FBCS Patch 22 Overview Program Integrity Integration

1. FBCS Patch 22OverviewProgram Integrity Integration

2. Patch 22Overview • Prerequisite Installations • Primary Purpose • Enhancement Functionality • Claim Flow • Fee Staff Process • PI Staff Process • Defect Repairs • Training, Testing & Deployment Schedule & Considerations • Questions and Answers

3. Prerequisite installations Required Builds: • GMRC 3.0*74 • Patch 23 • FB3.5*132 • Patch 34 • Patch 35

4. Primary Purpose Provide the VA with an automated method of integrating, sending and receiving, tracking and managing claims scored by the VA’s Program Integrity Tool (PIT).

5. Patch 22 – Program Integrity Integration Enhanced functionality

6. FBCS PIT Service • Deliver Files • Claims prepared for scoring • Daily processed data • “States” counts • Retrieve & Interpret Files • Scored claims

7. FBCS PIT Service

8. Queued/Sent - Resulting Actions When the claim is queued to be scored • The claim will be identified as ready to be scored • A claim history statement will be created annotating date and time and user who prepped the claim • PIT service will reference the claims to find those ready to be scored When a claim is sent to be scored • A claim history statement will be created annotating date and time service sent claims to be scored. • Claim cannot be rerouted, re-verified or updated while it is being scored.

9. Returned - Resulting Actions When a claim is returned from Scoring • PIT service will read, parse and store the score, reason and reason codes • The claim will be identified as returned from scoring & assigned a PIT Status based on the score • A claim history statement will be created annotating date and time the claim was returned and the assigned PIT Status • Claim will be routed based on the assigned PIT Status

10. Scoring Outcomes/PIT Status • Approved– Score (xxx – xxx) within range for claim to move forward with payment without review – appears in user’s payment claim queue • On Hold – Score (xxx – xxx) requires claim to be manually reviewed prior to moving forward with payment – appears in PIT Review payment queue • Rejected – Score (xxx – xxx) triggered an automated reject of the claim without manual review – appears in D&P under the rejected tab of the user who queued the claim to be scored.

11. Processing GUI Changes • Claim History Command Button • Details Window • User Statistics • Claim History Entries

12. Claim History Button • Displays the claims history for the active claim

13. Details Window • Displays calculation edits & PIT scoring data

14. User Statistics • Updated to include claims queued to scoring

15. New Claim History Entries • Claim is marked as ready for scoring by user • Claim has been sent for SCORING by System • Returned from PIT Scoring and • Sent to PAYMENT with PIT Status as “Score Approved” by System • Sent to PAYMENT with PIT Status as “Score On Hold” by System • On Hold claim – sent back to D&P by xxx, xx • On Hold claim approved by xxx, xx • REJECTED by “PIT Tool” with PIT Status as “Score Rejected” by System

16. Rejected Tab

17. Payment GUI Changes • Inpatient UB/Main Stay Tab • To PIT Command Button • PIT Review Queue

18. Inpatient UB/Main Stay • To PIT command button

19. Inpatient UB/Main Stay • Claims being scored will be displayed but ghosted – No Actions Can Be Taken

20. Inpatient UB/Main Stay Information on Inpatient Claim Window PIT Status – Used for troubleshooting by TSS PIT Scoring Progress – Describes where the claim is at in terms of being scored by PIT

21. Inpatient UB/Main Stay • Claims being returned with a PIT Status other than APPROVED will be removed from your Inpatient UB/Main Stay payment queue & you will be notified upon accessing/refreshing your queue when this happens.

22. PIT Review Queue • Accessible by PIT Review team only (users who hold the DSIF PITREVIEW security key) • Displays a read-only view of lines for claims with a PIT Status of On Hold • Requires a user to manually take action on the claim

23. Admin GUI Changes • New Alerts • Reportable Fields

24. 72 Hour Alert • User will be alerted if claims have not been sent or returned by the service within 72 hour (have been queued and not returned or have been sent and not returned. • Mismatched Companion and Feed file.

25. New Reportable Fields PITQUEUEDATE PITQUEUESTATUS PITRETURNDATE PITTRANSMITDATE

26. AMC GUI Changes • New Alerts • PFRAR changes

27. 72 Hour Alert • User will be alerted if claims are not been sent or returned by the service within 72 hour (have been queued and not returned or have been sent and not returned. • Mismatched Companion and Feed file.

28. PFRAR • PFRARS modified to include PIT reasons • Auto Reject will have a claim level reason of “PIT Reject” with a reason of “This claim was rejected for payment due to the Program Integrity Score exceeded the assigned threshold.”

