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Pega Foundation for Healthcare
SAMPLE DATA MANAGEMENT SPECIFICATIONS 7.4
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Pega Foundation for Healthcare
Document: Sample Data Management Specifications
Software Version: 7.4
Updated: April 2018
CONTENTS
Provider data management ............................................................................ 5
Overview ............................................................................................................. 5
Business entity ................................................................................................... 5
Practitioner ......................................................................................................... 6
Provider ............................................................................................................... 6
Provider Network ............................................................................................... 6
Provider Contract ............................................................................................... 7
Provider objects - Membership relationship and specifications ............... 8
Create Business Entity ....................................................................................... 9
Review Business Entity .................................................................................... 12
Update Business Entity - Metadata ................................................................ 15
Add/Update Business Entity - Contacts ......................................................... 17
Add/Update Business Entity - Locations ....................................................... 19
Create Provider ................................................................................................ 21
Review Provider ................................................................................................ 25
Update Provider - Metadata ........................................................................... 28
Add/Update Provider - Credentials ................................................................ 30
Add/Update Provider - Affiliations ................................................................. 31
Create Practitioner ........................................................................................... 33
Review Practitioner .......................................................................................... 38
Update Practitioner - Metadata ...................................................................... 42
Add/Update Practitioner - Credentials .......................................................... 44
Add/Update Practitioner - Affiliations ............................................................ 46
Create Provider Network ................................................................................. 49
Review Provider Network ................................................................................ 52
Update Provider Network ............................................................................... 55
Create Contract (Provider) .............................................................................. 58
Review Provider Contract ................................................................................ 62
Update Provider Contract ............................................................................... 65
Membership relationship and specifications ............................................. 70
Overview ........................................................................................................... 70
Create Member ................................................................................................ 73
Review Member ................................................................................................ 78
Update Member ............................................................................................... 83
Member policy relationships and specifications ....................................... 88
Create Policy ..................................................................................................... 89
Review Policy .................................................................................................... 92
Update Policy .................................................................................................... 96
Member contracts relationships and specifications ................................. 99
Create Membership Contract ....................................................................... 100
Review Membership Contract ...................................................................... 103
Update Membership Contract ...................................................................... 106
Company and payer specifications ............................................................ 109
Overview ......................................................................................................... 109
Create Company ............................................................................................. 110
Review Company ............................................................................................ 112
Update Company ........................................................................................... 114
Create Payer ................................................................................................... 116
Review Payer ................................................................................................... 118
Update Payer .................................................................................................. 120
Claim and authorization specifications .................................................... 122
Overview ......................................................................................................... 122
Create Claim ................................................................................................... 123
Review Claim ................................................................................................... 131
Update Claim .................................................................................................. 138
Create Authorization ...................................................................................... 145
Review Authorization ..................................................................................... 150
Update Authorization .................................................................................... 153
Pega Product Overview 5
Overview This document defines the business use case specifications for all the processes available in Pega Foundation for Healthcare to create and maintain Provider data objects.
Provider PractitionerGroup / Facility
Business Entity
Provider Contract
Business Affiliation
Provider NetworksContracted Products
Payer
Certifications
Malpractice Ins
Medical School
Post Grad Training
Credentialing Information
Provider types
Specialties
Geographic Locations
The following provider objects can be maintained in Pega Foundation for Healthcare:
Business entity A provider business entity is a legal structures recognized by the IRS and include such types as:
• Corporation
• Non-profit organization
• Partnership
• S-Corporation
• Sole Proprietor
Provider data management
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• Trust
A Business Entity functions in the capacity of a contracting entity, facilitating the relation of Practitioners and Providers to health plan contracts. A common example of a Business (Contracting) Entity is an IPA or PHO.
Business Entities unite Practitioners and Providers in business specific relationships, receive health plan remittance advices and annual IRS 1099 statements. Business entities manage locations (addresses), contain contact information and are linked to a provider contract. As Practitioners and Providers are related to a business entity, they inherit key attributes of the Business Entity such as TIN, locations, contracts and products.
Business Entities in themselves do not provide healthcare services. These are provided by the providers and practitioners associated with the Business Entity.
Practitioner A person who provides health care services. For example, a physician, registered nurse, chiropractor, etc. Practitioners are associated to a Type 1 NPI. Practitioner records contain metadata and credentials about the individual.
Practitioner records must relate to at least one Business Entity in order to inherit servicing locations or a contract. However, Practitioners may relate to more than one Business Entity to accurately describe multiple relationships.
Provider A provider is any non-person healthcare-servicing organization. They can include hospitals, DME Providers, freestanding radiology centers, etc. Providers are normally associated to Type 2 NPIs. Provider records contain metadata and credentials about an organization that provides health care services.
Provider records must relate to at least one Business Entity in order to inherit servicing locations and a contract. However, Providers may relate to more than one Business Entity to accurately describe multiple relationships.
Provider Network A provider network defines a grouping of practitioners and providers along with geographic parameters. They define the provider specialties and types of practitioners (moonlighting physicians / covering physicians / primary care physicians, specialists etc.) in the grouping as well as geographic boundaries for serve locations which can be high level including States or narrower to States and Counties or specific zip codes. Provider Networks are referenced in Provider Contracts.
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Provider Contract The documents mutually executed between business entities (on behalf of covered Practitioners and Providers) and health insurance plans. They define the terms of participation for the covered entities, member products for which Practitioners and Providers are considered in-network, reimbursement methodologies and pricing arrangements, policies and procedures, and rights and responsibilities of both parties. Provider contracts are directly related to one or more business entities. Practitioners and Providers related to a Business Entity will normally inherit the terms and conditions of the business entity’s contract. Provider Contracts hold the association of provider networks and products that are covered by the contract.
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Provider PractitionerGroup / Facility
Business Entity
Provider Contract
Business Affiliation
Provider NetworksContracted Products
Payer
Certifications
Malpractice Ins
Medical School
Post Grad Training
Credentialing Information
Provider types
Specialties
Geographic Locations
2 Provider objects - Membership relationship and specifications
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Create Business Entity Specification – Create Business Entity
Short Description: Create Business Entity
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new provider Business Entity data instance
Business impact:
Description
User selects New Business Entity button from the the business entity tab of Provider groper portal.
System launches a new New Business Entity flow as a three step process:
• Enter Business Entity Details
• Add Contacts
• Add Locations
Step 1: Enter Business Entity Details
User enters the following information to capture the business entity metadata:
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• Tax Identification Number – Required - this is used as the key for the business entity instance
• Business Entity Name – Required
• Business Type – Required – select desired value from the available options (Corporation / Non-Profit Organization / S-Corporation / Sole Proprietor / Partnership / Trust)
• Business Entity Effective Date – Required
• End Date
User clicks Continue to proceed to the next step to add contacts
Step 2: Add Contacts
User clicks on Add Contacts to open profile section and enters information about the contact
• Name - Required • Title • Role • Email • Phone Number • Phone Number Extension • Fax • Address Line 1 • Address Line 2 • Zip – Required
o system validates for valid zip codes based on zip code table and displays appropriate message if invalid zip code is entered
• City – Read-only - auto populates based on Zip Code • State - Read-only - auto populates based on Zip Code • Country - Read-only – defaulted to “United States”
User clicks on Submit to add the entered contacts
User can add additional contacts by clicking the Add Contact button to open another section for a new contact.
User clicks Continue to proceed to the next step to add Locations (Addresses) for the Business Entity
Locations
User clicks Add Location to open section to add the address information.
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Business Rules:
• At least one address needs to be added
• At least one address location should be flagged as Financial, Servicing, Remittance (see address type below)
• Only one address can be flagged as Financial
• Only one address can be flagged as Remittance
• Business Entity can have more than one Servicing addresses
Address Information
• Type – User checks one or more of the following three location type options
− Financial
− Servicing
− Remittance
• Address Line 1 – Required
• Address Line 2
• Zip – Required
− system validates for valid zip codes based on zip code table and displays appropriate message if invalid zip code is entered
• City – Read-only - auto populates based on Zip Code
• State - Read-only - auto populates based on Zip Code
• Country - Read-only – auto populates based on Zip Code
Servicing Addendum Information
If user checks the address type as ‘Servicing’, system displays a subsection to capture additional servicing information for the location
• Phone Number – Required
• Fax Number
• Website
Remittance Addendum Information
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If user checks the address type as ‘Remittance’, system displays a subsection to capture additional remittance information for the location
• DBA Name – Read-only – Defaulted to Business Entity name entered earlier
• Bank Routing Number
• Bank Account Number
• Bank Account Type – user selects from available options (DA / SG)
User can add more than one address by clicking the Add location button.
Click Finish when the desired location information is entered.
System validate the entered Location information based on the business rules mentioned above and displays appropriate message if validation fails. If the locations are validated, system creates a new Business Entity profile and displays the Review screen.
Review Business Entity Specification – Review Business Entity
Short Description: Review Business Entity
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
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Primary business objective: To review a provider Business Entity data instance
Business impact:
Description
User clicks on the Business Entities tab on the provider header panel of the portal.
System retrieves and displays a list of Business Entity data instances with the following columns:
• Tax ID Number
• Name
• Business Type
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Business Entity from the list to review details.
System retrieves the details of the selected Business Entity and presents a review screen organized as follows:
Header
Name (<< Tax ID >>)Business Entity Overview
• Business Type
• Effective Date
• End Date
• Default NPI
Contacts tab
Each Contact is displayed with following information along with a gear icon to display details:
• Name
• Title
• Role
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• Phone Number
• Phone Number Extension
• Fax
• Address Line 1
• Address Line 2 (if available)
• City
• State
• Zip
• Country
Locations tab
Each Location is displayed with following information along with a gear icon to display details:
• Name
• Is financial
• Is Servicing
• Is remittance
• Location Type
Address
• Address Line 1
• Address Line 2 – if available
• City
• State
• Zip
• Country
Servicing Addendum Information – if available
• Phone Number – Required
• Fax Number
• Website
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Remittance Addendum Information – if available
• DBA Name – Read-only – Defaulted to Business Entity name entered earlier
• Bank Routing Number
• Bank Account Number
• Bank Account Type – user selects from available options (DA / SG)
Provider Contracts tab
The provider contracts associated with the business entity are displayed as a list with the following columns:
• Contact ID
• Contract Type
• Payment Method
• Effective Date
• End Date
• Status
User can click on the gear icon to view additional details of any contract in the list. In addition to the above, the system displays the following information:
• Primary payment method
• Filing Limit – Plan default
• Prompt Pay requirement
• Version
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
Update Business Entity - Metadata Specification – Update Business Entity - Metadata
Short Description: Update Business Entity - Metadata
Type: Human Based Step
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Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To update the metadata of an existing provider Business Entity data instance
Business impact:
Description
Pre-condition: Business Entity instance is created and available in the system. Search and open the desired Business Entity review screen.
User clicks on the Edit > Metadata link on the Business Entity header.
System displays the Update Metadata screen with the following fields in edit mode (except Read-only as shown below):
• Tax ID
• Business Entity Name
• Business Type
• Business Entity Effective Date – Read-only
• End Date
• Default provider NPI
NOTE: Updating the Tax ID will create a new Business Entity instance as the Tax ID is used as a key.
User updates desired fields and clicks Update to save the changes.
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System displays the Business Entity review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Add/Update Business Entity - Contacts Specification – Update Business Entity - Contacts
Short Description: Add / Update Business Entity - Contacts
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To add or update the contacts associated with the an existing provider Business Entity data instance
Business impact:
Description
Pre-condition: Business Entity instance is created and available in the system. Search and open the desired Business Entity review screen.
User clicks on the Edit > Contacts link on the Business Entity header.
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System displays the Update Contacts screen with existing contacts information.
User clicks on the expand icon of the desired contact to view following contact information in edit mode (except Read-only fields as mentioned):
• Name
• Title
• Role
• Phone Number
• Phone Number Extension
• Fax
• Address Line 1
• Address Line 2 (if available)
• City – Read-only (auto refreshes if zip code is updated)
• State – Read-only (auto refreshes if zip code is updated)
• Zip
• Country - Read-only
User repeats the process for each contact that needs to be updated.
