Healthcare Claims Repair Solution Framework. Release Notes

Transcription

1 Healthcare Claims Repair Solution Framework Release Notes

2 Copyright 2010 Pegasystems Inc., Cambridge, MA All rights reserved. This document describes products and services of Pegasystems Inc. It may contain trade secrets and proprietary information. The document and product are protected by copyright and distributed under licenses restricting their use, copying distribution, or transmittal in any form without prior written authorization of Pegasystems Inc. This document is current as of the date of publication only. Changes in the document may be made from time to time at the discretion of Pegasystems. This document remains the property of Pegasystems and must be returned to it upon request. This document does not imply any commitment to offer or deliver the products or services described. This document may include references to Pegasystems product features that have not been licensed by your company. If you have questions about whether a particular capability is included in your installation, please consult your Pegasystems service consultant. For Pegasystems trademarks and registered trademarks, all rights reserved. Other brand or product names are trademarks of their respective holders. Although Pegasystems Inc. strives for accuracy in its publications, any publication may contain inaccuracies or typographical errors. This document or Help System could contain technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Pegasystems Inc. may make improvements and/or changes in the information described herein at any time. This document is the property of: Pegasystems Inc. 101 Main Street Cambridge, MA Phone: (617) Fax: (617) Healthcare Claims Repair Solution Framework Document Name: Release Notes Software Version: 7.4 Updated: August 2010

3 Release Notes The Healthcare Claims Repair Solution Framework (CRS) Version 7.4 is supported on PegaRULES Process Commander Version 5.5 SP1. The main RuleSet versions in the new release are: PegaHCCLM: Healthcare Claims Suite Foundation Layer PegaHCCLM4010: Healthcare Claims Suite Foundation Layer (for X ) PegaHCCLM5010: Healthcare Claims Suite Foundation Layer (for X ) PegaHCCLMRepairPre: Pre-Adjudication (New) Claims Repair Solution Layer PegaHCCLMRepairPost: Post-Adjudication (Pended) Claims Repair Solution Layer Application Records There are 2 Application Records in the Claims Repair Framework: CRS supports the X standard and contains a new RuleSet called PegaHCCLM4010. The administrator login is CRSAdministrator@MyHealthplan and the password is install. CRS supports the X standard and contains a new RuleSet called PegaHCCLM5010. The administrator login is 5010CRSAdmin@MyHealthPlan and the password is install.

4 4 Healthcare Claims Repair Solution Framework Release Notes CRS Application Rule (supports X ) CRS Application Rule (supports X )

5 CRS 7.4 Enhancements 5 CRS 7.4 Enhancements This release contains the following key enhancements: X Message Processing Enhancements X Message Processing Enhancements This release contains updates to the HIPAA EDI X message intake and parsing to support the 5010 version. X Message Intake and Parsing The X message intake processes parse the individual X12 segments contained in the message dynamically based on the delimiters available in the interchange header segment ISA. The message is parsed using three levels of delimiters specified in the X12 Implementation Guide (viz. Data Element Separator, Sub element Separator, and the Segment Terminator). The updated rules are packaged in the PegaHCCLM5010 RuleSet. X Message Mapping to Claim Work Object The X message mapping process parses relevant business data contained in the claim message (header, provider, subscriber, patient, claim lines etc.) and creates a claim work object. The key rules around this process are listed in the Integration chapter of the Claims Repair Deployment Guide (included on your media). The updated rules are packaged in the PegaHCCLM5010 RuleSet. X Output Message Generation The framework contains two activities to format and generate an 837 healthcare claim message output: X12GenerateProfessional creates a professional claim X message string X12GenerateInstitutional creates an institutional (facility) claim X message string These activities are invoked after the X12 claim message has been processed for the categories of business edits mentioned above. Executing either of the activities will process the data from the N837 claim page and create a new page called X12MessageOut of class PegaHC-X12-Data-. X12GenerateProfessional or X12GenerateInstitutional is used to generate a professional claim message and institutional (facility) claim message respectively. The key rules around this process are listed in the Integration chapter of the Claims Repair Implementation

6 6 Healthcare Claims Repair Solution Framework Release Notes Guide (included on your media). The updated rules are packaged in the PegaHCCLM5010 RuleSet. Navigating to Process Sample X Claims Select Sample X Claim Scenario Claim Work Object

7 CRS 7.4 Enhancements 7 Note: The sample X claim files are stored as Rule-File-Text instances. The 5010 standard of the X claim messages require that the NPI (National Provider Identifier) be used as the only key identifier for all Providers on the claim (Billing, Rendering, Service, etc.). To facilitate processing the claim against sample providers records included in the framework, the NPIs on the sample X claim messages have been substituted by relevant keys of the sample provider data instances (e.g. GEN1, INT1, MGH, GRP1, etc). To validate X inbound and outbound claim messages with third-party X12 validation engines (e.g. Edifecs Online Utility), ensure that the appropriate provider segments are updated with a valid NPI as shown below. Pega sample provider ID substituted for the NPI