providers

4.7. PCDIS Extract Reports

Run Data Extracts

View Extracts

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4.8. Use Preformatted Reports

Preformatted Summary Reports

Report Views

Save Reports as PDF

Save Report as Excel

TED/HCSR Detail Reports

Run a TED/HCSR Detail Report

View a HCSR Detail Report

4.9. Understand Cognos Query

Run a Cognos Query Report

Select Columns

Add a Filter

Use Filter Operators

Run Query

Cognos Query Toolbar

Display More Rows

Use CQ Design Tool

Hide Column

Sort - Single Column

Sort - Multiple Columns

Group Data

Add a Total Row

4.10 PCDIS PRDM Business Objects (BOXI) Reports

Top Non-Institutional Providers by State/Foreign Country

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Top Institutional Providers by State/Foreign Country

Procedure Code Listing for Provider (PCDISRTH135)

Non-Institutional Providers by Procedure Code with associated Detail Report(PCDISRTH136)

Non-Institutional Summary by Procedure Code/Fiscal Year (PCDISRTH138)

Procedure Code Summary Report For TIN (PCDISRTH139)

Non-Institutional Providers Specialty for Foreign Country that User Selects(PCDISRTH140)

Creating Ad-Hoc Reports in BOXI

Filtering and sorting reports in BOXI

Printing and Saving Reports in BOXI

5. HELP - MHS HELP DESK

6. Abbreviation List

7. DOCUMENT REVISION LIST

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Figure 1 Claims Processing Cycle

Figure 2 PEPR portal privacy statement

Figure 3 system flow

Figure 4 click on PCDIS

Figure 5 portal welcome screen

Figure 6 welcome to PCDIS screen

Figure 7 areas on the welcome screen

Figure 8 PCDIS navigation

Figure 9 search options

Figure 10 search screen methods

Figure 11 sponsor/beneficiary search screen

Figure 12 sponsor identifier/patient name search screen

Figure 13 search results

Figure 14 provider search screen

Figure 15 NAS/MTF search

Figure 16 TED/HCSR ICN Search

Figure 17 navigation search results

Figure 18 cross check search results

Figure 19 selecting records

Figure 20 next page of results

Figure 21 provider profile and sponsor/beneficiary profile

Figure 22 sponsor beneficiary profile

Figure 23 group summary screens

Figure 24 provisional and fully accepted TED/HCSR records

Figure 25 provider detail screen

Figure 26 legend

Figure 27 Field Help, Screen Help, and Definition Tables

Figure 29 TED/HCSR Detail Listing

Figure 28 TED/HCSR details

Figure 30 ICN Search results

Figure 31 CLAIMS RELATED DETAIL DATA SCREENS

Figure 32 FINANCIAL AND PROCESSING SCREEN

Figure 33 BENEFICIARY AND PROVIDER SCREEN

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Figure 34 INSTITUTIONAL UTILIZATION/REVENUE

Figure 35 LINE ITEM SUMMARY VIEW

Figure 36 records with multiple providers

Figure 37 procedure code help

Figure 38 line item expanded detail view

Figure 39 TED/HCSR provider detail listing

Figure 40 submit an extract

Figure 41 extract status screen

Figure 42 extract status screen

Figure 43 PCDIS formatted and ad-hoc reports screen

Figure 44 report views

Figure 45 save as type options

Figure 46 TED/HCSR detail

Figure 47 extract file dropdown list

Figure 48 Ad Hoc Downloads Using Cognos Query Packages

Figure 49 New Query Wizard screen

Figure 50 Add Delete Move or REname columns

Figure 51 Run Query in Design Mode

Figure 52 apply common filters and permissions

Figure 53 view query

Figure 54 cognos query toolbar

Figure 55 display more rows

Figure 56 hide a column

Figure 57 sort by a single column

Figure 58 sort multiple columns

Figure 59 group data

Figure 60 add totals

Figure 61 link to business objects in PCDIS

Figure 62 CAC login screen

Figure 63 select document list

Figure 64 select folders >PEPR>PRDM

Figure 65 select report

Figure 66 select the number of records to be returned

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Figure 67 provider specialty prompt

Figure 68 country code/state code prompt

Figure 69 fiscal year prompt

Figure 70 sample report Top Non-Institutional Provider by State/Foreign Country

Figure 71 select report

Figure 72 Please Enter Number of Records Returned

Figure 73 select type of institution(s)

Figure 74 select fiscal year

Figure 75 select country/state

Figure 76 sample report Top Institutional Provider by State/Foreign Country

Figure 77 select report

Figure 78 enter provider TIN(s)

Figure 79 enter fiscal year(s)

Figure 80 sample report PCDISRTH135 Procedure code listing for provider

Figure 81 select report

Figure 82 input procedure code

Figure 83 insert provider specialty

Figure 84 select fiscal years

Figure 85 sample report Non-Institutional Providers by Procedure Code (PCDISRTH136)

Figure 86 detail report

Figure 87 select report

Figure 88 select procedure codes

Figure 89 select fiscal year(s)

Figure 90 sample report header Non-Institutional Summary (PCDISRTH138)

