$TXT Created by LEYVA,KATHRYN at BATCACHE.FO-BIRM.MED.VA.GOV (KIDS) on Monday, 02/13/06 at 16:45 ============================================================================= Run Date: MAY 18, 2006 Designation: PRCA*4.5*230 Package : PRCA - ACCOUNTS RECEIVABLE Priority: Mandatory Version : 4.5 SEQ #216 Status: Released Compliance Date: JUN 18, 2006 ============================================================================= Associated patches: (v)PRCA*4.5*202<<= must be installed BEFORE `PRCA*4.5*230' (v)PRCA*4.5*208<<= must be installed BEFORE `PRCA*4.5*230' Subject: HIPAA NCPDP - Global Category: - Routine - Enhancement (Mandatory) Description: ============ The National Council for Prescription Drug Programs (NCPDP) standard was adopted under the Healthcare Insurance Portability and Accountability Act (HIPAA) for pharmacy claims. The HIPAA NCPDP - GLOBAL project involves six different applications that have been significantly changed to enable VA Medical Centers to perform third party electronic billing for prescriptions using the NCPDP standard. Below is a list of all the applications involved in this project along with their patch number: APPLICATION/VERSION PATCH ----------------------------------------------------------------- OUTPATIENT PHARMACY (OP) V. 7.0 PSO*7*148 INTEGRATED BILLING (IB) V. 2.0 IB*2*276 PHARMACY DATA MANAGEMENT (PDM) V. 1.0 PSS*1*90 CONSOLIDATED MAIL OUTPATIENT PHARMACY (CMOP) V. 2.0 PSX*2*48 ACCOUNTS RECEIVABLE (AR) V. 4.5 PRCA*4.5*230 ELECTRONIC CLAIMS MANAGEMENT ENGINE (ECME) V. 1.0 BPS*1*1 Veterans Health Information Systems and Technology Architecture (VistA) software applications and infrastructure were enhanced, in order to allow the electronic transmission of outpatient pharmacy prescription claims (WINDOW and MAIL fills) to third party payers via the network connections available through the Austin Automation Center (AAC). VistA will be enhanced to receive electronic adjudicated responses from the third party payers, which include real-time processing for Drug Review Utilization and Refill Too Soon rejects. Reject information will be displayed to the pharmacist as the prescription is being processed. The pharmacist will have the capability to take the appropriate action to ensure patient safety or to override the reject and resubmit the claim to the payer for payment. When a status of "PAYABLE" is returned by the payer for a released prescription, VistA will automatically create the bill in IB, authorize it and immediately create the receivable in the AR application. Since the exact amount being paid by the payer is known, a decrease adjustment will be automatically generated and applied so that the receivable is equal to the net amount due from the payer. The system also provides electronic payment matching capability (for electronically billable outpatient pharmacy prescriptions) using the existing Electronic Data Interchange (EDI) Lockbox functionality which processes other electronic payments from third party payers. This real-time electronic claims processing capability will be provided in accordance with the HIPAA, EDI and the NCPDP mandated format standards, specifically NCPDP Telecommunication Standard V. 5.1. Additional functionality delivered with this project includes: . Auto-Release/Outpatient Pharmacy Automation Interface (OPAI) Integration. . Back-billing capability to allow electronic billing of claims from within the IB application. . Capability to MOVE a group of subscribers from one insurance plan to another while automatically "expiring" the old plan, which is a major time saver. . Pharmacy Dispensed As Written (DAW) prescription processing. Overview of the Process: When a prescription is about to be filled and dispensed by the pharmacy, the OP application submits the prescription to the new ECME application. ECME then contacts IB to verify whether or not the prescription is electronically billable. If so, ECME gathers the information necessary to generate a NCPDP claim. The claim information is passed to the VistA Health Level Seven (HL7) package. The HL7 package then sends the billing information to the AAC, where it is routed to the corresponding