Information Systems File Layout & Specifications Manual Version 3.0

Information Systems

File Layout

&

Specifications Manual

Version 3.0

Table of Contents

1.0 Introduction ... 1-1 1.1 Overview ... 1-1 1.2 CPSA Standard Testing Criteria ... 1-2 1.3 CPSA Standard Certification Criteria ... 1-2 2.0 Data Certification & Testing Criteria ... 2-1 2.1 Overview ... 2-1 2.2 Data Certification Email Instructions ... 2-1 2.3 Data Certification Submittal Information ... 2-3 3.0 Referral, Intake, and Demographics... 3-4 3.1 Overview ... 3-4 3.2 Referrals ... 3-5 3.3 Intake ... 3-6 3.4 Demographic ... 3-7 4.0 Encounters ... 4-1 4.1 Overview ... 4-1 4.2 Encounter File Submission Schedule ... 4-2 4.3 Encounter Response Files & Reports ... 4-3 4.4 Web-based Claims Entry ... 4-20 4.5 Creating a Batch of Claims ... 4-26 4.6 Error Corrections ... 4-46 5.0 Future Releases ... 5-1 5.1 Pharmacy ... 5-1 File Layouts ... A-2 Appendix A

A.1 Encounter Weekly Response File & Quarterly Resync File Layout ... A-3 Sample Reports ...B-1 Appendix B

B.1 Sample Provider Inventory Report ...B-1 B.2 Sample Encounter Import Error Report ...B-2 B.3 Sample Encounter Submission Status by Service Month Report ...B-3 B.4 Sample Encounter Member UB Status by Service Month Report ...B-12 B.5 Sample Denial by Deny Code Summary...B-16 B.6 Sample UB Denial by Deny Code Summary ...B-17 B.7 Sample Industry Lag Report ...B-18 B.8 Sample Subcontractor Lag Report ...B-19

Revision History

Revision Comment Effective Date

CPSA Draft Internal Comments Comments Due 6/13/2008 May 23, 2008 Sent out for Provider Comment DRAFT Version 7.3 July 1, 2008

Version 1 Final Version 1 August 29, 2008

Version 1.1 Add Appendix D – Provider File Record Layout

October 2, 2008

Version 1.1 Added Claim Dispute information to Sections 4.4.1, 4.4.2 and Appendix A.4

October 14, 2008

Verson 1.2 Added Section 4.4.8 – Industry Lag Report and 4.4.9 – Subcontrator Lag Report

Added sample Industry Lag Report and Subcontractor Lag Report to Appendix B

June 7, 2010

Version 2.0 Major Revision

Version 2.0 Added Section 1.1 Overview

1.2 CPSA Standard Testing Criteria, and 1.3 CPSA Standard Certification Criteria. Added 3.0 Referral, Intake and

Demographic information.

May 9, 2012

Verson 2.1 Added Sections

4.5 Web-based Claim Entry 4.6 Creating a Batch of Claims 4.7 Error Corrections

June 22, 2012

Version 2.2 Added NCPDP Exchange File Formats July 5, 2012

Version 2.2 Updated Appendix C

Removed Edits and replaced with Denial Code Resolution Document

July 10, 2012

Version 3.0 Major Revision

Removal of File Layouts from Manual

1.0 Introduction

1.1 Overview

The purpose of testing and certifying EDI files submitted by providers to CPSA is to confirm that the provider can produce files which meet CPSA’s formatting requirements and that providers have sufficient edits and safeguards within their applications to produce records that successfully adjudicate through CPSA’s systems.

CPSA will test and certify all electronic transactions when a new contract has been awarded to a provider before the provider is allowed to submit into CPSA;s production systems. The transactions included in this policy are not limited to the following, but include:

 Referrals

 834 (Intakes & Closures)

 Demographics (Initial, Update, Annual, and Disenrollment)  837p (Professional Encounter)

 837i (Institutional Encounter)

 NCPDP SCRIPTS version 10.0 (Prescribing Information)

CPSA will also test and/or certify individual transactions when large changes to the format have been implemented OR as required by CPSA.

CPSA may also required re-certification of providers who are currently certified but cannot meet minimum standards for a form type. Low acceptance rates and repeated, unresolved format errors can result in re-certification.

Testing is defined as the process which confirms that the provider can produce an EDI file that meets CPSA formatting requirements. The provider must have a completed Contract or Letter of Agreement (LOA) with CPSA before testing can begin.