Figure 91 select report

Figure 92 select a single tin

Figure 93 input fiscal year

Figure 94 sample report header Procedure Code Summary for Provider TIN(PCDISRTH139)

Figure 95 select report

Figure 96 select a single foreign country

Figure 97 select desired specialities

Figure 98 select fiscal years

Figure 99 sample report PCDISRTH140 Non-Institutional Provider Specialty for Foreign Country

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Figure 100 under New > Web intelligence document

Figure 101 universe displays > select objects> run query

Figure 102 my favorites folder and user reports folder

Figure 103 Rank and Sort

Figure 104 save to my computer as excel/pdf

Figure 105 file name

Figure 106 do you want to open or save this file

Figure 107 click print icon

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1. PEPR OVERVIEW

1.1. TRICARE

TRICARE is the Department of Defense's managed healthcare program for active duty service members, service families, retirees and their families, survivors, and other TRICARE-eligible beneficiaries. TRICARE is a blend of care provided by the military's direct care system of hospitals and clinics and care received from the purchased care system of civilian providers.

1.2. DEFENSE HEALTH SERVICES SYSTEMS PROGRAM OFFICE

The Defense Health Services Systems (DHSS) Program Office provides decision support information and tools used by Military Healthcare System (MHS) managers, clinicians, and analysts to manage the business of healthcare within the MHS.

DHSS provides the centralized data store for the MHS. Its systems have active interfaces with more than 260 systems around the globe. They support more than 2,500 users and provide a robust suite of decision support tools to empower the effective management of the MHS healthcare operations.

1.3. WHAT IS PEPR

Patient Encounter Processing and Reporting (PEPR) is a suite of web-based reporting tools developed to help analyze and manage the purchased care portion of the TRICARE program. It accesses data stored in the Purchased Care Data Warehouse (PCDW). This data includes all processed claims-related data for purchased care; it does not include data for care provided by military personnel in a military facility (direct care).

PEPR also includes additional ad hoc reports and applications designed for specific end-user requirements not covered in the functionality of the main applications.

1.4. PEPR AD HOC REPORTING TOOLS

• PEPR also features additional ad hoc, or Satellite, reports and applications designed for specific end-user requirements.

Permissions to these reports and applications are limited to users with a "need to know".

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1.5. WHY PEPR

Replace and absorb the costly and outdated functions of the TMA-RT legacy mainframe systems

Integrate historic Health Care Service Records (HCSR) and Next Generation contracts TRICARE Encounter Data (TED) recordsrecords

Meet Health Insurance Portability and Accountability Act (HIPAA) code set, privacy and security requirements

Improve reporting system availability by leveraging web-based data mining technologies

Provide a common user interface across the PEPR application suite

1.6. HOW PEPR IS USED

Analyze purchased care cost and workload data

Identify resource sharing opportunities

Evaluate potential workload to be recaptured by the MTF

Forecast healthcare cost and workload

1.7. THE PEPR END USER COMMUNITY

All levels of managed care analysts, healthcare planners, resource managers, and financial analysts in the MHS

TRICARE Management Activity (TMA) Program Integrity (PI) in conjunction with Defense Criminal Investigative Service (DCIS), and other Department of Defense (DoD) staff investigating fraud and abuse

Department of Justice (DOJ) analysts reviewing cases for third-party liability recoupment

Beneficiary Counseling and Assistance Coordinators (BCACs)

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1.8. PURCHASED CARE DATA IN PEPR

The Purchased Care data is populated from four sources: the Health Care Service Record (HCSR) and Health Care Provider Record (HCPR) required under the outgoing Managed Care Support Contractor (MC SC) agreements, and the TRICARE Encounter Data (TED) record and TRICARE Provider (TEPRV) record required under the new Next Generation Contractor agreements.

1.9. WHAT IS A HCSR

A HCSR is a data set of information required for all care received/delivered under the Managed Care Support contracts and provided by the contractor in a government specified format and submitted to TMA via a telecommunication network. The claim information in the data set can be described in the following broad categories:

Beneficiary identification (i.e., enrollment/eligibility status, sponsor service branch affiliation, etc.)

Provider identification (including type of institution/provider specialty, etc.)

Health information

Place and type of service

Diagnosis and treatment-related data

Units of workload (i.e., admissions, days, services, visits, etc.)

Related financial information (i.e., billed, allowed, patient cost-share, government paid amounts, etc.)

Business rules for the HCSR require that a unique HCSR be comprised of one provider and one beneficiary. Claims submitted with multiple providers are assigned the same Internal Control Number by the claims processor and split to meet the business rule by the addition of an alpha suffix. For example, if a group practice submits a claim for a beneficiary with procedures for three different doctors who delivered care, this results in three HCSRs, one for each doctor.

Additionally, the HCSR contains line item procedure code cost information for Amount Billed and Amount Allowed. The Amount Pa id is aggregated at the total claim level. In the Purchased Care Data Warehouse the Amount Paid is estimated by line item procedure code for reporting purposes.HCSR records are required to pass both validity (data must be compatible with values and records on the TM A database) and relational (values of two or more data elements are dependent on each other and must be compatible) edits before being accepted electronically by TRICARE. Records that do not pass the edits are returned to the contractor for correction and resu bmission.