Alternatively, user clicks on Add Contact link to open a new contact section and enters the above information for the new contact. (See
Create Business Entity specification.).
Alternatively, user clicks on Remove Contact associated with any contact to delete the contact information.
User clicks Update to save the changes.
System displays the Business Entity review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Add/Update Business Entity - Locations Specification – Add / Update Business Entity - Locations
Short Description: Add / Update Business Entity - Locations
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To add or update the Locations associated with the an existing provider Business Entity data instance
Business impact:
Description
Pre-condition: Business Entity instance is created and available in the system. Search and open the desired Business Entity review screen.
User clicks on the Edit > Locations link on the Business Entity header.
System displays the Update Location screen with existing locations information.
User clicks on the expand icon of the desired Location to view following information in edit mode (except Read-only fields as mentioned):
• Location Type
Address
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• Address Line 1 - Required
• Address Line 2 – if available
• City - Read-only (auto refreshes if zip code is updated)
• State - Read-only (auto refreshes if zip code is updated)
• Zip
• Country
Servicing Addendum Information – if available
• Phone Number – Required
• Fax Number
• Website
Remittance Addendum Information – if available
• DBA Name – Read-only – Defaulted to Business Entity name entered earlier
• Bank Routing Number
• Bank Account Number
• Bank Account Type – user selects from available options (DA / SG)
User updates the desired information and repeats the process for each location that needs to be updated.
Alternatively, user clicks on Add Location link to open a new Location section and enters the above information for the new location.
Alternatively, user clicks on Remove Location associated with any location to delete the location information.
User clicks Update to save the changes.
System displays the Business Entity review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Create Provider Specification – Create Provider
Short Description: Create Provider
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new Provider data instance
Business impact:
Description
Pre-condition: Active Business Entities are required for adding Business Affiliations during Provider profile generation. Alternatively, provider profile can be created and then updated to add business affiliations.
User selects New Provider button from the provider tab of the provider grouper portal header.
System launches a new Create Provider flow as a three step process:
• Enter Provider Details
• Add Credentials
• Add Business Affiliations
Step 1: Enter Provider Details
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Provider Details
User enters the following information to capture the provider’s metadata:
• Name – Required
• NPI (National Provider Identifier) – Required – this is used as the key for the provider instance
− Data entered is validated for NPI format and appropriate message displayed if incorrect format is entered
− Data entered is validated for duplicity – appropriate message displayed if another provider record with same NPI already exists
• Effective Date – Required
• End Date
• FWA alert
User clicks Continue to proceed to the next step to add credentials
Step 2: Add Credentials
User enters the following credentialing information for the provider
• Licenses
• Credentialed Specialties
Licenses
• DEA Number – Required
− system validates the DEA Number for the format as per DEA format requirements and displays appropriate error message
− system provides tool tip for expected DEA format
• Medicare Number
• Medicaid Number & State
− User can add more than one Medicaid number and State combinations
• License Number & State - Required
− User can add more than one Medicaid number and State combinations
Credentialed Specialties
User can add one or more specialties for the provider
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• Specialty Type – select from the available options (typically ‘Hospitals’)
• Specialty – select from the available options
The list of available specialties is filtered based on the specialty type selected
User clicks Continue to proceed to the next step to add business affiliations.
Step 2: Add Business Affiliations
This step allows the user to associate the provider with one or more business entities and sets up the parameters of that association.
Pre-condition – Business Entity records are created and available in the system.
Business Rule: Only the business entities effective for the Provider’s effective period are displayed.
User selects desired business entity from the list. Upon selection, the system displays affiliation parameters below that the user uses to define the association
• Provider Capacity
• Specialties
• Locations
Provider Capacity
• Market In Directory – Required - select from available options
− Yes, No
Specialties
• Primary Specialty - select from available options
− List of specialties populated based on the selections made during Add Credentials step
• Secondary Specialties - select from available options
− List of specialties populated based on the selections made during Add Credentials step
− User can select more than one specialty depending on availability in the list
− Business Rule: Only one specialty can be selected as Primary and the selected primary specialty is not available for Secondary specialty selection
Business Affiliation Effective Period
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• Business Affiliation Effective Date – Required – Provider’s Effective Date is defaulted here)
• Business Affiliation End Date
Locations
System displays the locations (addresses) associated with the selected Business Entity.
• User selects the desired Location (check option).
• System displays the Purpose options (Service / Correspondence) for the selected Location
• User selects the desired Purpose for the selected location (whether the practitioner would like to use the selected address as the Service and / or the Correspondence address
Business Rule: At least one Service Location and one Correspondence Location needs to be selected for the Business Affiliation.
After the user has completed entering the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity if desired.
Click Finish to submit the Provider record. System saves the instance and displays the Provider Review screen.
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Review Provider Specification – Review Provider
Short Description: Review Provider
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a Provider data instance
Business impact:
Description
User clicks on the Providers tab on the provider header panel of the portal.
System retrieves and displays a list of Provider data instances with the following columns:
• NPI
• Organization Name
• Profession Type
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
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User clicks on desired Provider from the list to review details.
System retrieves the details of the selected Provider profile and presents a review screen organized as follows:
• Header
• Provider name (<<NPI>>)
• Provider overview
• Provider Name
• NPI
• Provider Type
• Effective Date
• End Date
• Credentials tab
• Licenses
• DEA Number
• Medicare Number
• Medicaid Number(s) & State
• License Number(s) & State
• Credentialed Specialties
• Specialty
Business Affiliations tab
Each associated Business Affiliation is displayed along with a gear icon to display details .. User clicks on gear icon to view additional details as follows:
• Business Affiliation Metadata
• Business Entity Name
• Business Entity Type
• Business Entity Tax ID
• Market In Directory Flag
• Primary Specialty
• Effective Date
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• End Date
• Locations
• Address Line 1
• Address Line 2 – if available
• City
• State
• Zip
• Country
Select Purpose (Servicing/Correspondence)
In addition, use can click on the ‘View location specifics’ hyperlink to view additional details about the location:
• Remittance Addendum
• DBA Name
• Bank Account Type
• Bank Routing Number
• Bank Account Number
• Servicing Addendum
• Phone Number
• Fax Number
• Website
• Contacts
The following information is displayed for each contact:
• Contact Name
• Contact Address
• Phone
• Phone Extension
• Fax
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• Associated Contracts
• The list has following columns:
• Contract Name
• Contract ID
• Payment Method
• Effective Date
• End Date
• Status
• Participating networks tab
• Network Name
• Type of network
• Associated business entity
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
Update Provider - Metadata Specification – Update Provider - Metadata
Short Description: Update Provider - Metadata
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
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Iteration:
Primary business objective:
To update the metadata of an existing provider data instance
Business impact:
Description
Pre-condition: Provider instance is created and available in the system. Search and open the desired Provider review screen.
User clicks on the Edit > Metadata link on the Provider header.
System displays the Update Metadata screen with the following fields in edit mode.
• Name - Required
• NPI - Required
• Effective Date - Required
• End Date
NOTE: Updating the NPI will create a NEW provider instance as the NPI is used as a key.
User updates desired fields and clicks Update to save the changes.
System displays the Provider review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Add/Update Provider - Credentials Specification – Add/Update Provider - Credentials
Short Description: Add/Update Provider - Credentials
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To add or update the credentials of an existing provider data instance
Business impact:
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Add/Update Provider - Affiliations Specification – Add/Update Provider - Affiliations
Short Description: Add/Update Provider - Affiliations
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To add or update the business affiliations of an existing provider data instance
Business impact:
Description
Pre-condition: Provider instance is created and available in the system. Search and open the desired Provider review screen.
User clicks on the Edit > Affiliations link on the Provider header.
System displays the Update Affiliations screen with the following fields in edit mode.
Business Rule: Only the business entities effective for the Provider’s effective period are displayed.
User selects desired business entity from the list. Upon clicking the gear icon , the system displays affiliation parameters below that the user uses to update on the association
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• Market In Directory – Required - select from available options
− Yes, No
• Primary Specialty - select from available options
− List of specialties populated based on the selections made during Add Credentials step
• Secondary Specialties - select from available options
− List of specialties populated based on the selections made during Add Credentials step
− User can select more than one specialty depending on availability in the list
− Business Rule: Only one specialty can be selected as Primary and the selected primary specialty is not available for Secondary specialty selection
Business Affiliation Effective Period
• Business Affiliation Effective Date – Required – (Provider’s Effective Date is defaulted here)
• Business Affiliation End Date
Affiliated locations
System displays the locations (addresses) associated with the selected Business Entity.
• User selects the desired Location (check option).
• System displays the Purpose options (Service / Correspondence) for the selected Location
• User selects the desired Purpose for the selected location (whether the practitioner would like to use the selected address as the Service and / or the Correspondence address
Business Rule: At least one Service Location and one Correspondence Location needs to be selected for the Business Affiliation.
After the user has completed updating the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity by clicking on the Add Business Affiliation link if desired.
User clicks Submit and then Update to save the changes.
System displays the Provider review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Create Practitioner Specification – Create Practitioner
Short Description: Create Practitioner
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new Practitioner data instance
Business impact:
Description
Pre-condition: Active Business Entities are required for adding Business Affiliations during Practitioner profile generation. Alternatively, practitioner profile can be created and then updated to add business affiliations.
User selects New Practitioner from the provider grouper portal header.
System launches a new Create Practitioner flow as a three step process:
• Practitioner Details
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• Credentials
• Business Affiliations
Step 1: Enter Practitioner Details
Practitioner Details
User enters the following information to capture practitioner’s metadata:
• First Name – Required
• Middle Name
• Last Name – Required
• NPI (National Provider Identifier) – Required – this is used as the key for the practitioner instance
− Data entered is validated for NPI format and appropriate message displayed if incorrect format is entered
− Data entered is validated for duplicity – appropriate message displayed if another practitioner record with same NPI already exists
• Suffix – select from available options
• Gender – Required - select from available options
• Date of Birth – Required
• Practitioner Title - Required - select from available options
• Effective Date – Required
• End Date
• FWA alert
Contact information
User enters the Phone, Email, and Social Media contact information for the practitioner. User can add multiple records for each contact type.
• Phone Information
− Phone Number
− Type – select from available options
• Email Information
− Email ID
− Type – select from available options
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• Social Media Information
− Social Media ID
− Type – select from available options
User clicks Continue to proceed to the next step to add credentials
Step 2: Add Credentials
User enters the following credentialing information for the practitioner
• Credentialed Specialties
• Licenses
• Hospital Admitting Privileges
• Languages
Credentialed Specialties
User can add one or more specialties for the practitioner
• Specialty Type – select from the available options
• Specialty – select from the available options
− The list of available specialties is filtered based on the specialty type selected
Licenses
• DEA Number – Required
− system validates the DEA Number for the format as per DEA format requirements and displays appropriate error message
− system provides tool tip for expected DEA format
• Medicare Number
• Medicaid Number & State
− User can add more than one Medicaid number and State combinations
• License Number & State - Required
− User can add more than one Medicaid number and State combinations
Hospital Admitting Privileges
Pre-condition – Provider records categorized as Hospitals is created and available in the system.
User can add one or more hospitals where the practitioner has admitting privileges
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• Hospital – Select desired hospital from the available options
− System displays a list of Provider records in the system categorized as Hospitals along with their respective NPI number
Languages
User can add one or more Languages to be associated with the practitioner
• Language – Select desired language from the available options
User clicks Continue to proceed to the next step to add business affiliations.
Step 2: Add Business Affiliations
This step allows the user to associate the practitioner with one or more business entities and sets up the parameters of that association.
Pre-condition – Business Entity records are created and available in the system. (see Create Business Entity specification)
Business Rule: Only the business entities effective for the Practitioner’s effective period are displayed.