Certification is defined as the process of confirming that the provider has the necessary edits and safegurads within their applications to successfully adjudicate their transactions through CPSA’s systems. Contract information must be implemented in both the

1.2 CPSA Standard Testing Criteria

The formatting requirements for each of the form types are defined in the following sections of this manual. Once the provider or the provider’s third party biller has set up their system to produce the file(s) in the required format(s), the following steps must be followed:

1. Submit a request for testing to the CPSA Help Desk [email protected]. Specify the form types that you wish to test and when you would like to begin. Also indicate who will be the point of contact for the testing process. The CPSA IS Operations group will contact you to begin the process. Note: Make sure that your

contact person has completed a CPSA Web Portal login form and been given access to CPSA Connect. They will need the access to submit files to CPSA.

2. Place test files in the ‘Test’ folder that is accessible through CPSA Connect. Send an email to [email protected] informing CPSA that the test file has been submitted. Please note that your test file will be immediately picked up by the CPSA test processes. An acknowledgement and summary report should be available within ten minutes from file being placed in the test folder.

3. If the test file passes the first part of testing (file format and translation), CPSA IS Operations will notify the provider’s contact person that the file will move forward for test adjudication. Any detailed results will be provided back to you in the ‘Test’ folder.

All test files must be produced by the provider’s system or by their third-party biller without manual manipulation of the file.

All test files must exercise every relevant section of the format. For instance, 837 files must be tested for successful submission of COB loops. The details for each form type are defined in detail in the following sections of this manual.

When testing membership files, CPSA strongly recommends starting with the referral file first, the 834 (intake and closure) file second, and the demographic file last.

1.3 CPSA Standard Certification Criteria

The following standards are required for certification of all form types. However, the IS Operations staff assigned to the provider will issue specific requirements to the provider before certification begins that spell out details of each form type’s certification.

Certification can be customized for each provider based on their expected volume of transactions and the variety of providers, members, and/or services that they are contacted for. The following criteria are always required:

1. A minimum of three files with at least ten claims per file must pass each system test with a 90% acceptance rate for certification. (i.e. no more than a 10% denial rate). 2. Each certification transaction must be an original transaction. An original transaction

is defined as having not been included on a previous certification file.

3. The provider must demonstrate implementation of basic edits in their system.

4. The certification files must be representative of the provider’s normal submissions. A baseline for each provider will be established by evaluating past data. When past data is not available, the baseline will be estimated from other available information. 5. The provider must certify that the data transactions have been generated by their

system and have not been changed in any manner (such as manually manipulated, manually generated, or generated from any other system).

6. If provider’s staff experience technical difficulties within their system, they must first seek assistance from their internal ITS staff. If the ITS staff cannot resolve the issue, the internal ITS staff should then contact CPSA’s Help Desk or CPSA IS Operations Group.

2.0 Data Certification & Testing Criteria

2.1 Overview

As part of the Deficit Reduction Act of 2005, the Medicaid Integrity Program (MIP) was created to combat fraud and abuse in Medicare and Medicaid. As part of this, federal regulations require all records resulting in payment to submit a Certification of Data. The Arizona Department of Health Services, Division of Behavioral Health Services (ADHS/DBHS) requires the Regional Behavioral Health Authorities (RBHAs) and Tribal Regional Behavioral Health Authorities (T/RBHAs) to certify enrollment, encounter, and disenrollment data when submitting.

In order for CPSA to meet this requirement, Comprehensive Service Provider (CSP) must certify enrollment, encounter, and disenrollment data when submitting electronically to CPSA.

Data must be certified by the Chief Executive Officer, Chief Financial Officer, or an individual who has delegated authority of such and reports directly to either the Chief Executive Officer or Chief Financial Officer, by means of an automated data certification email process.

The Data Certification email must attest, based on best knowledge, information and belief, that the data being submitted is complete, accurate, and truthful and complies with federal

regulations. The CSP is responsible for submitting this data in accordance with applicable Federal and State laws, rules, policies, the CPSA contract and within file specifications provided. The Data Certification email must be submitted concurrently with the certified data.

CPSA will maintain and update a table containing all persons authorized to submit the Data Certification email.

To accomplish this, each individual authorized to submit the Data Certification email must also submit relevant information to CPSA. Please see the following section for instructions on completing the Data Certification Submittal Information.

2.2 Data Certification Email Instructions

To comply with the Deficit Reduction Act of 2005, the Medicaid Integrity Program (MIP), a data certification email must accompany data submissions to CPSA for enrollments, encounters, and disenrollments. The Data Certification email must be submitted by the CFO, CEO or a direct report thereof.