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1.10. WHAT IS A HCPR

A HCPR is a Health Care Provider record identifying an individual or institution licensed or otherwise authorized to practice medicine or deliver healthcare services, supplies, or equipment.

1.11. WHAT IS A TED RECORD

A TED record is a data set of information required for all care received/delivered under the Next Generation Contracts and provided by the contractor in a government specified format and submitted to TMA via a telecommunication network. The claim information in the data set can be described in the following broad categories:

Beneficiary identification (i.e., enrollment/eligibility status, sponsor service branch affiliation, etc.)

Provider identification (including type of institution/provider specialty, etc.)

Health information Place and type of service Diagnosis and treatment-related data

Units of workload (i.e., admissions, days, services, visits, etc.)

Related financial information (i.e., billed, allowed, patient cost-share, government paid amounts, etc.)

Business rules for the TED record allow multiple providers for one beneficiary on the same claim. For example, if a group practice submits a claim for a beneficiary with procedures for three different doctors who delivered care, this results in one TED.

Additionally, the TED record contains line item procedure code cost information for Amount Billed, Amount Allowed, Amount Paid, Amount Applied to Deductible, Patient Cost Share, and Amount Paid by Other Health Insurance.

TED records are required to pass only validity (data must be compatible with values and records on the TMA database) edits before being accepted electronically by TRICARE. Records that do not pass the relational edits are accepted provisionally into the TRICARE database and the contractor is required to correct these records in a timely manner via the adjustment submission process. Data in PCDIS, and PCURES includes the data from provisionally accepted records.

1.12. WHAT IS A TEPRV

A TEPRV is a TRICARE Encounter Provider record identifying an individual or institution licensed or otherwise authorized to practice medicine or deliver healthcare services, supplies, or equipment.

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1.13. DATA COLLECTION AND PROCESSING

Purchased care claims processed by the Managed Care Support Contractors/Next Generation Contractors are electronically transmitted to TRICARE on a daily basis. The claims processing cycle is represented in Figure 1.

The accepted TED records and HCSRs are populated to respective Operational Data Stores (ODS).

The Purchased Care Data Warehouse is populated with the data from both the TED record and HCSR ODSs. Data values are standardized for consistency when necessary so both record types can be housed in the same data warehouse.

The data is further manipulated and loaded to a number of data marts to meet the unique requirements of the PEPR downstream reporting applications..

FIGURE 1 CLAIMS PROCESSING CYCLE

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2. THE PEPR PORTAL

2.1. LOGGING INTO THE PEPR PORTAL

Access the PEPR portal at https://peprsite.den.disa.mil. The first screen to display upon entry to the PEPR portal is the Privacy Statement screen.

1. Click <I Agree> to agree to the terms of usage and access the PEPR applications to which you have been granted access.

Note: The For Official Use Only (FOUO) statement appears at the bottom of the screen. This footer is present on all PEPR screens and is printed on PEPR output that is accomplished using the PEPR application tools. Click on the FOUO footer to read the full Privacy Statement.

FIGURE 2 PEPR PORTAL PRIVACY STATEMENT

https://peprsite.den.disa.mil/

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2. Click in the User ID field and type your login name.

3. Advance to the Password field by pressing <Tab> or clicking in the field.

4. Type your password. Click <Sign In>.

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3. PURCHASED CARE DETAIL INFORMATION SYSTEM (PCDIS) APPLICATION OVERVIEW

3.1. PCDIS DESCRIPTION

The Purchased Care Detail Information System (PCDIS) is an application that provides quick and easy access to TRICARE claims-related data stored in the Purchased

Care Data Warehouse (PCDW). PCDIS functions as a "search window" into the purchased care claims database.

PCDIS data includes all processed Health Care Service Records (HCSR) and TRICARE Encounter Data (TED) claims for care provided to TRICARE beneficiaries by civilian network and non-network providers.

Features of online PCDIS include:

Web-based, real time information

Access to TED and HCSR detail claims and summary data for institutional and professional purchased care

Online retrieval paths to view detail and summary claims data

Ten years of Purchased Care data

Consolidated search screens

Enhanced beneficiary and provider name searches

Additional print functions

Field descriptions, screen- and field-level Help via mouse click

Mouse click access to ICD-9-CM and CPT-4 description tables

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3.2. BENEFITS OF PCDIS

PCDIS provides TRICARE healthcare managers and analysts, fraud and abuse investigators, and third party liability litigators the ability to report on detail and summary level purchased care claims data in order to evaluate and manage the TRICARE program for the MHS. Data in PCDIS assists in the analysis and reporting of purchased care cost and workload, resource sharing opportunities, network and non-network provider information, and potential dollars to be recaptured by MTFs. It is also a tool for Beneficiary Counseling and Assistance Coordinators (BCACs) assisting beneficiaries with claims-related questions.

3.3. PCDIS DATA

As a PCDIS end user you access the PCDW directly when performing online searches. These searches will allow you to access cost and workload data by provider, sponsor/beneficiary, or MTF/NAS (Non-Availability Statement).