User selects desired business entity from the list. Upon selection, the system displays affiliation parameters below that user uses to define the association
• Practitioner Capacity
• Specialties
• Admitting Hospitals
• Locations
Practitioner Capacity
• Practitioner Capacity - Required – select from available options
− Covering practitioner, Moonlighting practitioner, Primary Care Physician, Primary Care with Subspecialty, Specialist Only
• Accepting New Patients - - Required – select from available options
− Yes, No
• Market In Directory – Required - select from available options
− Yes, No
• Age Restrictions
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Specialties
• Primary Specialty - select from available options
− List of specialties populated based on the selections made during Add Credentials step
• Secondary Specialties - select from available options
− List of specialties populated based on the selections made during Add Credentials step
− User can select more than one specialty depending on availability in the list
− Business Rule: Only one specialty can be selected as Primary and the selected primary specialty is not available for Secondary specialty selection
Admitting Hospitals
• Primary Admitting Hospital - select from available options
− List of hospitals populated based on the selections made during Add Credentials step
Business Affiliation Effective Period
• Business Affiliation Effective Date – Required - Practitioner’s Effective Date is defaulted here)
• Business Affiliation End Date
Locations
System displays the locations (addresses) associated with the selected Business Entity.
• User selects the desired Location (check option).
• System displays the Purpose options (Service / Correspondence) for the selected Location
• User selects the desired Purpose for the selected location (whether the practitioner would like to use the selected address as the Service and / or the Correspondence address
Business Rule: At least one Service Location and one Correspondence Location needs to be selected for the Business Affiliation.
After the user has completed entering the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity if desired.
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Click Finish to submit the Practitioner record. System saves the instance and displays the Practitioner Review screen.
Review Practitioner Specification – Review Practitioner
Short Description: Review Practitioner
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a Practitioner data instance
Business impact:
Description
User clicks on the Practitioners tab provider panel of the portal.
System retrieves and displays a list of Practitioner data instances with the following columns:
• NPI
• Last Name
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• First Name
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Practitioner from the list to review details.
System retrieves the details of the selected Practitioner profile and presents a review screen organized as follows:
Header
• Practitioner name (<<NPI>>)
Practitioner details
• Gender
• Date of Birth
• Practitioner Title
• Effective Date
• End Date
• National ancillary provider
Languages
Contact Information
• Phone Number & Type
• Email ID & Type
Social Media ID & TypeCredentials tab
Licenses
• DEA Number
• Medicare Number
• Medicaid Number(s) & State
• License Number(s) & State
Credentialed Specialties
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• Specialty
Hospital Admitting Privileges
• Hospital Name
Business Affiliations tab
Each associated Business Affiliation is along with gear icon. User clicks on gear icon to view additional details as follows:
Business Affiliation Metadata
• Business Entity Name
• Business Entity Type
• Business Entity Tax ID
• Practitioner Capacity Information
− Practitioner Capacity
− Accepting New Patients flag
− Market In Directory flag
− Age Restrictions
• Specialty Information
− Primary Specialty
− Secondary Specialties (if any)
• Admitting Hospital Privileges
− Hospital Name
• Effective Date
• End Date
Locations
• Address Line 1
• Address Line 2 – if available
• City
• State
• Zip
• Country
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• Select Purpose (Servicing / Correspondence)
In addition, use can click on the ‘View location specifics’ hyperlink to view additional details about the location:
Remittance Addendum
• DBA Name
• Bank Account Type
• Bank Routing Number
• Bank Account Number
Servicing Addendum
• Phone Number
• Fax Number
• Website
Contacts
Following information is displayed for each contact:
• Contact Name
• Contact Address
• Phone
• Phone Extension
• Fax
Associated Contracts
The list has following columns:
• Contract Name
• Contract ID
• Payment Method
• Effective Date
• End Date
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Participating Networks
The list has following columns:
• Network Name
• Type of Network
• Associated Business Entity
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
Update Practitioner - Metadata Specification – Update Practitioner - Metadata
Short Description: Update Practitioner - Metadata
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective:
To update the metadata of an existing practitioner data instance
Business impact:
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Pre-condition: Practitioner instance is created and available in the system. Search and open the desired Practitioner review screen.
User clicks on the Edit > Basic Details link on the Practitioner header.
System displays the Update Basic Details screen with the following fields in edit mode.
Practitioner Details
User updates the desired information:
• First Name – Required
• Middle Name
• Last Name – Required
• NPI (National Provider Identifier) – Required – this is used as the key for the practitioner instance
− Data entered is validated for NPI format and appropriate message displayed if incorrect format is entered
− Data entered is validated for duplicity – appropriate message displayed if another practitioner record with same NPI already exists
• Suffix – select from available options
• Gender – Required - select from available options
• Date of Birth – Required
• Practitioner Title - Required - select from available options
• Effective Date – Required
• End Date
• FWA alert
NOTE: Updating the NPI will create a NEW provider instance as the NPI is used as a key.
Languages
User can edit or add one or more Languages to be associated with the practitioner
• Language – Select desired language from the available options
Contact information
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User adds / edits the Phone, Email, and Social Media contact information for the practitioner. User can add multiple records for each contact type.
• Phone Information
− Phone Number
− Type – select from available options
• Email Information
− Email ID
− Type – select from available options
• Social Media Information
− Social Media ID
− Type – select from available options
User updates desired fields and clicks Update to save the changes.
System displays the Practitioner review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Add/Update Practitioner - Credentials Specification – Add / Update Practitioner - Credentials
Short Description: Add / Update Practitioner - Credentials
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
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Release:
Iteration:
Primary business objective:
To add or update the credentials of an existing practitioner data instance
Business impact:
Description
Pre-condition: Practitioner instance is created and available in the system. Search and open the desired Practitioner review screen.
User clicks on the Edit > Credentials link on the Practitioner header.
System displays the Update Credentials screen with the following fields in edit mode.
User updates the following credentialing information for the practitioner as desired
Credentialed Specialties
User can edit or add one or more specialties for the practitioner
• Specialty Type – select from the available options
• Specialty – select from the available options
− The list of available specialties is filtered based on the specialty type selected
Licenses
• DEA Number – Required
− system validates the DEA Number for the format as per DEA format requirements and displays appropriate error message
− system provides tool tip for expected DEA format
• Medicare Number
• Medicaid Number & State
− User can edit or add more than one Medicaid number and State combinations
• License Number & State - Required
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− User can edit or add more than one Medicaid number and State combinations
Hospital Admitting Privileges
Pre-condition – Provider records categorized as Hospitals is created and available in the system.
User can edit or add one or more hospitals where the practitioner has admitting privileges
• Hospital – Select desired hospital from the available options
− System displays a list of Provider records in the system categorized as Hospitals along with their respective NPI number
User updates desired fields and clicks Update to save the changes.
System displays the Practitioner review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Add/Update Practitioner - Affiliations Specification – Add / Update Practitioner - Affiliations
Short Description: Add / Update Practitioner - Affiliations
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
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Primary business objective:
To add or update the business affiliations of an existing practitioner data instance
Business impact:
Description
Pre-condition: Practitioner instance is created and available in the system. Search and open the desired Practitioner review screen.
User clicks on the Edit > Affiliations link on the Practitioner header.
System displays the Update Affiliations screen with the following fields in edit mode.
User selects desired business entity from the list and clicks on gear icon. Upon clicking on gear icon , the system displays affiliation parameters below that user uses to update in the association
Practitioner Capacity
• Practitioner Capacity - Required – select from available options
− Covering practitioner, Moonlighting practitioner, Primary Care Physician, Primary Care with Subspecialty, Specialist Only
• Accepting New Patients - - Required – select from available options
− Yes, No
• Market In Directory – Required - select from available options
− Yes, No
• Age Restrictions
Specialties
• Primary Specialty - select from available options
− List of specialties populated based on the selections made during Add Credentials step
• Secondary Specialties - select from available options
− List of specialties populated based on the selections made during Add Credentials step
− User can select more than one specialty depending on availability in the list
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− Business Rule: Only one specialty can be selected as Primary and the selected primary specialty is not available for Secondary specialty selection
Admitting Hospitals
• Primary Admitting Hospital - select from available options
− List of hospitals populated based on the selections made during Add Credentials step
Business Affiliation Effective Period
• Business Affiliation Effective Date – Required - Practitioner’s Effective Date is defaulted here)
• Business Affiliation End Date
Locations
System displays the locations (addresses) associated with the selected Business Entity.
• User selects the desired Location (check option).
• System displays the Purpose options (Service / Correspondence) for the selected Location
• User selects the desired Purpose for the selected location (whether the practitioner would like to use the selected address as the Service and / or the Correspondence address
Business Rule: At least one Service Location and one Correspondence Location needs to be selected for the Business Affiliation.
After the user has completed entering the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity if desired.
Alternatively, user clicks on the Remove Affiliation link under the business affiliation to remove the association.
User clicks Update to save the changes.
System displays the Practitioner review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Create Provider Network Specification – Create Provider Network
Short Description: Create Provider Network
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new provider network data instance
Business impact:
Description
User selects New Provider Network from the provider grouper portal header.
System launches a new Create Provider Network flow as a three step process:
• Network Details
• Define Geography
• Define Provider Qualifiers
Step 1: Enter Network Details
User enters the following information to capture the Network metadata:
• Name – Required
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• Network ID - Read-only – auto-generated by the system
• Network Type – Required – select desired value from the available options (Accountable Care Organization (ACO) / Full / Limited / Medical Home / Super Network / Tiered)
• Customer-specific? – Yes / No option (defaulted to ‘No’)
• If user selects ‘Yes’, the system displays a list of available Companies (data instances of Company object). The list displays for following information about the available companies
− Company Name
− Type (Large Group / Small Group
− Company Industry Type (based on Standard Industry Code) (High Tech / Retail / Financial / Healthcare etc.)
− Company Industry Sub Type (based on Standard Industry Code) (Computers / Motor Vehicle Dealers etc.)
• Effective Date – Required
• End Date
− Status - Required – select from available options (Available / Under Development / Terminated)
• Status
User clicks Continue to proceed to the next step to define geographic details for the provider network
Step 2: Define Geography
Geographic Details
User enters the following data to capture the geographic details of the provider network
• Country –Read-only (defaulted to USA)
• State – User can select one or more States from the available options
• State & County – User can select one or more State & County from the available options
− the list of Counties is filtered based on the selected State
• Zip Code – User can select one or more Zip Codes from the available options
− The system displays the County, City, & State for the selected zip code
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User clicks Continue to proceed to the next step to define the following provider qualifiers for the provider network
Step 3: Define Provider Qualifiers
User enters the following information about providers to be associated with the network.
Provider Specialties
User clicks on Add Taxonomy to add the specialties. System displays a modal window to search and select provider specialties based on the provider taxonomy Classification.
• Select desired provider taxonomy classification from the available options and click Search
• System displays list of specialties for selected classification
• User selects desired specialties from the list
− Alternatively user can use the Select All option to select all specialties displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected specialties and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any specialties
System displays list of any added specialties with three columns:
• Classification
• Specialty
• Taxonomy Code
Practitioner Types
User clicks on ‘+ Add practitioner type’ icon to add Practitioner Types to be associated with the Provider Network.
User selects desired practitioner type from available options (Covering Practitioner / Moonlighting Practitioner / Primary Care Physician / Primary Care Physician with Sub-Specialty / Specialist Only)
• This is the same list used in the Practitioner Capacity when adding Business Affiliations to the Practitioner
User can add additional Practitioner Types to be associated with the Provider Network.
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Click Finish when the desired provider qualifier information is entered.
System creates a new Provider Network profile and displays the Review screen.
Review Provider Network Specification – Review Provider Network
Short Description: Review Provider Network
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a provider network data instance
Business impact:
Description
User clicks on the Provider Networks tab on the provider panel of the portal.
System retrieves and displays a list of Provider Network data instances with the following columns:
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• Network ID
• Network Name
• Network Type
• Effective Date
• End Date
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Provider Network from the list to review details.
System retrieves the details of the selected Provider Network and presents a review screen organized as follows:
Header
• Provider Network Name (<<Provider Network ID>>)
Provider Network Overview
• Type of Network
• Status
• Effective Date
• End Date
The Provider Network details are presented in two tabs:
• Provider Details
• Geographic Details
Provider Details Tab
This tab displays the associated provider contracts, provider specialties, and practitioner types that make up the network.
Provider contracts
List showing the following columns:
• Contract Name
• Effective Date
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• Contract Status
• Contract Type
Provider specialties
Paginated list showing 10 records per page and with the following columns:
• Classification
• Specialty
• Taxonomy Code
Practitioner Types
List showing the associated Practitioner Types
• Practitioner Type
Geographic Details Tab
This tab displays the geographic details associated with the provider network.