third party insurance via Emdeon (formerly WebMD). Once the payer processes the information, the response coming back from the payer is passed back to the site that made the request, and the information is stored in the ECME package. If the third party payer accepted the claim, the adjudicated information is passed along to IB. If the claim was rejected the problem can be worked on and a new claim can be submitted to the payer. For electronically billable CMOP prescription processing, the third party claim is sent before the prescription information is transmitted to the CMOP facility to be filled. Once the adjudicating response is electronically received from the third party payer, if there are no Drug Utilization Review or Refill Too Soon rejects, the prescription is then transmitted to the CMOP facility. When the CMOP center sends the dispensing information back to VistA, the National Drug Code (NDC) information is checked against the NDC sent to the third party payer and, if different, a new claim is generated in the background and is sent to the third party payer. In case the CMOP facility indicates that it is unable to fill a "PAYABLE" prescription fill, a reversal is automatically submitted to the third party payer for the corresponding fill. This patch represents the AR portion of the HIPAA NCPDP - Global project. The specific functionality for this patch is listed below. Functional Description ----------------------- This patch modifies the EDI Lockbox functionality by adding the ability to manually process Explanation of Benefits (EOB) related to NCPDP claims. There are no changes to the existing user interface introduced by this patch. All changes are related to internal EDI Lockbox processing of the Health Care Claim Payment/Advice (835) transaction, also referred to as the Electronic Remittance Advice (ERA), related to the NCPDP electronic pharmacy claims. The 835-transaction is sent to VistA from the AAC in a flat file message via MailMan. There are two functional changes introduced with this patch: 1. Enhancements were made to the ECME matching procedure. As implemented in the PRCA*4.5*202 patch, AR was using the Statement Date to find a matching IB/AR bill. With this patch, AR will be using the Service Date for matching purposes. 2. The EDI Lockbox functionality was modified to screen out electronic EOB records related to electronic pharmacy rejects. When VistA submits NCPDP electronic pharmacy claims and they get rejected, bills are not created in IB/AR. Therefore VistA does not need to be receiving electronic EOB records in response to those claims since VistA is unable to process rejected claims related to electronic EOB records. Before the changes were introduced in this patch, electronic EOB records associated with rejected claims were displayed on the EDI LOCKBOX EXCEPTIONS User Screen of the EDI Lockbox 3rd Party Exceptions option [RCDPE EXCEPTION PROCESSING], and therefore required the user to resolve manually. The changes delivered in this patch enable the software to identify these specific electronic EOB records and disregard them. This means that the specific electronic EOB records are not stored in the ELECTRONIC REMITTANCE ADVICE file (#344.4) and therefore are not displayed on the EDI LOCKBOX EXCEPTIONS screen. Technical Description ---------------------- 1. Enhancements to the EDI EOB Matching functionality This patch modifies the EDI EOB matching algorithm that was implemented earlier by patch PRCA*4.5*202. There are two places in AR where EDI Lockbox software tries to match the reference number in the EOB to an IB/AR bill number. The first routine, RCDPESR4, verifies (performs matching) of the reference number in the electronic EOB before the EOB is stored in the ELECTRONIC REMITTANCE ADVICE file (#344.4). The second routine, RCDPESR2, performs the same matching logic after the electronic EOB has been retrieved from the ELECTRONIC REMITTANCE ADVICE file (#344.4) and before storing the electronic EOB in the EXPLANATION OF BENEFITS file (#361.1). In both cases the software is calling the IB function $$RXBIL^IBNCPDPU. This function has 2 parameters: the ECME Number and the Rx Fill Date. Before the creation of this patch, the AR software made a call to the matching IB function and had in its argument list the ECME Number and the Statement Date (835-transaction Flat File, Segment '05' Piece #9). The routine has been modified to replace the Statement Date with the Service Date in the argument list (835-transaction Flat File, Segment '40' Piece #19). In order to be able to get the Service Date when processing the '05' Segment, the AR software will need to pre-process the 835 Flat File transaction and link the Service Date to the respective '05' segment. 