29. Patch 22 – Program Integrity Integration NEW Claim WORK Flow

30. Claim Flow To Scoring

31. Claim Flow From PIT Scoring

32. Receiving Claims From PIT PIT Status Approved • Payment module will place the returned claim into the queue of the clerk who queued the claim for scoring. • Claim history will be updated with an entry indicating the claim stating “Returned from PIT Scoring and sent to PAYMENT with PIT Status as “Score Approved” by System.

33. Receiving Claims From PIT PIT Status On Hold • Payment module will place the returned claim in a special PIT Review queue. • Claim history will be updated with an entry indicating the claim stating “Returned from PIT Scoring and sent to PAYMENT with PIT Status as “Score On Hold” by System.

34. Receiving Claims From PIT PIT Status Rejected • If score equates to “reject”, the claim status will update to rejected. • A “hard-coded” reject reason of “PIT Rejected” will be used. • Reason description will read PIT rejected; this reason will display on PFRARs & will be used for reporting and D&P view purposes. • The claim will be listed in the originating (Sent to Payment By/Clicked To PIT By) clerk’s Rejected Tab • Claim history will be updated with an entry indicating the claim stating “Returned from PIT Scoring and REJECTED by the “PIT Tool” with PIT Status as “Score Rejected” by System

35. Claim Flow From PIT Review

36. Patch 22 – Program Integrity Integration Fee Staff process

37. Sending Claim to PIT Outpatient/Ancillary claims will be flagged to be sent when clicking the Send to Payment button in Processing

38. Sending Claim to PIT Inpatient UB claims will be flagged to be sent when clicking the To PIT button in Payment.

39. Outpatient/Ancillary Claims • Perform all necessary functions to prepare the claim for payment and meet the requirements of the Send To Payment button (edit review, auth/approval linkage, Medicare fee schedule calculation, etc.) • Click Send To Payment • Wait approximately 48 - 72 hours for claim to be returned from Scoring. • Log into FBCS Payment and retrieve APPROVED claim from Outpatient/Ancillaryqueue. • Perform all the normal payment steps for outpatient/ancillary claims.

40. Inpatient UBs • Perform all necessary functions to prepare the claim for payment and meet the requirements of the Send To Payment button (edit review, auth/approval linkage). • Send To Payment. • Perform all the necessary payment steps to obtain the NVH Pricer and/or set the amount to pay in the DRG/PPS data window.

41. Inpatient UBs cont’d 4. Click To PIT. 5. Wait approximately 48 - 72 hours for claim to be returned from Scoring. 6. Log into FBCS Payment and retrieve APPROVED claim from Inpatient UB/Main Stay queue. 7. Complete the Payment.

42. Determining PIT Status & Score • Claim History • Details • Claim Queue tab • Memo field • Suspended Claim tab • Suspended reason • Rejected Tab

43. Patch 22 – Program Integrity Integration PIT Review TEAM process

44. PIT Reviewer Process • Log into FBCS Payment • Click PIT Review tab • Select claim for review • Review line data • Line Item # - The line on the claim • Marked To Pay - Indicates whether or not the line was indicated for payment when sent to be scored • CPT, Mods, Date of Service, Diagnosis, Total Charges, Amt to Pay – The line item information • Returned Score – The numeric score returned • Reason Code – The reason code returned • Description – The reason description returned

45. PIT Reviewer Process • Log into FBCS Processing • Retrieve claim via Claim Search • Review claim information, claim history and/or documentation (via Doc Search button), if applicable • Make a decision on how to proceed with the claim • X • X

46. OK To Pay • PIT Reviewer will be required to confirm decision • Claim will be moved to the payment queue of the clerk who queued the claim for scoring • Claim history will be updated • No further action required by PIT Reviewer

47. Return to D&P • PIT Reviewer will be required to confirm decision • Claim will be moved to the Claim Queue tab of the PIT Reviewer in FBCS Processing • Claim history will be updated • PIT Reviewer must take action on claim in Processing

48. Installation Preparation • There are no special installation requirements for this patch other than having the pre-requisite patches installed.

49. Defect Repairs • Corrected truncating reason codes on PFRARS • Corrected errors generated when utilizing the Reset Tool • Corrected issue with the “Count My Claims” button • Corrected an error when displaying the reassign grid under the Administrator tab.

50. PIT Help • For non-technical inquiries concerning PIT processes and procedures, please use the following email: • CBOPC PIT Inquiry CBOPCPITInquiry@va.gov • For supporting FBCS documentation and training material, please visit the following site: • https://docs.dssinc.com/SitePages/Home.aspx