• Country
• State list
• State & County list
• Zip Code – County – City – State list
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
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Update Provider Network Specification – Update Provider Network
Short Description: Update Provider Network
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To add or update an existing provider network data instance
Business impact:
Description
Pre-condition: Provider Network instance is created and available in the system. Search and open the desired Provider Network review screen.
User clicks on the Edit link on the Provider Network header.
System displays the Update Provider Network screen in edit mode.
User navigates the three step process to update the information as desired.
Step 1: Network Details
User edits the desired Network metadata:
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• Name – Required
• Network ID - Read-only – auto-generated by the system
• Network Type – Required – select desired value from the available options (Accountable Care Organization (ACO) / Full / Limited / Medical Home / Super Network / Tiered)
• Customer-specific? – Yes / No option (defaulted to ‘No’)
− If user selects ‘Yes’, the system displays a list of available Companies (data instances of Company object). The list displays for following information about the available companies
- Company Name
- Type (Large Group / Small Group
- Company Industry Type (based on Standard Industry Code) (High Tech / Retail / Financial / Healthcare etc.)
- Company Industry Sub Type (based on Standard Industry Code) (Computers / Motor Vehicle Dealers etc.)
• Effective Date – Required
• End Date
− Status - Required – select from available options (Available / Under Development / Terminated)
• Status
• User clicks Continue to proceed to the next step to update the geographic details for the provider network
Step 2: Define Geography
Geographic Details
User updates the desired geographic details of the provider network
• Country –Read-only (defaulted to USA)
• State – User can select one or more States from the available options
• State & County – User can select one or more State & County from the available options
− the list of Counties is filtered based on the selected State
• Zip Code – User can select one or more Zip Codes from the available options
− The system displays the County, City, & State for the selected zip code
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User clicks Continue to proceed to the next step to update the provider qualifiers for the provider network
Step 3: Define Provider Qualifiers
User updates the desired provider qualifier information about providers associated with the network.
Provider Specialties
To remove an existing specialty, user clicks on the ‘X’ icon next to the specialty listing to delete it from the list.
To add new specialties, user clicks on Add Taxonomy link. System displays a modal window to search and select provider specialties based on the provider taxonomy Classification.
• Select desired provider taxonomy classification from the available options and click Search
• System displays list of specialties for selected classification
• User selects desired specialties from the list
− Alternatively user can use the Select All option to select all specialties displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected specialties and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any specialties
System displays list of any added specialties with three columns:
• Classification
• Specialty
• Taxonomy Code
Practitioner Types
To remove an existing practitioner type, user clicks on the ‘X’ icon next to the specialty listing to delete it from the list.
User clicks on ‘+ Add practitioner type’ icon to add Practitioner Types to be associated with the Provider Network.
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User selects desired practitioner type from available options (Covering Practitioner / Moonlighting Practitioner / Primary Care Physician / Primary Care Physician with Sub-Specialty / Specialist Only)
• This is the same list used in the Practitioner Capacity when adding Business Affiliations to the Practitioner
User clicks Finish to save the changes.
System displays the Provider Network review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Create Contract (Provider) Specification – Create Contract (Provider)
Short Description: Create Provider Contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new provider contract data instance
Business impact:
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Description
Pre-condition: Active Business Entity needs to be available before a Provider Contract can be created.
Pre-condition: Active Provider Networks need to be available for associating with the provider contract. Alternatively a Provider Contract can be generated and updated later to associate with provider networks.
Pre-condition: Active Products need to be loaded into the system for associating with the provider contract. See GET Plan API section in the PFHC(HCIF) API Technical Specification document on Pega Developer Network (PDN) for details on the REST API. Alternatively a Provider Contract can be generated and updated later to associate with products once they are loaded into the system.
User selects New Contract from the Contract (Provider) tab Plan & Contract grouper on the portal header.
System launches a new Create Provider Contract flow as a four step process:
• Metadata
• Contract Details
• Associate Networks
• Associate Products
Step 1: Enter Metadata
User enters the following information to capture the Provider Contract metadata:
• Contract ID – Required – Read-only - auto-generated by the system
• Type – Required - select from the available options (Ancillary / Direct Group / Direct Individual / Hospital / Independent Physician Association / Integrated Delivery Network / Management Services Organization / Physician Hospital Organization)
• Status - Required - select from the available options (Active / Open / Terminated)
• Name – Required
• Effective Date – Required
• End Date
• Description
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User selects the desired Business Entity from the available list. The list is filtered to only active Business Entities for the Contract Effective Date entered above. The following information is displayed for available business entities:
• Name
• Tax ID
• Type
• Effective Date
After selection the system displays the Name, Tax ID, and Type of the selected business entity
User clicks Continue to proceed to the next step to enter contract details.
Step 2: Enter Contract Details
User enters the following data to capture the provider contract details:
• Primary Payment Method – Required – select from the available options (Capitation / Fee-For-Service / Pay For Performance)
• Filing Limit – Plan Default? – Yes / No – Default selection is ‘Yes’
− If ‘No’ option is selected, system displays field to enter Claim Filing Limit.
• Prompt Pay Requirement? – Yes / No – Default selection is ‘No’
− If ‘Yes’ option is selected, system displays field to enter Number of Days.
• By-Pass Auth requirements? – Yes / No – Default selection is ‘No’
− If ‘Yes’ option is selected, system displays field to enter code groups.
• Late Payment Interest? – Yes / No – Default selection is ‘No’
− If ‘Yes’ option is selected, system displays field to enter Percentage (%).
• Contract States – Required – At least one State needs to be selected. User can select more than one
• Version
User clicks Continue to proceed to the next step to associate available Provider Networks to the contract. Active Provider Network(s) need to be available for this selection.
Step 3: Associate Provider Networks
User clicks Add Network(s) button to search and select provider networks to be associated with the contract.
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System displays a modal window for provider network search and selection.
• Search the desired provider network from the dynamic search list which auto-populates with available active provider networks
• System displays the list of networks for selected search criteria
• User selects desired network from the list
− Alternatively user can use the Select All option to select all networks displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected networks and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any networks
System displays list of any added provider networks with three columns:
• Name
• ID
• Type
User can click on the Clear all Networks link to remove any selected networks.
User clicks Continue to proceed to the next step to associate available Products to the contract.
Step 4: Associate Plans
User clicks Add Plan(s)(s) button to search and select products to be associated with the contract.
System displays a modal window for product search and selection.
• Search the desired product ID from the dynamic search list which auto-populates with available active products for the contract effective date entered earlier
• System displays the list of products for selected search criteria
• User selects desired product(s) from the list
− Alternatively user can use the Select All option to select all products displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected products and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any products
System displays the following information for selected products:
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• Product Number
• Category
• Plan Type
• Product Name
• Start Date
• End Date
User can click on the Clear all Products link to remove any selected products.
Click Finish when the desired Product(s) are associated.
System creates a new Provider Contract profile and displays the Review screen.
Review Provider Contract Specification – Review Provider Contract
Short Description: Review Provider Contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a provider contract data instance
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Business impact:
Description
User clicks on the Provider Contracts tab Plan & Contract panel of the portal.
System retrieves and displays a list of Provider Contract data instances with the following columns:
• Contract ID
• Contract Name
• Type
• Product category
• Effective Date
• End Date
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Provider Contract from the list to review details.
System retrieves the details of the selected Provider Contract and presents a review screen organized as follows:
Header
• Provider Contract Name (<<Provider Contract ID>>)
Contract Summary
• Type
• Product category
• Status Effective DateEnd DatePrimary Payment Method
• Filing Limit-Plan Default?
• Prompt Pay Requirement?
• By- Pass Auth requirements?
• Contract State(s)
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• Version
Associated Business Entity
• Business Entity Name
• Tax ID
• Business Type
Networks in Contract
List of provider networks associated with the contract with following columns:
• Network Name
• ID
• Type
• Effective Date
• End Date
Plan benefits (PCS) in Contract
Paginated list of products associated with the contract with 10 products per page and with the following columns:
• ID
• Category
• Plan type
• Name
• Effective Date
• End Date
Plan benefits in Contract
Paginated list of products associated with the contract with 10 products per page and with the following columns:
• Product Number
• Category
• Plan type
• Product Name
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• Start Date
• End Date
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
Update Provider Contract Specification – Update Provider Contract
Short Description: Update Provider Contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To add or update an existing provider contract data instance
Business impact:
Description
Pre-condition: Provider Contract instance is created and available in the system. Search and open the desired Provider Contract review screen.
User clicks on the Edit link on the Provider Contract header.
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System displays the Update Provider Contract screen in edit mode.
User navigates through the four step process to updated the contract information:
Step 1: Enter Metadata
User updates the following information on the Provider Contract metadata as desired:
• Contract ID – Required – Read-only - auto-generated by the system
• Type – Required - select from the available options (Ancillary / Direct Group / Direct Individual / Hospital / Independent Physician Association / Integrated Delivery Network / Management Services Organization / Physician Hospital Organization)
• Status - Required - select from the available options (Active / Open / Terminated)
• Name – Required
• Effective Date – Required
• End Date
• Description
User selects the desired Business Entity from the available list. The list is filtered to only active Business Entities for the Contract Effective Date entered above. The following information is displayed for available business entities:
• Name
• Tax ID
• Type
• Effective Date
After selection the system displays the Name, Tax ID, and Type of the selected business entity
User clicks Continue to proceed to the next step to update the contract details.
Step 2: Enter Contract Details
User updates the desired provider contract details:
• Primary Payment Method – Required – select from the available options (Capitation / Fee-For-Service / Pay For Performance)
• Filing Limit – Plan Default? – Yes / No – Default selection is ‘Yes’
− If ‘No’ option is selected, system displays field to enter Claim Filing Limit.
• Prompt Pay Requirement? – Yes / No – Default selection is ‘No’
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− If ‘Yes’ option is selected, system displays field to enter Number of Days.
• By-Pass Auth requirements? – Yes / No – Default selection is ‘No’
− If ‘Yes’ option is selected, system displays field to enter code groups.
• Late Payment Interest? – Yes / No – Default selection is ‘No’
− If ‘Yes’ option is selected, system displays field to enter Percentage (%).
• Contract States – Required – At least one State needs to be selected. User can select more than one
• Version
User clicks Continue to proceed to the next step to associate available Provider Networks to the contract. Active Provider Network(s) need to be available for this selection.
Step 3: Associate Provider Networks
To remove an existing network listing, user clicks ‘X’ icon next to the listing to delete its association.
To add new Network associations, user clicks Add Network(s) button to search and select provider networks.
System displays a modal window for provider network search and selection.
• Search the desired provider network from the dynamic search list which auto-populates with available active provider networks
• System displays the list of networks for selected search criteria
• User selects desired network from the list
− Alternatively user can use the Select All option to select all networks displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected networks and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any networks
System displays list of any added provider networks with three columns:
• Name
• ID
• Type
User can click on the Clear all Networks link to remove any selected networks.
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User clicks Continue to proceed to the next step to update Product associations to the contract.
Step 4: Associate plans
To remove an existing product listing, user clicks ‘X’ icon next to the listing to delete its association.
To add new products, user clicks Add Product(s) button to search and select products.
System displays a modal window for product search and selection.
• Search the desired product ID from the dynamic search list which auto-populates with available active products for the contract effective date entered earlier
• System displays the list of products for selected search criteria
• User selects desired product(s) from the list
− Alternatively user can use the Select All option to select all products displayed
− Alternatively user can use the Deselect All option to clear the selections
• User clicks Submit to add the selected products and close the modal window
− Alternatively user can use the Close button to close the modal window without selecting any products
System displays the following information for selected products:
• ID
• Category
• Plan type
• Name
• Effective Date
• End Date
System displays the following information for selected plan benefits (PCS):
• Product Number
• Category
• Plan type
• Product Name
• Start Date
• End Date
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User can click on the Clear all Products link to remove any selected products.
User clicks Finish to save the changes.
System displays the Provider Contract review screen with the updated information.