2. Excluding electronic EOB records related to the rejected NCPDP Electronic Pharmacy claims. Routine RCDPESR6 was modified to exclude reject-related electronic EOB records from the EDI LOCKBOX EXCEPTIONS screen of the EDI Lockbox 3rd Party Exceptions option [RCDPE EXCEPTION PROCESSING]. To give an example, if a given EOB record is not "matched" (valid bill not found), and the reference number does match the ECME# format which is no less or no greater than 7 numeric characters, and the Amount Paid on the electronic EOB is zero; then AR will call the new IB function, $$REJECT^IBNCPDPU(), to check whether it was a rejected electronic pharmacy claim. If all above criteria are met, the electronic EOB will not be stored in the ERA DETAIL subfile (#344.41) of the ELECTRONIC REMITTANCE ADVICE file (#344.4). This patch addresses the following New Service Request (NSR): ------------------------------------------------------------- There is no NSR associated with this patch. This patch addresses the following NOIS/Remedy Ticket(s): --------------------------------------------------------- There are no NOIS/Remedy tickets associated with this patch. ROUTINES SENT WITH PATCH ------------------------ The following is a list of the routines included in this patch. The second line of each of these routines now looks like: ;;4.5;Accounts Receivable;**[patch list]**;Mar 20, 1995 CHECK^XTSUMBLD results Routine Before Patch After Patch Patch List ------- ------------ ----------- ---------- RCDPESR2 28554504 25767267 173,216,208,230 RCDPESR4 18189947 18833833 173,216,208,230 RCDPESR6 13274626 13575600 173,214,208,230 Total number of routines - 3 CHECK1^XTSUMBLD results Routine Before Patch After Patch Patch List ------- ------------ ----------- ---------- RCDPESR2 76459663 77266952 173,216,208,230 RCDPESR4 67024899 73890637 173,216,208,230 RCDPESR6 26998339 28091668 173,214,208,230 Total number of routines - 3 Test Sites: =========== ANN ARBOR, MI BATTLE CREEK, MI DETROIT, MI HEARTLAND-WEST, KS IRON MOUNTAIN, MI CENTRAL ARKANSAS LOUISVILLE, KY NEW YORK HARBOR HCS NORTH TEXAS HCS SAGINAW, MI Documentation Retrieval: ======================== The HIPAA NCPDP - GLOBAL project documentation is available on the ANONYMOUS.SOFTWARE directory at one of the following Office of Information (OI) Field Offices. Sites may retrieve documentation in one of the following ways: 1. The preferred method is to FTP the files from download.vista.med.va.gov, which will transmit the files from the first available FTP server. 2. Sites may also elect to retrieve documentation directly from a specific server as follows: Albany ftp.fo-albany.med.va.gov Hines ftp.fo-hines.med.va.gov Salt Lake City ftp.fo-slc.med.va.gov The documentation distribution includes: FILE NAME DESCRIPTION ------------------------------------------------------------------------ BPS_1_UM_R0406.PDF ECME V. 1.0 User Manual BPS_1_TM_R0406.PDF ECME V. 1.0 Technical Manual/Security Guide ECME_HIPAA_NCPDP_1_IG.PDF HIPAA NCPDP Connection for EDI Pharmacy (Active Release) Installation Guide ECME_HIPAA_NCPDP_1_RN.PDF HIPAA NCPDP Connection for EDI Pharmacy (Active Release) Release Notes IB_2_PRCA_4_5_RN.PDF HIPAA NCPDP IB/AR Release Notes PSO_7_TM_R0406.PDF OP V. 7.0 Technical Manual/Security Guide PSO_7_P148_TM_CP.PDF OP V. 7.0 Technical Manual/Security Guide Change Pages PSO_7_UM_R0406.PDF OP V. 7.0 User Manual PSO_7_P148_UM_CP.PDF OP V. 7.0 User Manual Change Pages PSS_1_TM_R0406.PDF PDM V. 1.0 Technical Manual/Security Guide PSS_1_P90_TM_CP.PDF PDM V. 1.0 Technical Manual/Security Guide Change Pages