1. Email must be sent to [email protected].

2. Email must be sent from a person authorized to submit the Data Certification Email. 3. Subject line must contain: “BBA Certification” and the date in MMDDYYYY format.

4. The body of the email must have the same text as in the following example. Include filenames to specify the data files being submitted with this certification.

In addition, the Data Certification Submittal form must be filed with CPSA for each Provider staff member authorized to certify data submissions, or to remove a staff member no longer employed with the Provider. The completed form must be faxed to (520) 784-5324 to the attention of the IS Operations Manager.

TO: [email protected]

Subject: BBA Certificate MMDDYYYY

By submission of this email, I certify that the data and/or documents so recorded and submitted as input data or information, based on my best knowledge, information, and belief, is in compliance with Subpart H of the Balanced Budget Act Certification requirements; is complete, accurate, and truthful; and is in accordance with all Federal and State laws, regulations, policies and the CPSA contract now in effect. [Provider

Name] further certifies that it will retain and preserve all original documents as

required by law, submit all or any part of the same, or permit access to same for audit purposes, as required by the State of Arizona, or any agency of the Federal

government, or their representatives.

Data files submitted:

• Enrollment/Intake – (HIPAA-compliant 834 EDI files) • HCFA – (HIPAA-compliant 837p EDI files)

• UB – (HIPAA-compliant 837i EDI files) • Pharmacy – (HIPAA-compliant NCPDP files)

2.3 Data Certification Submittal Information

Provider Name and ID:_______________________________________________________

First Name:________________________________________________________________ Last Name:________________________________________________________________ Your Title:_________________________________________________________________ Telephone Number:_________________________________________________________ Fax Number:_______________________________________________________________ Email Address:_____________________________________________________________

Who do you report to and their title:_____________________________________________

CEO _________________________________________________Date:_____________________ Print CEO _________________________________________________Date:_____________________ Signature CFO _________________________________________________Date:_____________________ Print CFO _________________________________________________Date:_____________________ Signature

Authorized Signee Title _________________________________________________ Authorized Signee _________________________________________________Date:_____________________ Print Authorized Signee _________________________________________________Date:_____________________ Signature

3.0 Referral, Intake, and Demographics

3.1 Overview

Pace is the primary membership application for all of CPSA. Anyone who is currently or previously enrolled with any of CPSA’s Comprehensive Service Providers (CSPs) or has been enrolled by AHCCCS and assigned to CPSA. It is used throught the life cycle of a member to track their Referral to a behavioral health organization, their Intake (if applicable) by that organization, and Assessments made on then by their organization through their enrollment period.

When a member is undergoing treatment by a CSP, they are in an “Episode of Care”. An Episode of Care (EOC) is started and ended by the entry of a special kind of Demographic. There are three distinct types of members, with their own separate (though realted) workflows in PACE:

1. AHCCCS Eligible Members (also known as TXIX or TXXI) 2. State-Only Members (also known as NTXIX)

3. Title 36 Members

AHCCCS Eligible and State-Only make up a majorite of PACE membership.

Adds, Changes, and Disenrollments of AHCCCS Eligible Members are driven by the AHCCCS membership files, also called the AHCCCS 834 files.

PACE is used by both CPSA as well as all of CPSA’s CSPs. Information is entered into the system either through direct data entry in the online screens made available through

CPSAConnect, or through a batch file process that imports files from our CSP every hour, on the hour.

The information collected in PACE is used throughout the organization, either through direct reference, or by reference to data generated from, but not located directly within, the PACE application.

There are three key documents in PACE: Referral, Intakes, and Demographics. They can be entered either through an oline screen or a batch file process.

3.2 Referrals

Referrals represent a Referral to a Behavioral Health Care procider. They are broken down into three sub-documents:

Referral Master

The Referral Master contains a majority of the information in the Referral, including Member identifying information (name, date of birth, gender), insurance information, and the CSP the member was referred by.

Referral Source

The Referral Source contains a list of all of the Referral Sources for a given Referral. Only one Referral Source can be entered for a Referral.

Referral Detail

The Referral Detail contains a history of the CSP’s contact with the member, including the type of contact and the date and time of contact. The Referral Detail may also be referred to as the Referral History.