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Overview • Member -- A member is anyone covered under a health insurance plan, an enrollee or
eligible dependent.
• Policy – The employer or other group that purchases the group insurance contract is known as the policyholder.
• Contract – The document that explains the benefits, risk and assumptions that insurance company offers to an employer.
3 Membership relationship and specifications
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Member / Patient(Consumer)
Unique member record
Subscriber(Policy holder)
Holds policy holder info and links all members
associated with a given policy
Policy(Account)
Medical / Dental insurance account for
an individual or family
Employer Group Contract
Payer(Health Plan)
Insurance provider
Company(Employer)
Contracted Plan/
Products
Selected Plan/
Product
Offered Plan/
Products
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Member Record
PCP Information
A Member is associated with a PCP.
• Member ID and Suffix• NPI• Effective Date• End Date
Address Information
A Member is associated multiple address types
• Member ID and Suffix• Address Type• Address Line 1• Address Line 2• City, State, Zip• Country• Effective Date• Term Date
Communication Options
A Member is associated with multiple communication modes and types.• Communication mode (Email, Phone, Social
Media)• Communication Type (Home, Personal)
HCIF Member Relationships and Fields
Account Information (Account No, Routing Number, Bank Name etc)
COB Information (Needs to be Added) – If we know Member has a
Policy not captured within our System.
Pend Information (Needs to be Added)
Medicaid & Medicare InformationMedicaid and Medicare Number
A Member if eligible has the following information captured for Medicare and Medicaid:
• Eligibility Reason• Qualifying Date• Medicare ID• Medicaid ID • Part A and Part B
Effective Dates.
A Member record contains the following attributes:
• First Name• Last Name• Middle Name• Date of Birth• Gender• Prefix Martial Status
• Gender• Member ID and Suffix• Previous Name and Effective Date• Employment Status & Hire Date• Student Status
Policy
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Create Member Specification – Create Member
Short Description: Create Member
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new Member data instance
Business impact:
Description
User selects Member from the member grouper portal header.
System launches a new Create Member flow as a three step process:
• Member
• Details
• Contact
Step 1: Enter Member
User enters the following information to capture the Member metadata:
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• Member Member ID –Required – this is used as the key for the member instance
• First Name – Required
• Middle Name
• Last Name – Required
• Prefix
• Suffix – select desired value from the available options (Jr./Sr./I/II/III/IV/V)
• Date of Birth – Required
• Gender – Required – select desired value from the available options (Male/Female/Unknown)
• Marital Status --– select desired value from the available options (B- Registered Domestic Partner/D- Divorced/I- Single/M - Married/R - Unreported/S - Separated/U – Unmarried/W – Widowed/X – Legally Separated)
• Race/Ethnicity – select desired value from the available options (7 – Not Provided/A – Asian or Pacific Islander/B - Black/C - Caucasian/H - Hispanic/I – American Indian/ N – Black (Non-Hispanic)/O – White (Non- Hispanic))
• Social security number
• Exchange ID
• VIP – User checks the option if applicable
• Employee -- User checks the option if applicable
• Picture :- Choose picture file by clicking on button
Previous name(s)If user clicks on the add symbol, system displays a subsection to capture additional Previous Name information for the member
Users can add multiple Previous name by clicking on Add symbol
• First Name
• Middle Name
• Last Name
• Effective Date
• End Date
• Employment and education Employment status – select desired value from the available options (AO – Active Military-Overseas/AU – Active Military - USA/FT – Full-time/L1 – Leave of Absence/PT – Part time/RT - Retired/TE - Terminated)
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• Student – select desired value from the available options (F- Full-Time/N – Not a Student/P – Part-Time)
Hire Date
If user checks the Employment status as ‘Part-Time’, system displays a subsection to capture additional information for the employment
• Hire Date
School Address Information
If user checks the Student type as ‘Full-Time’ or ‘Part-Time’, system displays a subsection to capture additional School address information for the student
• School Name
• Address
• Zip
• City – Read-only - auto populates based on Zip Code
• State– Read-only - auto populates based on Zip Code
User clicks NEXT to proceed to the next step to Other Details
Step 2: Details
User enters the following other detail information for member.
• Primary Care physician NPI – User search by NPI or First Name of Primary Care Physician and then selects
• Effective Date
• End Date
• Medicaid/Medicare detailsMedicaid -- User checks the option if applicable
• Medicare - User checks the option if applicable
Medicaid Details
If user checks ‘Medicaid’, system displays a subsection to capture additional Medicaid information for the member
• Medicaid Number – Required
Medicare Details
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If user checks ‘Medicare, system displays a subsection to capture additional Medicare information for the member
• Eligibility reason – Required
• Qualifying Date – Required
• Medicare number (HICN) – Required
• Medicare plan type
• Account Information Account type
• Bank Name
• Account holder name
• Account Number
• Routing number
User clicks Continue to proceed to the next step to add Contact Information for member.
Step 3: Contact
Contact
• Preferred language -- select desired value from the available options
User enters the Phone, Email, and Social Media contact information for the Member. User can add multiple records for each contact type.
• Phone number
− Phone number
− Type -- select desired value from the available options (Home/Business/Pager/Mobile)
− Type -- select desired value from the available options (Personal/Work)
• Social Media
− Social Media -- select desired value from the available options (Facebook/Twitter/FaceTime/Skype/LinkedIn)
− ID
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• Guardian Type -- select desired value from the available options (Power of Attorney Nominee/Spouse/Adult Child/Parent/Close Relative/Trust/Voluntary Agency/Government Agency/Other Designee)
• First Name
• Guardian address Line 1
• Guardian address line 2
• Last Name
• Phone
• Zip
• City – Read-only - auto populates based on Zip Code
• State – Read-only - auto populates based on Zip Code
Address User enters the Address for the Member by clicking on Add Address button. User can add multiple records for each contact type.
• Type -- select desired value from the available options (Billing/Home/Location1)
• Address Line1
• Address Line 2
• Zip
• City -- Read-only - auto populates based on Zip Code
• State -- Read-only - auto populates based on Zip Code
• Effective Date
• End Date
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Review Member Specification – Review Member
Short Description: Review Member
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a member data instance
Business impact:
Description
User clicks on the Members tab Member panel of the portal.
System retrieves and displays a list of Member data instances with the following columns:
• Member ID
• Member last name
• Member first name
• Date of Birth
• Gender
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
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User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Member from the list to review details.
System retrieves the details of the selected Member and presents a review screen organized as follows:
The Member details are presented in four tabs:
• Member
• Details
• Contact
• Policy
Member tab
This tab displays the member header, previous names and employment and education details of the member
Header
• Name (<<Member ID>>)
Member Summary
• Member ID
• Gender
• Date of birth
• Marital status
• Social security number
• Employee?
Member
• Member ID
• First Name
• Middle name
• Last Name
• Prefix
• Suffix
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• Date of Birth
• Gender
• Marital status
• Race/Ethnicity
• Social security number
• Exchange ID
• VIP?
• Employee?
Previous name(s)
• First Name
• Middle Name
• Last Name
• Effective Date
• End Date
Employment and education
• Employment status
• Student
Details tab
Primary Care physician
• NPI
• Name
• Specialty
• Effective Date
• End Date
• Reason for PCP Change
• Policy ID
Medicaid/Medicare details
• Medicaid
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If the field is true, below details are displayed
− Medicaid Number
• Medicare
If the field is true, below details are displayed
− Eligibility reason
− Qualifying Date
− Medicare number (HICN)
− Medicare plan type
Account information
• Account type
• Bank Name
• Account holder name
• Account Number
• Routing number
Contact tab
Contact
• Preferred language -- select desired value from the available options
• Phone number
− Phone number
− Type
− Type
• Social Media
− Social Media
− ID
Guardian Information
• Guardian Type
• First Name
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• Guardian address Line 1
• Guardian address line 2
• Last Name
• Phone
• Zip
• City
• State
Address information
• Type
• Address Line1
• Address Line 2
• Zip
• City
• State
• Effective Date
• End Date
Policy tab
Medical Policies
• Policy Type
• Contract ID
• Contract Type
• Plan Type
• Plan ID
• Payer Name
• Member ID
• Member effective date
• Member end date
Dental Policies
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• Policy Type
• Contract ID
• Contract Type
• Plan Type
• Plan ID
• Payer Name
• Member ID
• Member effective date
• Member end date
User clicks on the ‘x’ icon on the top right of the data instance to close the review.
Update Member Specification – Update Member
Short Description: Update member
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update the data of an existing member data instance
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Business impact:
Description
Pre-condition: Member instance is created and available in the system. Search and open the desired member review screen.
User clicks on the Edit button on the Member header.
System displays the Member Metadata screen as a three step process with the following fields in edit mode.
• Member Details
• Other details
• Contact Info
Member Details
• Member ID
• First Name
• Middle Name
• Last Name
• Prefix
• Suffix
• Date of Birth
• Gender
• Marital Status
• Race/Ethnicity
• Social security number
• Exchange ID
• VIP
• Employee
• Picture :- Choose picture file by clicking on button
• Previous Name(s) First Name
• Middle Name
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• Last Name
• Effective Date
• End Date
Employment and Education EMPLOYMENT AND EDUCATION
• Employment status
− Hire Date
• Student
− School Name
− Address
− Zip
− City
− State
User clicks Continue to proceed to the next step to Other Details
Other Details
• Primary Care Physician NPI
• Effective Date
• End Date
Medicaid/ Medicare Details MEDICAID/MEDICARE DETAILS
• Medicaid
− Medicaid Number
• Medicare
− Eligibility reason
− Qualifying Date
− Medicare number (HICN)
− Medicare plan type
• Account Information Account type
• Bank Name
• Account holder name
• Account Number
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• Routing number
User clicks Continue to proceed to the next step to edit Contact Information for member
Contact
• Contact Preferred language
• Phone number
− Phone number
− Type
− Type
• Social Media
− Social Media
− ID
• Guardian Guardian Type
• First Name
• Guardian address Line 1
• Guardian address line 2
• Last Name
• Phone
• Zip
• City
• State
• Address Type
• Address Line1
• Address Line 2
• Zip
• City
• State
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User clicks on submit to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Policy
Plan
Member
Each Policy will have the following basic fields:
• Policy ID• Insurance Type (Group, Individual)• Policy Coverage Type (Individual, Individual + spouse etc)• Policy Effective Date• Policy Term Date• Policy Elected Amount• Policy used Amount• Policy remaining Amount• VIP Indicator
Policy
A Member can be associated multiple policies.
A Policy contains the Family Structure:
• Relationship Code / Policy Role• Effective Date• Term Date
Employer Group Contract.
Member Policies
A Policy can be associated to only one Contract.
Based on the Plans available in the Employer Group Contract, a policy can be associated with only 1 Plan.
4 Member policy relationships and specifications
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Create Policy Specification – Create Policy
Short Description: Create Policy
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new Policy data instance
Business impact:
Description
Pre-condition: Active Contract and Plan are required during policy generation
User selects New Policy from the the Member grouper portal header.
System launches a new Create Policy flow as a five step process:
• Policy
• Contract
• Plan
• Subscriber
• Dependents
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Step 1: Enter Policy Metadata
User enters the following information to capture the Member metadata:
MEMBER HEADER
• Policy ID –Required – this is used as the key for the policy instance and is auto generated
• Insurance Type – Required – select desired value from the available options (GP –Group Policy/IP – Individual Policy/MC - Medicaid/MP – Medicare Primary/WC – Workers Compensation)
• Policy coverage type – Required -– select desired value from the available options (Employee Only/Employee and Spouse/Employee and Children/Employee and Family)
If user select Insurance Type as ‘Medicaid’ or ‘Medicare Primary’ or ‘Workers Compensation’ the Policy coverage type is read only as ‘Employee Only’
• Policy effective date – default date is current date
• Policy term date
• Policy elected amount
• Policy used amount
• Policy remaining amount
• VIP indicator – User checks the option if applicable
User clicks Continue to proceed to the next step to select contract
Step 2: Select contract
User enters the following contract information.