PSS_1_UM_R0406.PDF PDM V.1.0 User's Manual PSS_1_P90_UM_CP.PDF PDM V.1.0 User's Manual Change Pages PSX_2_TM_R0406.PDF CMOP V. 2.0 Technical Manual PSX_2_P48_TM_CP.PDF CMOP V. 2.0 Technical Manual Change Pages PSX_2_UM_R0406.PDF CMOP V. 2.0 User's Manual PSX_2_P48_UM_CP.PDF CMOP V. 2.0 User's Manual Change Pages 3. Documentation can also be retrieved from the VistA Documentation Library (VDL) on the Internet at the following address, http://www.va.gov/vdl. Installation Instructions: ========================== IT IS VERY IMPORTANT THAT THESE INSTRUCTIONS ARE FOLLOWED STEP BY STEP IN THE EXACT ORDER INDICATED BELOW. ONCE STARTED, THE INSTALLATION NEEDS TO BE COMPLETED. FAILURE TO FULLY COMPLETE THE INSTALLATION (ONCE STARTED) WILL LIKELY CAUSE PROBLEMS FOR USERS OF THE 6 APPLICATIONS INVOLVED IN THIS PROJECT. BEFORE PROCEEDING, please read item number 12.2 and make sure you have the information needed in order to complete this installation. Users should not be on the system during installation of these patches. These patches should be installed during non-peak hours to avoid disruptions. Installation should take approximately 15 minutes. Notes: 1. You cannot queue this installation for a later time, because you will be prompted to enter information during the installation. 2. DO NOT install patch PSX*2*48 when prescriptions are being transmitted to CMOP. Wait for the CMOP transmission to finish or complete the installation before the transmission starts. 3. For existing test sites, stop the BPS NCPDP logical link. Turn off the logical link using the Start/Stop Links [HL START] option, which is on the Filer and Link Management Options option [HL MENU FILER LINK MGT] submenu of the HL7 Main Menu [HL MAIN MENU] option. When prompted for the HL LOGICAL LINK NODE, enter BPS NCPDP and when asked whether it is "Okay to shut down this job?", enter YES. 1. These patches will be sent to your system upon release from the National Patch Module: - Patch PSS*1*90 - Patch PSX*2*48 - Patch PRCA*4.5*230 Obtain the host file ECME_HIPAA_NCPDP_P3.KID, which contains the following three KIDS build distributions: PSO*7.0*148 BPS*1.0*1 IB*2.0*276 Sites may retrieve the host file in one of the following ways: 1.1 The preferred method is to FTP the file from download.vista.med.va.gov, which will transmit the file from the first available FTP server. 1.2 Sites may also elect to retrieve the file directly from a specific server as follows: Albany ftp.fo-albany.med.va.gov Hines ftp.fo-hines.med.va.gov Salt Lake City ftp.fo-slc.med.va.gov 2. From the Kernel Installation and Distribution System (KIDS) Menu, select the Installation menu. 3. From this menu, for each of the three patches (PSS*1*90, PSX*2*48 and PRCA*4.5*230), you may select to use the following options: 3.1. Backup a Transport Global - this option will create a backup message of any routines exported with the patch. It will NOT backup any other changes such as Data Dictionaries (DDs) or templates. 3.2. Compare Transport Global to Current System - this option will allow you to view all changes that will be made when the patch is installed. It compares all components of the patch (routines, DDs, templates, etc.). 3.3. Verify Checksums in Transport Global - this option will ensure the integrity of the routines that are in the transport global. Note: When prompted for INSTALL NAME, you should enter the corresponding names for each patch as shown below: PATCH INSTALL NAME ----------------------------------- PSS*1*90 PSS*1.0*90 PSX*2*48 PSX*2.0*48 PRCA*4.5*230 PRCA*4.5*230 4. From the Installation menu, select the Install Package(s) option and for each one of the three patches (PSS*1*90, PSX*2*48 and PRCA*4.5*230) follow the instructions below: 4.1. When prompted for the "Select INSTALL NAME:", enter the corresponding name for the patch you are installing (see table above). 4.2. When prompted "Want KIDS to INHIBIT LOGONs during the install? YES//", respond "NO." 4.3. When prompted "Want to DISABLE Scheduled Options, Menu Options, and Protocols? YES//", respond "NO." 4.4. When prompted, "Device: Home//" respond with the correct device and DO NOT queue to P-Message. 