Searches and reports that you run against the PCDIS summary databases actually pull the data from the PCDIS Summary Table, which is populated from the PCDW

3.4. DETAILED SYSTEM OVERVIEW

The Purchased Care Detail Information System (PCDIS) Application allows the government to access healthcare detail claim-related data by Provider, Beneficiary, Non-Availability Statements/Care Authorizations or Internal Control Number

FIGURE 3 SYSTEM FLOW

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Healthcare records are updated daily

Users can also report on summarized data for Provider, Beneficiary, or Non-Availability Statements/Care Authorizations for a MTF

3.5. ABOUT THIS USER GUIDE

This user guide provides step-by-step instructions to access the TRICARE Patient Encounter Processing and Reporting (PEPR) Purchased

Care Detail Information System (PCDIS) system using an internet accessible computer system.

This user guide can be used in two ways: as a new user's learning tutorial and as a reference guide for experienced users.

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3.6. CONVENTIONS

The following conventions will be used to indicate buttons and identify field names and toolbar instructions within the application.

Underlined and Bold text represents user action, ex. Click <Submit>

"< >" indicates buttons that are to be selected; ex. Click <Submit>

Bold text indicates fields or toolbar instructions; ex. Type your name in the User ID field.

"|" indicates a selection sequence; ex. Select File | Open | Look in | My Documents | Select desired Word document

"*" indicates a required field; ex. Provider*

You can return to the PEPR satellite applications screen by clicking on its link at the top of the screen.

Do not use your browser's back arrow

FIGURE 4 CLICK ON PCDIS

NOTE: The screenshots used within this document were taken from the PEPR Portal and may not reflect more recent changes. However, the functionality of the application remains the same

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4. USING THE PCDIS SYSTEM

4.1. PEPR PORTAL WELCOME SCREEN

The PEPR Main Menu Bar remains active throughout your PCDIS session. It is comprised of the following standard hyperlinks.

Home - returns you to the PEPR Welcome Screen from anywhere in PCDIS

Help - accesses screen-level Help for PCDIS

Profile - provides view and edit features for your User Profile and accesses the Change Password utility

Logout - logs you out of PEPR

FIGURE 5 PORTAL WELCOME SCREEN

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Click the PCDIS link on the top of the PEPR Main Menu Bar and the Welcome to PCDIS screen will be displayed.

FIGURE 6 WELCOME TO PCDIS SCREEN

Authorized PRDM users will see this screen where they can run the original PCDIS with the original Provider Summary, or PCDIS PRDM.

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4.2. PCDIS WELCOME SCREEN

The PCDIS Welcome Screen, also referred to as the Main Menu, is comprised of four primary areas.

The PEPR Main Menu Bar at the top of the screen

A News area (will only display when there is News available)

The PCDIS Search Option links

The TRICARE Provider Directory link

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FIGURE 7 AREAS ON THE WELCOME SCREEN

PEPR MAIN MENU BAR

The PEPR Main Menu Bar remains active throughout your PCDIS session. It is comprised of the following standard hyperlinks.

Home - returns you to the PEPR Welcome Screen from anywhere in PCDIS

Help - accesses screen-level Help for PCDIS

Profile - provides view and edit features for your User Profile and accesses the Change Password utility

Logout - logs you out of PEPR

NEWS

Updates and information specific to the PCDIS data and application are posted to the News area on the PCDIS Welcome Screen. Look for updates on this screen each time you log in to PCDIS.

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SEARCH OPTIONS

PCDIS provides four search options or search paths to access the purchased care TED record/HCSR data. Your choice of search option will be dependent on the type of information you have available about the claim or group of claims you need to access.

Sponsor/Beneficiary Search

Provider Search

NAS/MTF Search

TED/HCSR ICN Search

PROVIDER DIRECTORY

This link launches the TRICARE Provider Directory web page. Use this link to search for authorized TRICARE providers.

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4.3. PCDIS NAVIGATION

Navigation in PCDIS is accomplished using links found on the Primary and Secondary Navigation toolbars. The links that appear on the navigation bars are specific to the screen you are viewing.

PRIMARY NAVIGATION BAR

The Primary Navigation Bar is the gray bar at the top of each screen located directly below the PEPR Portal banner. The Primary Navigation Bar allows movement between your current screen and previously accessed screens. The deeper you go into your search the more links appear on the bar. Use these links, rather than your browser's <Back> button to navigate backwards.

FIGURE 8 PCDIS NAVIGATION

SECONDARY NAVIGATION BAR

The Secondary Navigation Bar is located on the gray bar under the Search Criteria line. Additional PCDIS screens appear as links on this navigation bar. The secondary navigation bar also houses Next and Previous hyperlinks used to navigate through record lists.

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4.4. USE PCDIS SEARCH OPTIONS

Each PCDIS search option screen provides multiple search sections containing one or more search fields. Each search section has one required field (denoted with an asterisk *) and one or more optional fields, grouped in a "boxed" section on the screen. You can only use one search section at a time.

Note that each search section has its own Search button. You must click the <Search> button boxed with the search fields you use.