• Contract ID -- Required – User search by Contract ID or Contract Name or Group ID or Group Name and then selects
Once user has selected ‘Contract ID, system displays a subsection to capture additional Contract information
• Contract identifier – Read only
• Contract type – Read only
• Group ID – Read only
• Group Name – Read only
• Effective date – Read only
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• End date – Read only
User clicks Continue to proceed to the next step to select plan
Step 3: Select plan
User enters the following plan information.
• Plan ID – Required -- User search by Plan ID or Name and then selects
Once user has selected ‘Plan ID’, system displays a subsection to capture additional Plan information
• Plan ID – Read only
• Category– Read only
• Plan type – Read only
• Plan name – Read only
• Effective date – Read only
• End date – Read only
• Network ID – Read only
User clicks Continue to proceed to the next step to select subscriber
Step 3: Select subscriber
User enters the following plan information.
• Subscriber – Required -- User search by Member ID or Name and then selects
Once user has selected ‘Subscriber’, system displays a subsection to capture additional Subscriber information
• Subscriber ID – Read only
• Member profile key– Read only
• Policy Role – Read only
• Effective date
• Term Date
System also displays a subsection to capture additional Primary care physician information
• Name – Read only
• NPI – Read only
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• Specialty – Read only
Create New
User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section to capture additional information for the subscriber.
• Member ID -- Required
• First Name -- Required
• Last Name -- Required
• Date of Birth -- Required
• Gender – Required - select desired value from the available options (Male/Female / Unknown)
Add/Edit PCP
User Clicks ‘Add PCP’ or ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section to capture additional information for the subscriber.
• PCP
• Reason for PCP change -- select desired value from the available options (Dissatisfaction with Office staff/Dissatisfaction with Medical Care or Services Rendered / Inconvenient Office location/Dissatisfaction with Office Hours/Unable to Schedule Appointments in a Timely Manner/ Dissatisfaction with Physician’s Referral Policy/Less Respect and Attention Time Given than to Other Patients/Patient Moved to a New Location/No Reason Given/Appointment Times not Met in a Timely Manner)
Review Policy Specification –Review Policy
Short Description: Review Policy
Type: Human Based Step
Status: New
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Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a Policy data instance
Business impact:
Description
User clicks on the Policies tab member panel of the portal.
System retrieves and displays a list of Member data instances with the following columns:
• Policy ID
• Subscriber name
• Group name
• Plan type
• Effective date
• End Date
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Policy from the list to review details.
System retrieves the details of the selected Policy and presents a review screen organized as follows:
• Policy metadata
• Contract details
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• Plan details
• Subscriber details
• Members
Policy Metadata
• Policy ID
• Insurance Type
• Policy coverage type
• Policy effective date
• Policy term date
• Policy elected amount
• Policy used amount
• Policy remaining amount
• VIP indicator
• Reason for policy Cancellation
Contract details
• Contract ID
• Contract identifier
• Contract type
• Group ID
• Group Name
• Effective date
• End date
Plan Details
• Plan ID
• Category
• Plan type
• Plan name
• Effective date
• End date
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• Network ID
Subscriber details
• Subscriber ID
• Subscriber
• Policy Role
• Effective date
• Term Date
• PCP
Members
• Member ID
• Dependent ID
• Policy Role
• Effective date
• End date
• PCP
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Update Policy Specification – Update Policy
Short Description: Update Policy
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update a Policy data instance
Business impact:
Description
Pre-condition: Policy instance is created and available in the system. Search and open the desired member review screen.
User clicks Edit on the Policy header and selects one of the available link from four options
• Add member
• Update Member PCP
• Cancel Member
• Cancel Policy
Add Member
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System displays the Policy Metadata screen with the following fields in edit mode.
• Policy coverage type
User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section with the following fields in edit mode
• Member ID
• First Name
• Last Name
• Date of Birth
• Gender
User Clicks ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section with the following fields in edit mode
• PCP
• Reason for PCP change
User clicks on Update to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Update Member PCP
System displays the Policy Metadata screen with the following fields in edit mode.
User Clicks ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section with the following fields in edit mode
• PCP
• Reason for PCP change
User clicks Update to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Cancel Member
System displays the Policy Metadata screen with the following fields in edit mode.
• Cancellation Reason
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User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section with the following fields in edit mode
• Member ID
• First Name
• Last Name
• Date of Birth
• Gender
User Clicks ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section with the following fields in edit mode
• PCP
• Reason for PCP change
User clicks on Update to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Cancel Policy
System displays the Policy Metadata screen with the following fields in edit mode.
• Policy Term date
• Reason for policy cancellation
User clicks on Update to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Employer Group Contract.
A Contract helps with the association of the Member’s Policy to the Group. A
Contract is specific to a Group / Company.
Payer
Company
Company ID, Effective Date and End Date.
Company A Company can also be defined as a Employer Group.
Address Information
Generic Information
• Company ID• Company Name• Tax ID• Marketing Segment• SIC Code
Subgroup Information (Need
to be added)
Company / Group
Member Contracts
Generic Information
• Contract ID• Contract Type (Group, Individual,
Cobra)• Product Category
• Financial Billing Info• Sales Info• Performance Guarantee
Contracted Plans (Available Plans for Members within
this Group)
5 Member contracts relationships and specifications
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Create Membership Contract Specification – Create Membership Contract
Short Description: Create membership contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new contract data instance
Business impact:
Description
Pre-condition: Active Payer, Group and Plan are required during membership contract generation
User selects Contract (Membership) from Plan & contract grouper portal header.
System launches a new Create membership flow as a three step process:
• Contract details
• Contract information
• Contracted plan
Step 1: Contract details
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User enters the following information to capture the Member metadata:
• Contract ID – Required – this is used as the key for the policy instance and is auto generated
• Contract Type – Required - select desired value from the available options
• Product category – Required - select desired value from the available options (Medical/Dental / Pharmacy/Vision)
• Payer ID – Required -- User search by Payer ID or Payer Name and then selects
• Payer Name – Read only
• Group ID – Required --User search by Group ID or Group Name and then selects
• Group Name – Read only
• Effective date – Required
• End Date
PCP Configuration
Add configuration – User clicks to add configuration. User can add multiple configuration.
User clicks Continue to proceed to the next step to add contract information
Step 2: Contract information
User enters the following contract information.
Financial/Billing
• Contract state- select desired value from the available options
• Funding arrangement - select desired value from the available options (Fully Insured/Self Insured)
• Claim fiduciary -- select desired value from the available options (Yes/No)
• Enrollment type
• Billing cycle -- select desired value from the available options (Monthly/Quarterly)
Sales Info
• Sales representative name
• Sales representative phone
• Preferred broker
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• Open enrollment period
Performance guarantees
• ID card turnaround time
• Enrollment app turnaround time
• PCP assignment turnaround time
• Timely filling days
• Claims processing SLA
User clicks Continue to proceed to the next step to select contracted plan
Step 3: Contracted plan
User clicks on the ‘Add plan(s)’, system open a new window where users selects the plan
• Plan ID –User search by Plan ID or Name and then selects
Once user has selected ‘Plan ID’, system displays a subsection to capture additional Plan information
• Plan ID – Read only
• Category– Read only
• Plan type – Read only
• Plan name – Read only
• Effective date – Read only
• End date – Read only
Or it displays following for Plan benefits in contract
• Product number– Read only
• Category– Read only
• Plan Type– Read only
• Product name– Read only
• Start date– Read only
• End date– Read only
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Review Membership Contract Specification – Review Membership contract
Short Description: Review membership contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review contract data instance
Business impact:
Description
User clicks on the Contracts (Membership) tab on Plan & Contract panel of the portal.
System retrieves and displays a list of Membership contracts data instances with the following columns:
• Contract ID
• Contract Type
• Product category
• Group Name
• Payer Name
• Effective date
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• End date
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired membership contract from the list to review details.
System retrieves the details of the selected membership contract and presents a review screen organized as follows:
• Summary Plan benefits(PCS) in contract Plan Benfits in contract
• Financial/Billing
• Sales Info
• Performance guarantees
Header
• Contract ID
Contract summary
• Contract Type
• Product category
• Effective date
• End Date
• Payer ID
• Payer Name
• Group ID
• Group Name
• Plan benefits in contract Product number
• Category
• Product Name
• Start Date
• End Date
Plan Benefits (PCS) in contract
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• ID
• Category
• Name
• Effective date
• End date
Financial/Billing
• Contract state
• Funding arrangement
• Claim fiduciary
• Enrollment type
• Billing cycle
Sales Info
• Sales representative name
• Sales representative phone
• Preferred broker
• Open enrollment period
Performance guarantees
• ID card turnaround time
• Enrollment app turnaround time
• PCP assignment turnaround time
• Timely filling days
• Claims processing SLA
PCP Configuration
• Configuration
• Priority
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Update Membership Contract Specification – Update membership Contract
Short Description: Update membership contract
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update membership contract data instance
Business impact:
Description
Pre-condition: Membership Contract instance is created and available in the system. Search and open the desired membership contract review screen.
User clicks on the Edit button on the Membership contract header.
System displays the Membership Contract Metadata screen as a three step process with the following fields in edit mode.
• Contract Details
• Contact Information
• Contracted plans
Contract details
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• Contract ID –Read Only
• Contract Type
• Product category
• Payer ID
• Payer Name – Read only
• Group ID
• Group Name – Read only
• Effective date
• End Date
• PCP Configuration.
Contract information
Financial/Billing
• Contract state
• Funding arrangement
• Claim fiduciary
• Enrollment type
• Billing cycle
Sales Info
• Sales representative name
• Sales representative phone
• Preferred broker
• Open enrollment period
Performance guarantees
• ID card turnaround time
• Enrollment app turnaround time
• PCP assignment turnaround time
• Timely filling days
• Claims processing SLA
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Contracted plan
User clicks on the ‘Add plan(s)’, system open a new window where users selects the plan
• Plan ID
Once user has selected ‘Plan ID’, system displays a subsection to capture additional Plan information
• Plan ID – Read only
• Category– Read only
• Plan type – Read only
• Plan name – Read only
• Effective date – Read only
• End date – Read only
User clicks on Submit to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Pega Product Overview 109
Overview • Company – A company is an Account / Group / Employer that is associated with
Membership Contracts.
• Payer – A Payer is the health plan entity that has contracts with employer groups and provider business entities.
6 Company and payer specifications
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Create Company Specification – Create Company
Short Description: Create company instance
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new company instance
Business impact:
Description
User selects New Compan from the Plan & Contract grouper portal header.
System launches a new company flow
Create Company
User enters the following information to capture the Company
Company
• Company ID – Required – this is used as the key for the policy instance and is auto generated
• Company Name – Required
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• Tax ID
• Market segment -- select desired value from the available options (HIX/Individual/Large Group/Medium Group/National Accounts/Small Group)
• Customer industry -- select desired value from the available options (Communications/Entertainment/Financial Services/Government/Healthcare/High Tech/Insurance/Manufacturing/Media/Retail)
Industry
• Standard Industry Code – User selects the value by searching using link ‘Don’t Know the SIC Code’
Don’t Know the SIC Code – System opens a window allowing user to enter following to select industry standard code
− Select Division – search and select the value
− Select Group – search and select the value
− Select Industry Code – search and select the value
• Description – Read Only
Addresses information
Add Address
User enters the Address for the company by clicking on Add Address button. User can add multiple records for each contact type.
• Type -- select desired value from the available options (Billing/Home/Location1)
• Address Line1
• Address Line 2
• Zip
• City -- Read-only - auto populates based on Zip Code
• State -- Read-only - auto populates based on Zip Code
Communication Options
• Phone
• Fax
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Review Company Specification – Review Company
Short Description: Review company instance
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a company instance
Business impact:
Description
User clicks on the Companies tab Plan & Contract panel of the portal.
System retrieves and displays a list of Membership contracts data instances with the following columns:
• Company ID
• Company Name
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
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User clicks on desired membership contract from the list to review details.
System retrieves the details of the selected membership contract and presents a review screen organized as follows
Company data
• Company ID
• Company Name
• Tax ID
• Market segment
• Customer industry
Industry details
• Standard Industry Code
• Description
Addresses information
• Address Type
• Address Line1
• Address Line 2
• Zip
• City
• State
• Phone
• Fax
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Update Company Specification – Review Company
Short Description: Update company instance
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update a company instance
Business impact:
Description
Pre-condition: Company instance is created and available in the system. Search and open the desired membership contract review screen.