5. After the installation of the 3 patches is complete (PSS*1*90, PSX*2*48, PRCA*4.5*230), return to the Kernel Installation and Distribution System (KIDS) Menu, select the Installation menu. 6. From the Installation menu, select the Load a Distribution option. 7. When prompted for "Enter a Host File:", enter the full directory path where you saved the host file ECME_HIPAA_NCPDP_P3.KID (e.g., SYS$SYSDEVICE:[ANONYMOUS]ECME_HIPAA_NCPDP_P3.KID). 8. When prompted for "OK to continue with Load? NO//", enter "YES." The following will display: Loading Distribution... ECME HIPAA NCPDP P3 1.0 BPS*1.0*1 PSO*7.0*148 IB*2.0*276 Use INSTALL name ECME HIPAA NCPDP P3 1.0 to install this Distribution. 9. From the Installation menu, you may select to use the following options: (when prompted for "Select INSTALL NAME:", enter "ECME HIPAA NCPDP P3 1.0") 9.1. Backup a Transport Global - this option will create a backup message of any routines exported with the patch. It will NOT backup any other changes such as Data Dictionaries (DDs) or templates. 9.2. Compare Transport Global to Current System - this option will allow you to view all changes that will be made when the patch is installed. It compares all components of the patch (routines, DDs, templates, etc.). 9.3. Verify Checksums in Transport Global - this option will ensure the integrity of the routines that are in the transport global. 10. Back in the Installation menu, select the Install Package(s) option. 11. When prompted for the "Select INSTALL NAME:", enter "ECME HIPAA NCPDP P3 1.0." 12. For each one of the builds contained in the master build, the following set of prompts will be asked: Note: Information such as the example below about files contained in the build will be displayed for each KIDS build that contains Data Dictionary changes: Incoming Files: 52 PRESCRIPTION (Partial Definition) Note: You already have the 'PRESCRIPTION' File. 12.1. When prompted "Want KIDS to Rebuild Menu Trees Upon Completion of Install? Yes//". For the builds PSO*7.0*148 and IB*2.0*276, respond "NO." For the BPS*1.0*1 build, respond "YES." 12.2. For the BPS*1.0*1 installation, when prompted for Incoming Mail Groups: "Enter the Coordinator for Mail Group 'BPS OPECC':" Please, contact your Medical Care Cost Recovery (MCCR) business department prior to installation to determine who will be the coordinator for this new mail group. This mail group will be used by the BPS Nightly Background Job. Its members will receive bulletins about electronic claims. 13. When prompted "Want KIDS to INHIBIT LOGONs during the install? YES//", respond "NO." 14. When prompted "Want to DISABLE Scheduled Options, Menu Options, and Protocols? YES//", respond "NO." 15. When prompted, "Device: Home//" respond with the correct device and DO NOT queue this to P-Message. 16. TEST SITES ONLY: A post-installation step for test sites is to restart the BPS NCPDP Logical link. To turn on the logical link use the Start/Stop Links [HL START] option, which is on the Filer and Link Management Options option [HL MENU FILER LINK MGT] submenu of the HL7 Main Menu [HL MAIN MENU] option. When prompted for the HL LOGICAL LINK NODE, enter "BPS NCPDP" and that will enable the logical link. 17. The functionality will be implemented at sites in a phased schedule. Before performing the steps to activate ePharmacy functionality, all non-test sites should wait to be contacted by the Chief Business Office (CBO). Routine Information: ==================== The checksums below are new checksums, and can be checked with CHECK1^XTSUMBLD. Routine Name: RCDPESR2 Before: B76459663 After: B77266952 **173,216,208,230** Routine Name: RCDPESR4 Before: B67024899 After: B73890637 **173,216,208,230** Routine Name: RCDPESR6 Before: B26998339 After: B28091668 **173,214,208,230** ============================================================================= User Information: Entered By : TUSEYEV,ANDREY Date Entered : MAR 21, 2005 Completed By: EVERETT,BRIAN Date Completed: APR 27, 2006 Released By : BOTTINI,STEVE Date Released : MAY 18, 2006 ============================================================================= Packman Mail Message: ===================== $END TXT