All PCDIS search screens contain a Reset button in the upper right hand corner. This button clears all existing search criteria from the screen.

FIGURE 9 SEARCH OPTIONS

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USING SEARCH SCREENS

There are three primary methods for entering data in the PCDIS search screens.

FIGURE 10 SEARCH SCREEN METHODS

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SPONSOR /BENEFICIARY SEARCH SCREEN

The Sponsor/Beneficiary search contains three search paths.

Sponsor Identifier Search which requires the Sponsor Identifier (SSN) number to be entered

Patient Name Search requiring at least one letter in the patient last name field (not case sensitive)

Patient Identifier Search which requires that the Patient Identifier (SSN) be entered

The Sponsor Identifier and Patient Name search sections include two optional fields to narrow down your search.

DEERS Dependent Suffix

Patient DOB

Note: The DEERS Dependent Suffix (DDS) was eliminated for HCSR and TED records in

April 2004 with the exception of TMOP pharmacy records. The Patient Relationship to

Sponsor field (HCSR) and Health Care Coverage Member Relationship Code field (TED record) should be used to determine patient relationship to sponsor.

USING SPONSOR/BENEFICIARY NAME SEARCHES

PCDIS assumes an "implied wildcard" on the last, first and middle name fields for Patient

Name searches where at least one character of data is entered in the field. For example, if you enter John Doe in the first and last name fields respectively, the system will return records for all individuals with a last name Doe as well as those that begin with Doe such as Doebber, Doebbler, Doerning, etc. The first name will be treated similarly capturing John, Johnson, and so forth. No wildcard is applied to the middle initial field in this example because no value has been entered in that field.

FIGURE 11 SPONSOR/BENEFICIARY SEARCH SCREEN

FIGURE 12 SPONSOR IDENTIFIER/PATIENT NAME SEARCH SCREEN

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It is important to cross check Patient Identifier (SSN) searches by Sponsor Identifier (SSN) as the Patient Identifier field on the HCSR is actually the beneficiary SSN which is not a required field on the HCSR. A TED record requires the Patient Identifier (SSN) so the Patient Identifier search is more reliable for these records.

Additionally, PCDIS, unlike the legacy CDIS application, no longer distinguishes patients by different names because the application is able to create a correlation to a unique patient regardless of name differences, changes or misspellings as displayed in Figure 12.

FIGURE 13 SEARCH RESULTS

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PROVIDER SEARCH SCREEN

The Provider Search screen has three unique search paths which are boxed. Each boxed section has a required field marked by an asterisk (*).

Provider ID - requires the Provider SSN/TIN/EIN

Provider Name - enter at least on alpha character (not case sensitive)

Provider Zip or State - enter the Zip Code or the State to satisfy the required field prerequisite

Users of the legacy CDIS system will note that the State and Provider Type (Institutional/Professional) fields are new search fields in PCDIS.

PCDIS assumes an "implied wildcard" on the last name for Provider Name searches where at least one character of data is entered in the field. For example, if you enter

Marks in the last name field, the system will return records for all individuals with a last name Marks as well as those that begin with Marks, such as Markson; the search is based on the initial string entered.

TRICARE business rules identify a unique provider by the combination of Provider ID, Sub ID, Specialty and Zip code. Providers are further identified by their

Institutional or Non-institutional status.

FIGURE 14 PROVIDER SEARCH SCREEN

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NAS/MTF

You can look at claims processed against Non-Availability Statements (NASs) or Care Authorizations (CAs) for all healthcare records associated with a specific NAS/CA number or for all NASs/CAs issued by a specific inpatient Medical Treatment Facility (MTF). In the NAS Summary by MTF search section, select a radio button to specify whether you want to retrieve HCSR, TED, or both kinds of records. The default is HCSR.

To query the database by NAS/CA number, use the section of the screen for

TED or HCSR as the NAS/CA numbers are formatted differently on the respective records and must be entered in different fields.

NASs and CAs are differentiated on the database by the Reason For Issuance (RFI) field on the first screen of the detail record. A NAS is required for Inpatient Care rendered in a civilian facility for a beneficiary residing in an MTF catchment area under the Managed Care Support Contracts. CAs are required for TRICARE Prime enrollees assigned to a military doctor as a Primary Care Manager who are provided inpatient care in a non-military facility.

FIGURE 15 NAS/MTF SEARCH

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TED/HCSR ICN

The internal control number (ICN) format is different for TED and HCSR record formats. As such, PCDIS provides a search path for each. The ICN number format rules appear to the right of the TED and HCSR ICN entry fields respectively. ICNs are assigned by the claims processor pursuant to contractual requirements. When you search by ICN, you will see different search results depending on whether you are accessing a HCSR or TED record.

A HCSR ICN search may return multiple records sharing that ICN but with unique alpha suffixes. The claim has been "split" to comply with the business rule requiring that a unique HCSR be comprised of only one provider and one beneficiary.

Business rules for the TED record allow multiple providers for one beneficiary on the same claim so a TED ICN search will generally result in a single record.