User clicks on the Edit button on the Company header.
System displays the Company Metadata screen with the following fields in edit mode.
Company data
• Company ID
• Company Name
• Tax ID
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• Market segment
• Customer industry
Industry details
• Standard Industry Code
Don’t Know the SIC Code – System opens a window allowing user to enter following to select industry standard code
− Select Division
− Select Group
− Select Industry Code
• Description – Read Only
Addresses information
Add Address
User enters the Address for the company by clicking on Add Address button. User can add multiple records for each contact type.
• Type
• Address Line1
• Address Line 2
• Zip
• City
• State
Communication Options
• Phone
• Fax
User clicks on Submit to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Create Payer Specification – Create Payer
Short Description: Create Payer
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a new payer instance
Business impact:
Description
User selects New Payer from Plan & Contracts tab of the portal header.
System launches a new Payer flow as a twostep process:
• Payer details
• Address Details
Step 1: Payer details
User enters the following information to capture the payer information
Payer header
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• Payer ID – Required – this is used as the key for the policy instance and is auto generated
• Payer Name – Required
• Federal Tax ID – Required
• National plan ID
• External payer -- User checks the option if applicable
User clicks Continue to proceed to the next step to add address details
Step 2: Address details
Addresses information
Add Address
User enters the Address for the company by clicking on Add Address button. User can add multiple records for each contact type.
• Type -- select desired value from the available options (Billing/Home/Location1)
• Address Line1
• Address Line 2
• Zip
• City -- Read-only - auto populates based on Zip Code
• State -- Read-only - auto populates based on Zip Code
Communication Options
• Phone
• Fax
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Review Payer Specification – Review Payer
Short Description: Review Payer
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a payer instance
Business impact:
Description
User clicks on the Payers tab on Plan & Contract panel of the portal.
System retrieves and displays a list of Membership contracts data instances with the following columns:
• Payer ID
• Payer Name
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
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User clicks on desired payer from the list to review details.
The system retrieves the details of the selected payer and presents a review screen organized as follows:
Payer header
• Payer ID
• Payer Name
• Federal Tax ID
• National plan ID
• External payer
Addresses information
• Type
• Address Line1
• Address Line 2
• Zip
• City
• State
• Phone
• Fax
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Update Payer Specification – Update Payer
Short Description: Update Payer
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update payer instance
Business impact:
Description
Pre-condition: Company instance is created and available in the system. Search and open the desired membership contract review screen.
User clicks on the Edit button on the Payer header.
System displays the Payer Metadata screen with the following fields in edit mode.
• Payer Header
• Address Information
Payer header
• Payer ID
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• Payer Name
• Federal Tax ID
• National plan ID
• External payer
Address details
Add Address
User enters the Address for the company by clicking on Add Address button. User can add multiple records for each contact type.
• Type
• Address Line1
• Address Line 2
• Zip
• City
• State
Communication Options
• Phone
• Fax
User clicks on submit to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
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Overview • Claim -- A claim is a detailed invoice that your health care provider (such as your doctor,
clinic, or hospital) sends to the health insurer. This invoice shows exactly what services were received.
• Authorization -- A decision by health insurer or plan that a health care’s service, treatment plan, prescription drug or durable medical equipment is medically necessary.
7 Claim and authorization specifications
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Create Claim Specification – Create Payer
Short Description: Create Claim
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create a Claim instance
Business impact:
Description
Pre-condition: Active Payer, Provider and member are required during claims generation
User selects New Claim from the Claim tab of Member groper of the portal
System launches a new Claim flow as a five step process:
• claim header
• claim lines
• patient
• provider
• payer
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Step 1: Enter claim header
User enters the following information to capture the claim information
Claim header
• Claim type -- select desired value from the available options (Professional/Institutional/Pharmacy/Vision)
Details
• Claim Number -- Required -- this is used as the key for the claim instance and is auto generated
• Status -- Required -- select desired value from the available options
• Status date -- Required
Initial dates
• Received date -- Required
• Initial treatment date
• Current illness onset date
• Statement from date – Required – Information entered only when user select Claim type ‘Institutional’
• Statement to date – Required -- – Information entered only when user select Claim type ‘Institutional’
Admission
• Admission Type – Required – – Information entered only when user select Claim type ‘Institutional’ -- select desired value from the available options (1-Emegency/2-Urgent/3- Elective/4- New born/5-Information Not Available)
• Admission Date -- Required – Information entered only when user select Claim type ‘Institutional’
• Discharge Date
• Discharge hour – Information entered only when user select Claim type ‘Institutional’
• Admission source – Required – Information entered only when user select Claim type ‘Institutional’
• Admission Hour – Information entered only when user select Claim type ‘Institutional’
• Patient discharge status –Required – Information entered only when user select Claim type ‘Institutional’
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Accident
• Accident date
• Accident state -- select desired value from the available options
• Trace number
• Authorization number
• Type of Bill – Required –– Information entered only when user select Claim type ‘Institutional’ -- search by code or description and select
Diagnosis information
• Code Type -- Required -- select desired value from the available options (ICD9/ICD10/DSM)
• Code -- search by code or description and select
• Description – Read only
DRG information
• Code
Condition code information – Information entered only when user select Claim type ‘Institutional’
User enters the Condition code information for the Claim. User can add multiple records.
• Code – User Search and selects the code
• Description – Read only
Occurrence code information – Information entered only when user select Claim type ‘Institutional’
User enters the Occurrence code information for the Claim. User can add multiple records.
• Code – User Search and selects the code
• Description – Read only
Occurrence Span Code Information – Information entered only when user select Claim type ‘Institutional’
User enters the Occurrence Span Code Information for the Claim. User can add multiple records.
• Code – User Search and selects the code
• Description – Read only
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Value Code information – Information entered only when user select Claim type ‘Institutional’
User enters the Value Code information for the Claim. User can add multiple records.
• Code – User Search and selects the code
• Description – Read only
Admitting Diagnosis Information – Information entered only when user select Claim type ‘Institutional’
• Code Type -- select desired value from the available options (ICD9/ICD10)
• Code – User Search and selects the code
• Description – Read only
Patient reason for visit diagnosis information – Information entered only when user select Claim type ‘Institutional’
• Code Type -- select desired value from the available options (ICD9/ICD10)
• Code – User Search and selects the code
• Description – Read only
External cause of injury diagnosis information – Information entered only when user select Claim type ‘Institutional’
• Code Type -- select desired value from the available options (ICD9/ICD10)
• Code – User Search and selects the code
• Description – Read only
Principal procedure information – Information entered only when user select Claim type ‘Institutional’
• Code Type -- select desired value from the available options (ICD9/ICD10)
• Code – User Search and selects the code
• Description – Read only
Other Procedure Information – Information entered only when user select Claim type ‘Institutional’
User enters the Other Procedure Information for the Claim. User can add multiple records.
• Code Type -- select desired value from the available options (ICD9/ICD10)
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• Code – User Search and selects the code
• Description –Read Only
• Date
User clicks Continue to proceed to the next step to add claim line details
Step 2: Add Claims lines
Claim Line
Add claim line
Service information
Information entered only when user select Claim type ‘Professional’
• Line number – Required
• Service from date -- Required
• Service to date – Required
• Service code type – Required -- select desired value from the available options (HCPCS/NDT/CPT)
• Service Code – Required –Search by Code and select
• Code description – Read only
• Service Units – Required
• Place of service -- select desired value from the available options
Information entered only when user select Claim type ‘Institutional’
• Service Date – Required
• Service code type
• Code Description
• Service units
• Line number – Required
• Revenue code -- Required
• Revenue code description
Payment Information
• Charge Amount -- Required
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• Paid amount
• Non-covered amount
• Patient co-insurance
• Patient copay
• Patient deductible
Service Provider
Information entered only when user select Claim type ‘Professional’
• NPI type ---- select desired value from the available options (1/2)
• Rendering provider ID –Search by NPI and select
• Last Name – Read only
• First Name – Read only
• Specialty – Read only
Modifiers and diagnosis information
Information entered only when user select Claim type ‘Professional’
• Diagnosis pointer1 -- Required
• Modifier 1
• Diagnosis pointer2
• Modifier 2
• Diagnosis pointer3
• Modifier 3
• Diagnosis pointer4
• Modifier 4
User clicks Continue to proceed to the next step to add patient details
Step 3: Add Patient
Patient
• Select patient ID – Required -- Search by Member ID and select
System displays a subsection of details of member after user selects patient ID
• Name – Read only
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• Gender – Read only
• Date of Birth – Read only
• Policy Number – Read only
• Policy role/relationship – Read only
• Plan name – Read only
• Phone – Read only
• Email – Read only
• Address – Read only
User clicks Continue to proceed to the next step to add provider details
Step 4: Add Provider
Billing provider
• NPI type -- select desired value from the available options (1/2)
• Provider ID – search by NPI and select
• Specialty – Read only
• Address – Read only
Referring provider
• NPI type -- select desired value from the available options (1/2)
• Provider ID – search by NPI and select
• Specialty – Read only
• Address – Read only
Rendering provider
• NPI type -- select desired value from the available options (1/2)
• Provider ID – search by NPI and select
• Specialty – Read only
• Address – Read only
Service facility
• NPI type -- select desired value from the available options (1/2)
• Provider ID – search by NPI and select
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• Specialty – Read only
• Address – Read only
Attending provider
Information entered only when user select Claim type ‘Institutional’
• NPI type -- select desired value from the available options (1/2) • Provider ID – search by NPI and select • Specialty – Read only • Address – Read only
Operating provider
Information entered only when user select Claim type ‘Institutional’
• NPI type -- select desired value from the available options (1/2)
• Provider ID – search by NPI and select
• Specialty – Read only
• Address – Read only
User clicks Continue to proceed to the next step to add patient details
Step 5: Add Payer
Payer
Primary payer
• Primary payer name – Search by Payer Name and select
• Payer ID – Read only
• Health plan ID – Read only
• Prior payment amount – Read only
• Secondary Payer? – user checks if applicable
Secondary payer
System displays a subsection of details of secondary payer after user checks ‘Secondary Payer?’
• Secondary payer name
• Payer ID – Read only
• Health plan ID – Read only
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• Prior payment amount – Read only
Review Claim Specification – Review Claim
Short Description: Review Claim
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review a Claim instance
Business impact:
Description
User clicks on the Claims tab l on the Member panel of the portal.
System retrieves and displays a list of Claims data instances with the following columns:
• Claim number
• Claim type
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• Member name
• Received Date
• Total Charge
The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Claim from the list to review details.