FIGURE 16 TED/HCSR ICN SEARCH

PRACTICE SEARCHING

Using information specific to your "need to know", let's review some of the search features by performing some sample searches. Be prepared with a Provider

Name, Patient Name, and State for this practice session. Each search result will display a Search Results screen which we will discuss in the next section of this chapter.

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PERFORM A PROVIDER SEARCH

1. Click the PCDIS link on the PEPR Main Menu Bar.

2. Select the Provider Search link from the PCDIS Welcome Screen.

3. Type the full or partial name of a provider in the required field of the Provider Name Search section.

4. Click the <Search> button boxed with the Provider Name Search fields.

5. Click the PCDIS link on the primary navigation bar to return to the main screen.

PERFORM A SPONSOR/BENEFICIARY SEARCH

1. Select the Sponsor/Beneficiary Search link.

2. Type a patient name in the required field of the respective search section.

3. Click the <Search> button. Note the DEERS Dependent Suffixes on the Search Results screen and select one to use in the upcoming portion of this exercise.

4. Click the Sponsor/Beneficiary Search link on the primary navigation bar to return to the Sponsor/Beneficiary Search screen. Note that your original criteria still appears on the screen.

5. Type a DEERS Dependent Suffix in the appropriate field of your original Patient Name search. Remember this is a two character numeric field!

6. Click the <Search> button. Notice how your search results have changed!

7. Click the Sponsor/Beneficiary Search link on the primary navigation bar to return to the Sponsor/Beneficiary Search screen.

8. Click the <Reset> button to clear the screen of all search criteria.

9. Click the PCDIS link on the primary navigation bar to return to the main screen.

PERFORM A SEARCH USING A DROPDOWN LIST

1. Select the Provider Search link.

2. Navigate to the Provider Zip or State Search section of the screen.

3. Select a State from the State dropdown list.

3. Select 03 Allergy from the Specialty dropdown list.

4. Click the <Search> button.

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4.5. NAVIGATE SEARCH RESULTS

A successful search provides you with a list of all records that meet the criteria you entered for your search. There are three different versions of Search Result screens in

PCDIS; one each for Sponsor/Beneficiary, Provider and HCSR/TED ICN. The screens are similar in appearance; however the type of search you perform dictates the columns displayed on the Search Result Screen.

The columns displayed on each Search Result screen are designed to help you determine which records you want to exclude or query further. For example, the Provider Search

Results screen lists provider information that includes the Provider Name, Provider ID, Sub-ID, and Specialty Code. Each record is also flagged to identify if the provider specialty is affiliated with the Institutional or Non-Institutional record format. Conversely, a Sponsor/Beneficiary Search Result screen contains information including the Sponsor

SSN and DEERS Dependent Suffix. View the differences in the search results examples below.

FIGURE 17 NAVIGATION SEARCH RESULTS

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CROSS CHECK SEARCH RESULTS

Submitted purchased care claims information must pass a series of edits prior to acceptance to the TRICARE database. Business requirements make it impractical to edit every field. Examples of fields not subject to edit are the Provider Name and Patient Name fields. Although the standard for entering names is Lastname, Firstname, MI, or hospital billing name, the standard is not always met. This can result in incomplete results when performing name-based searches in PCDIS. Whenever you execute a name search it is recommended that you cross check the results by searching using the Provider ID (EIN, TIN, SSN) or Sponsor Identifier (SSN) to ensure that you do not miss any records where a name may have been entered differently.

The Sponsor/Beneficiary Search Results screen is designed to streamline cross checking. You can click on the active Sponsor SSN hyperlink next to a beneficiary name to generate a search by that Sponsor SSN. When the search completes, a screen with all beneficiary records related to that Sponsor SSN are displayed. If you then click on the Sponsor/Beneficiary link on the primary navigation bar, the Sponsor SSN field will be populated with that Sponsor SSN.

FIGURE 18 CROSS CHECK SEARCH RESULTS

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SELECTING RECORDS

PCDIS Search Result screens provide three methods for selecting records and provide your first view of the PCDIS Secondary Navigation Bar.

To select records from the returned results do one of the following:

Click individual checkbox(es) to select specific records from the list.

Click the Select All checkbox to select all records on the screen in Figure 12 below.

Click the Select All Results checkbox to select all records on all the returned screens. Note: In the figure, Select All Results would select results from four screens as indicated by the Page Number.

FIGURE 19 SELECTING RECORDS

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The Next Page link is a scroll feature that takes you to the next page of results (when you scroll to page 2 a Previous link displays allowing you to scroll back to the previous page). Note that your Search Criteria description is displayed on the left directly above the Secondary Navigation Bar.

There is a Goto Page link (highlighted in blue box) that allows a user to go to a specific page of results if needed. For example, if the search returns 20 pages, and you want to go to page 15, instead of clicking the Next Page link from the Secondary Navigation Bar, type in the page number you wish to display and press the

Enter key.

The Provider Profile, Group Summary and Provider Detail links on the Secondary Navigation Bar in Figure 13 are specific to the Provider Search Results screen. You will see Sponsor/Beneficiary- or TED/HCSR ICN-related links on their respective summary screen Secondary Navigation Bars.

Note: The Group Summary and the Provider Profile links on the Secondary Navigation Bar will be discussed in the next section of this chapter.

FIGURE 20 NEXT PAGE OF RESULTS

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PROFILE, GROUP SUMMARY, AND DETAIL SCREENS

From the Results screen(s), you can choose other links to view additional information, such as the Profile, Group Summary, and Detail links.

PROFILE SCREENS

When you click on the Sponsor/Beneficiary Profile link from the Sponsor/Beneficiary Search Results screen, PCDIS provides a profile of the sponsor and the patient as well as summarized data by fiscal year for the patient.

When you click on the Provider Profile link on the Provider Search Results screen, a Provider Profile is available. It displays provider identifying information and summarized claims-related data by fiscal year

FIGURE 21 PROVIDER PROFILE AND SPONSOR/BENEFICIARY PROFILE

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DATE OF CARE SEARCH

There is a search section on the Sponsor/Beneficiary Profile [SBOO4a] and on the Sponsor/Beneficiary Profile [SB004b] (next page**) screens. This search section consists of two fields: Begin Date of Care and End Date of Care.

FIGURE 22 SPONSOR BENEFICIARY PROFILE

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GROUP SUMMARY SCREENS

Provider Group Summary data is available based on your selections, regardless of the providers relationship to one another. If you have selected only one provider, obviously your Provider Profile and Group Summary data will be identical.

FIGURE 23 GROUP SUMMARY SCREENS

To view a Sponsor/Beneficiary Group Summary, you must first select only beneficiaries associated with the same sponsor. Group Summary screens provide claim cost and workload data summarized by fiscal year for the group you have selected.

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PROVISIONAL AND FULLY ACCEPTED TED/HCSR RECORDS

Profile screens in PCDIS contain fiscal year summary cost and workload data which is displayed in table format, similar to the example in Figure 16. Data for each fiscal year is further summarized by Total and Participated claim information (Provider or Sponsor-Beneficiary searches) or Total versus Inpatient cost and workload (NAS/MTF searches).

Within these breakouts, the data is then reported as Provisional (Prov.), Fully and Total.

Provisional represents claims that have passed the Validity edit. These will only be TED claims.

Fully represents records (TEDS or HCSR) that have passed both the Validity and Relational edits. Below is an explanation of the edit types.

FIGURE 24 PROVISIONAL AND FULLY ACCEPTED TED/HCSR RECORDS

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VALIDITY EDITS

Validity edits are generated when the data submitted for a data element is not one of the code values defined in the TRICARE Systems Manual (TSM), Chapter 2. The data submitted on TED and HCSR records must be consistent with expected values, and records must be compatible when compared to the TMA database. If these conditions are not met, the records cannot be processed by TMA and they are returned to the contractor for correction.

RELATIONAL EDITS

Relational edits are generated when the values of two or more data elements are dependent on each other and the values are not compatible. Institutional and Non-

Institutional TED records that do not pass the relational edits are provisionally accepted into the database and a copy is returned to the contractor for correction.

The corrected record is later married to the "provisionally" accepted record and the claim is then flagged as "fully" accepted.

All HCSR records must still pass relational edits before they can be processed.

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PROVIDER DETAIL SCREEN

The Provider Detail screen displays current provider identifying information such as location and billing address and contract code. It also displays all prior detail information for the provider including changes to their demographics or contractual relationship with TRICARE.

FIGURE 25 PROVIDER DETAIL SCREEN

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4.6. TED/HCSR DETAIL RECORDS

OVERVIEW

This chapter introduces you to the TED/HCSR Detail screens. It covers how the screens are organized and navigation features.

Three screens comprise the detail claim-related information: Processing and Financial, Beneficiary and Provider, and Institutional Utilization Revenue or Non-

Institutional Utilization.

PRINT AND LEGEND FUNCTIONS

The Print link on the detail screens allows you to print the screen you are viewing. It will not print the other two TED/HCSR screens associated with the claim. The PCDIS print feature includes the FOUO footer on your printed output.

The Legend link displays the color coded legend used on the screens to help differentiate between fields that are either HCSR or TED record specific, or that are fields for both types of data.

FIGURE 26 LEGEND

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FIELD HELP, SCREEN HELP, AND DEFINITION TABLES

Bolded PCDIS detail data fields are linked to their respective field descriptions provided via the Purchased Care Data Dictionary or to online field Help screens. To obtain a field description for any of these data elements, simply click on the field name and a pop-up window will provide the definition and available criteria for the field.

PCDIS also provides screen-level Help accessed from the Help link on the Main Menu bar.

PCDIS ICD-9-CM and CPT-4 code tables are also accessed from PCDIS allowing you to click on the code field to view the descriptive value for the code appearing on a screen. We will view and discuss these later in this chapter.

FIGURE 27 FIELD HELP, SCREEN HELP, AND DEFINITION TABLES

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TED RECORD/HCSR DETAIL SCREENS

TED/HCSR detail screens are accessed from the Profile, Group, or Provider Detail screens, once you have completed a Provider, Sponsor/Beneficiary, or NAS search.