System retrieves the details of the selected payer and presents a review screen organized as follows:
• Claim header
• Claim lines
• Provider
• Patient
• Payer
Claim Summary
• Claim Number
• Claim type
• Status
• Received date
• Status date
• Claim headerClaim Number
• Trace number
• Status
• Received date
• Status date
• Initial treatment date
• Current illness onset date
• Statement from date
• Statement to date
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Admission
• Admission Type
• Admission Date
• Discharge Date
• Discharge hour
• Admission source
• Admission Hour
• Patient discharge status
Accident
• Accident date
• Accident state
• Trace number
• Authorization number
• Type of Bill
Diagnosis information
• Code
• Description
DRG information
When Claim type is ‘Institutional’
• Code
• Description
Occurrence code information -- When Claim type is ‘Institutional’
• Code – User Search and selects the code
• Description – Read only
Occurrence Span Code Information – When Claim type is ‘Institutional’
• Code – User Search and selects the code
• Description – Read only
Value Code information – When Claim type is ‘Institutional’
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• Code
• Description
Admitting Diagnosis Information – When Claim type is ‘Institutional’
• Code
• Description
Patient reason for visit diagnosis information – When Claim type is ‘Institutional’
• Code
• Description
External cause of injury diagnosis information – When Claim type is ‘Institutional’
• Code Type
• Code
• Description
Principal procedure information – When Claim type is ‘Institutional’
• Code Type
• Code
• Description
Other Procedure Information – When Claim type is ‘Institutional’
• Code Type
• Code
• Description
• Date
Claim Line
When Claim type is ‘Professional’
• Line number
• Service from date
• Service to date
• Service code type
• Service Code
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• Code description
• Service Units
• Place of service
When Claim type is ‘Institutional’
• Service Date
• Service code type
• Code Description
• Service units
• Line number
• Revenue code
• Revenue code description
Payment Information
• Charge Amount
• Paid amount
• Non-covered amount
• Patient co-insurance
• Patient copay
• Patient deductible
Service Provider
When Claim type is ‘Professional’
• NPI type
• Rendering provider ID
• Last Name
• First Name
• Specialty
Modifiers and diagnosis information
When Claim type is ‘Professional’
• Diagnosis pointer1
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• Modifier 1
• Diagnosis pointer2
• Modifier 2
• Diagnosis pointer3
• Modifier 3
• Diagnosis pointer4
• Modifier 4
Patient
• Patient ID
• Name
• Gender
• Date of Birth
• Policy Number
• Policy role/relationship
• Plan name
• Phone
• Address
Provider
Billing provider
• NPI type
• Provider ID
• Specialty
• Address
Referring provider
• NPI type
• Provider ID
• Specialty
• Address
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Rendering provider
• NPI type
• Provider ID
• Specialty
• Address
Service facility
• NPI type
• Provider ID
• Specialty
• Address
Attending provider
When Claim type is ‘Institutional’
• NPI type
• Provider ID
• Specialty
• Address
Operating provider
When Claim type is ‘Institutional’
• NPI type
• Provider ID
• Specialty
• Address
Payer
Primary payer
• Primary payer name
• Payer ID
• Health plan ID
• Prior payment amount
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Secondary payer – If applicable
• Secondary payer name
• Payer ID
• Health plan ID
• Prior payment amount
Update Claim Specification – Update claim
Short Description: Update Claim
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update a Claim instance
Business impact:
Description
Pre-condition: Claim instance is created and available in the system. Search and open the desired claim review screen.
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User clicks on the Edit button on the Claim header.
System displays the Claim Metadata screen as a three step process with the following fields in edit mode.
• Enter claim header
• Add claim lines
• Add patient
• Add provider
• Add payer
Enter claim header
Claim header
• Claim type
Details
• Claim Number
• Status
• Status date
Initial dates
• Received date
• Initial treatment date
• Current illness onset date
• Statement from date
• Statement to date
Admission
• Admission Type
• Admission Date
• Discharge Date
• Discharge hour
• Admission source
• Admission Hour
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• Patient discharge status
Accident
• Accident date
• Accident state --
• Trace number
• Authorization number
• Type of Bill
Diagnosis information
• Code Type
• Code
• Description
DRG information
• Code
For Claim type ‘Institutional’.
• Code
• Description
Occurrence code information -- For Claim type ‘Institutional’
• Code – User Search and selects the code
• Description – Read only
Occurrence Span Code Information -- For Claim type ‘Institutional’
• Code – User Search and selects the code
• Description – Read only
Value Code information -- For Claim type ‘Institutional’
• Code – User Search and selects the code
• Description – Read only
Admitting Diagnosis Information -- For Claim type ‘Institutional’
• Code Type
• Code
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• Description – Read only
Patient reason for visit diagnosis information -- For Claim type ‘Institutional’
• Code Type
• Code
• Description – Read only
External cause of injury diagnosis information -- For Claim type ‘Institutional’
• Code Type
• Code
• Description – Read only
Principal procedure information -- For Claim type ‘Institutional’
• Code Type
• Code
• Description – Read only
Other Procedure Information -- For Claim type ‘Institutional’.
• Code Type
• Code
• Description –Read Only
• Date
Add claim line
Service information
For Claim type ‘Professional’
• Line number
• Service from date
• Service to date
• Service code type
• Service Code
• Code description
• Service Units
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• Place of service
For Claim type ‘Institutional’
• Service Date
• Service code type
• Code Description
• Service units
• Line number
• Revenue code
• Revenue code description
Payment Information
• Charge Amount
• Paid amount
• Non-covered amount
• Patient co-insurance
• Patient copay
• Patient deductible
Service Provider
For Claim type ‘Professional’
• NPI type
• Rendering provider ID
• Last Name
• First Name
• Specialty
Modifiers and diagnosis information
For Claim type ‘Professional’
• Diagnosis pointer1
• Modifier 1
• Diagnosis pointer2
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• Modifier 2
• Diagnosis pointer3
• Modifier 3
• Diagnosis pointer4
• Modifier 4
Add Patient
Patient
• Patient ID
System displays a subsection of details of member after user selects patient ID
• Name – Read only
• Gender – Read only
• Date of Birth – Read only
• Policy Number – Read only
• Policy role/relationship – Read only
• Plan name – Read only
• Phone – Read only
• Email – Read only
• Address – Read only
Add Provider
Billing provider
• NPI type
• Provider ID
• Specialty
• Address
Referring provider
• NPI type
• Provider ID
• Specialty – Read only
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• Address – Read only
Rendering provider
• NPI type
• Provider ID
• Specialty – Read only
• Address – Read only
Service facility
• NPI type
• Provider ID
• Specialty – Read only
• Address – Read only
Attending provider
For Claim type ‘Institutional’
• NPI type
• Provider ID
• Specialty – Read only
• Address – Read only
Operating provider
For Claim type ‘Institutional’
• NPI type
• Provider ID
• Specialty – Read only
• Address – Read only
Add Payer
Primary payer
• Primary payer name
• Payer ID
• Health plan ID
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• Prior payment amount
• Secondary Payer?
Secondary payer
• Secondary payer name
• Payer ID – Read only
• Health plan ID – Read only
• Prior payment amount – Read only
User clicks on submit to update the information
Click the ‘X’ icon on the top right corner of the review screen to close the data instance.
Create Authorization Specification – Create Authorization
Short Description: Create Authorization
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To create Authorization
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Business impact:
Description
Pre-condition: Active Provider and member are required during claims generation
User selects New Authorization from the Authorization tab of member grouper portal header.
System launches a new authorization flow as a six step process:
• Authorization
• Requesting provider
• Servicing provider
• Patient
• Look up Facility
• Enter detail request
Step 1: Enter Authorization
User enters the following information to capture the claim information
Request information
• Authorization Number -- Required -- this is used as the key for the claim instance and is auto generated
• Request date -- Required
• Request type – Required -- select desired value from the available options (Inpatient/Outpatient/Pharmacy/Referral)
• Status – Required -- select desired value from the available options (A1- Certified in Total/A3- Not Certified/A4 – Pended/A6- Modified/CT- Contact Payer/NA – No Action Required)
• Contact Channel – Required -- select desired value from the available options (Email/Fax/Letter/Phone/SMS/Web)
• Urgency – Required -- select desired value from the available options (03- Emergency/U- Urgent)
User clicks Continue to proceed to the next step to add requesting provider details
Step 2: Requesting provider
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Requesting provider
• NPI type -- select desired value from the available options (1/2)
• ID – Required – Search by NPI and select
System displays a subsection of details of provider after user selects NPI ID
• Specialty – Read only
• Phone – Read only
• Email – Read only
• ETIN – Read only
• Address – Read only
User clicks Continue to proceed to the next step to add servicing provider details
Step 3: Servicing provider
Serving provider
• NPI type -- select desired value from the available options (1/2)
• ID – Required – Search by NPI and select
System displays a subsection of details of provider after user selects NPI ID
• Specialty – Read only
• Phone – Read only
• Email – Read only
• ETIN – Read only
• Address – Read only
User clicks Continue to proceed to the next step to add patient details
Step 4: Patient
Patient
• Select patient ID – Required – Search by Member ID and select
System displays a subsection of details of member after user selects patient ID
• Gender – Read only
• Date of Birth– Read only
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• Policy Number – Read only
• Policy role/relationship – Read only
• Plan name
• Phone
User clicks Continue to proceed to the next step to add look up details
Step 5: Look up Facility
Facility
• ID – Required – Search by NPI and select
System displays a subsection of details of member after user selects patient ID
• NPI – Read only
• Organization Name– Read only
• Tax ID – Read only
• Type – Read only
• City – Read only
• State – Read only
User clicks Continue to proceed to the next step to add detail request
Step 6: Enter detail request
Authorization details
• Service type – Required -- select desired value from the available options
• Place of service code – Required -- select desired value from the available options
Admission information
• Admission Date -- Required
• Request length of stay -- Required
• Approved length of stay -- Required
• Facility Name -- Required
• Facility type – Required -- select desired value from the available options
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Diagnosis information
• Code Type – Required -- select desired value from the available options (ICD9/ICD10/DSM)
User enters the Diagnosis Information for the Claim. User can add multiple records.
• Date -- Required
• Code -- Required
• Description
Procedure information
User enters the Other Procedure Information for the Claim. User can add multiple records.
• Line number
• Date
• Code Type -- select desired value from the available options (CPT/HCPCS/ICD9/ICD10/Revenue Code)
• Code – Search By code and select
• Description
• Requested units
• Approved Units
• Denied units
Certification information
• Certification eff date
• Certification end date
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Review Authorization Specification – Review Authorization
Short Description: Review Authorization
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To review Authorization
Business impact:
Description
User clicks on the Authorization tab on the member panel of the portal.
System retrieves and displays a list of Authorization data instances with the following columns:
• Authorization number
• Authorization type
• Service type
• Member last name
• Member first name
• Request date
• Status
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The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.
User can sort and filter the list by any of the columns mentioned above.
User clicks on desired Authorization from the list to review details.
System retrieves the details of the selected payer and presents a review screen organized as follows
• Authorization request
• Provider
• Patient
Authorization request
• Authorization Number
• Request date
• Request type
• Status
• Contact Channel
• Urgency
• Service type
• Place of service code
Admission information
• Admission Date
• Request length of stay
• Approved length of stay
• Facility Name
• Facility type
Diagnosis information
• Code Type
• Date
• Code
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• Description
Procedure information
• Line number
• Date
• Code Type
• Code
• Description
• Requested units
• Approved Units
• Denied units
Certification information
• Certification eff date
• Certification end date
Provider
Requesting provider
• NPI type
• ID
• Specialty
• Phone
• ETIN
• Address
Servicing provider
• NPI type
• ID
• Specialty
• Phone
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• ETIN
• Address
Patient
• Patient ID
• Gender
• Date of Birth
• Policy Number
• Policy role/relationship
• Plan name
• Phone
Update Authorization Specification – Update Authorization
Short Description: Update Authorization
Type: Human Based Step
Status: New
Actors: Any
Triggers: Web Browser
Complexity: Medium
Release:
Iteration:
Primary business objective: To update Authorization
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Business impact:
Description
Pre-condition: Authorization instance is created and available in the system. Search and open the desired authorization review screen.
User clicks on the Edit button on the Authorization header.
System displays the Authorization Metadata screen as a six step process with the following fields in edit mode.
• Authorization
• Requesting provider
• Servicing provider
• Patient
• Look up Facility
• Enter detail request
Authorization
Request information
• Authorization Number
• Request date
• Request type
• Status
• Contact Channel
• Urgency
Requesting provider
• NPI type
• ID
• Specialty – Read only
• Phone – Read only
• Email – Read only
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• ETIN – Read only
• Address – Read only
Servicing provider
• NPI type
• ID
• Specialty – Read only
• Phone – Read only
• Email – Read only
• ETIN – Read only
• Address – Read only
Patient
• Select patient ID
• Gender – Read only
• Date of Birth– Read only
• Policy Number – Read only
• Policy role/relationship – Read only
• Plan name
• Phone
Look up Facility
Facility
• ID
• NPI – Read only
• Organization Name– Read only
• Tax ID – Read only
• Type – Read only
• City – Read only
• State – Read only
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Enter detail request
Authorization details
• Service type
• Place of service code
Admission information
• Admission Date
• Request length of stay
• Approved length of stay
• Facility Name
• Facility type
Diagnosis information
• Code Type
• Date
• Code
• Description
Procedure information
• Line number
• Date
• Code Type
• Code
• Description
• Requested units
• Approved Units
• Denied units
Certification information
• Certification eff date
• Certification end date
User clicks on submit to update the information
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Click the ‘X’ icon on the top right corner of the review screen to close the data instance.