The TED/HCSR Detail link takes you to a TED/HC SR Detail Listing screen as shown in the examples below. These screens list each claim-related record available for the search criteria you entered. Like the Search Result screens, the information displayed on the screen will differ depending on the Search Option you initially selected.

FIGURE 29 TED/HCSR DETAIL LISTING

FIGURE 28 TED/HCSR DETAILS

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An ICN search accesses an ICN Search Results screen. The ICN Search does not have Profile or Summary screens.

When a provider claim is submitted to the claims processor with multiple providers submitting on the same claim, TRICARE business rules limit each HCSR to one provider and one beneficiary. The claims processor assigns a suffix to the ICN (contractor assigned claim number) that maintains the integrity of the claim submission while making each provider's submission a unique HCSR. The suffixed ICNs display on the Search Result screen.

TED records have a numeric suffix unless the TED record is an Adjustment To an Original HCSR (ATOH). For ATOH records the suffix will reflect the original HCSR suffix value.

FIGURE 30 ICN SEARCH RESULTS

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CLAIMS-RELATED DETAIL DATA SCREENS

Another feature is the ability to go to any of the three screens that comprise the TED record/HCSR claims-related detail data. The three screens are: Processing and

Financial, Beneficiary-Provider, and Utilization (Non-Institutional or Institutional). Each of these screens will be discussed in the following pages.

FIGURE 31 CLAIMS RELATED DETAIL DATA SCREENS

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FINANCIAL AND PROCESSING

This is the first of the three screens that comprise the TED record/HCSR claims-related detail data. Some key fields to note on the header area of this screen include the Record Type that indicates whether the record is related to an Institutional or Non-Institutional processed claim along with fields related to contractor and TED record/HCSR processing information from the claims processor. To view more data on this screen, use the vertical scroll bar on the right side of the screen. The lower portion of the screen houses TED record/HCSR payment data at a summarized level in table format.

To move to another screen for this claim, go to the secondary navigation bar and click on the Beneficiary-Provider or NonInst/Inst Utilization link.

FIGURE 32 FINANCIAL AND PROCESSING SCREEN

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BENEFICIARY AND PROVIDER

The second screen of data contains the claim-related Beneficiary, Sponsor, and Provider information. It contains Protected Health Information, including patient and related sponsor information, as well as provider demographic data. To view data at the bottom of the screen, use the vertical scroll bar on the right side of the window.

PCDIS isolates patient identifiable data on the second screen of the TED record or HCSR. When you view or print detail data the patient identifying information never appears on the same output as the billing, payment, or diagnosis/treatment information.

Remember, all PHI should be handled in accordance with Privacy Act and HIPAA guidelines!

Depending on whether you are viewing an Institutional or Non-Institutional record, the secondary navigation bar will have one of two links: Institutional Utilization-

Revenue or Non-Institutional Utilization. Also on the secondary navigation toolbar will be the Processing & Financial link.

FIGURE 33 BENEFICIARY AND PROVIDER SCREEN

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DETAIL-INSTITUTIONAL UTILIZATION/REVENUE

The Detail-Institutional Utilization/Revenue Information screen contains information specific to charges for Inpatient Hospital services.

The revenue cost and workload detail is located at the very bottom of the screen. The vertical scroll bar on the right side of the window is used to scroll and view the information in its entirety.

The Revenue Codes are active links to their associated field help.

FIGURE 34 INSTITUTIONAL UTILIZATION/REVENUE

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NON-INSTITUTIONAL UTILIZATION

Now, let's look at the Non-Institutional Utilization screen and discuss the data found there as it differs from the Institutional Utilization screen.

The Non-Institutional Utilization screen contains Inpatient and Outpatient professional cost and workload. From this screen, the record can be viewed in either line item summary view, which shows all associated procedures and their associated codes on the claim, or by line item expanded view, which shows the detail for only one selected procedure code.

We'll first look at the line item summary view. An additional feature on the Non-Institutional Utilization screen is that specific line item data is linked to definition screens. You will see these links as bolded text. An example is Diagnosis Code data. Clicking on the bolded data retrieves the International Classification of Diseases, or ICD-9-CM information.

On the line item summary list view, the column names wrap allowing for two rows of data for each procedure code. The procedure information populated in the table follows the same formatting configuration.

Use the navigational links, Next and Previous, to move forward or back through the different claims selected from your ICN search results.

FIGURE 35 LINE ITEM SUMMARY VIEW

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RECORDS WITH MULTIPLE PROVIDERS

As covered in the PEPR Overview, business rules for TED records allow for multiple providers on the same claim. This first becomes apparent on the Beneficiary -

Provider screen of a TED record. If more than one provider is included on a TED, a dropdown list is available in the Provider/Procedure table header field on the screen.

To select from multiple providers or procedures:

1. Select the Provider/ Procedure from the dropdown list.

2. Click the <Display> button to refresh the screen with the selected provider/ procedure detail data.

A key data element within the line item detail table is the procedure code. The procedure code is a five-digit representation of procedures and services performed by physicians, or other authorized health care providers. Each is related to specific healthcare payment information.

FIGURE 36 RECORDS WITH MULTIPLE PROVIDERS

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On the Non-Institutional Utilization screen, there are two