In order for a member to enter an Episode of Care, the Referral must be “closed”. To close a Referral, the following must be true:

 The Referral Status field must be populated  The Program field must be populated

 The Network Provider field must be populated  The Service Provider field must be populated

 The Referral Detail History must be completed with at least one of the following Outcomes:

o 15 – Crisis Service Completed: No Additional Services Needed (Crisis Referral Only)

o 20 – Crisis Not Solved: Face-to-Face Follow-up Requested (Crisis Referral Only)

o 25 – Transport to Hospital (Crisis Referral Only) o 30 – Face-to-Face Follow-up (Crisis Referral Only) o 35 – Referred to Urgent Intake (Crisis Referral Only) o 40 – Referred to Routine Intake (Crisis Referral Only) o 55 – Intake/Enrollment Completed

o 67 – Referred to Hospital: Medical (Crisis Referral Only) o 68 – Referred To Hospital: Psychiatric (Crisis Referral Only) o 69 – Referral to Criminal Justice System (Crisis Referral Only) o 70 – Other (Crisis Referral Only)

o 80 – Referral Closed (Crisis Referral Only) o 99 – Waiting List

3.3 Intake

Intakes represent enrollment, either by a CSP or by AHCCCS. They primarily contain member identifying information and other basic member demographics (address, phone number, etc.) The Intake also contains a member’s Third Pary Liability (TPL) information. For AHCCCS Eligible members, the Intake cannot be directly modified, as this information comes directly from AHCCCS.

In addition to containing member information, the Intake contains the “Stage” the member is currently in. The stages defined for a member are as follows:

 1 – Provider: The member record needs to be modified by the Provider (usually because of errors that occurred when the enrollment was sent to the State)

 2 – Enrolling: We have received and accepted the Intake for a member and it is in a queue to be submitted to the State.

 5 – Active: The member is currently in an Active Episode of Care. (Note: This used to be called the “Enrolled” stage)

 6 – Submitting Changes: After a change has been made to the Intake and the record is put in a queue to be submitted to the State.

 7 – Submitting Closure: A closure has been created for the Intake and it has been placed in a queue to be submitted to the State.

 8 – Disenrolled: The member has been disenrolled, either by the enrolling CSP, or by AHCCCS.

 9 – CPSA State Errors: The Intake was transmitted to the State but had one or more errors preventing the enrollment transaction from being entered into their system.

 10 – Waiting for State Response: Intake has been transmitted to the State and we are waiting for a response.

 12 – CPSA – Suspend: A stage manually set by the CPSA staff. Suspend workflow and indicated that the record needs to be acted on by CPSA.

 16 – Eligibility Suspend: The member is not currently eligible for benefits based on available information. A member is defined as eligible for benefits if one or more of the following is true:

o The member is TXIX or TXXI

o The member is NTXIX and one or more of the following is true:

 Has a Behavioral Health Category of “SMI” in their most recent Demographic

 Has a Behavioral Health Category of “SED” is their most recent Demographic

 Has a value of “Y” in the SAPT-IV Drug User field in their most recent Demographic

 Has a value of “Y” in the SAPT-IV Pregnant Woman field in their most recent Demographic

 Has a value of “Y” in the SAPT-Dependent Child field in their most recent Demographic

 Has a value of “Y” in th SAPT-Non Priority field in their most recent Demographic

 Was enrolled by a Crisis CSP

Note that there is a daily scheduled task that places a member in Stage 16 if they are no longer benefit eligible and moves a member from Stage 16 to Stage 5 (Active) if they are benefit eligible.

 17 – Closed – No Eligibility: A Referral and Intake were sent for this member, but benefit eligibility was never confirmed and the record was closed. This happens after 10 days.

 18 – Awaiting Eligibility: Enrollment will not be sent to the State until benefit eligibility is confirmed. Record closed after 10 days.

 19 – Inative: This AHCCCS Eligible member does not currently have an active EOC.

 20 – Waiting EOC: This AHCCCS member requires an EOC Start Demographic to be Activated.

 21 – Incomplete AHCCCS Enrollment: This member is enrolled by AHCCCS but is missing membership information.

3.4 Demographic

Demographics, (also called Assessments) are one of the most important documents in PACE. They begin and end Episodes of Care, specify the type of EOC, and contain detailed information about the member’s current health status. There are seven types of Demographics:

 1 – EOC Start – Required for all non-crisis members. Used to begin an Episode of Care.

 2 – Full Assessments – Required on a yearly basis for all members over the age of 17. For members 17 or younger, this is required semi-annually.  3 – Minor Change – Submitted whenever a small change to member

information is required.

 4 – EOC End – Used to end a standard Episode of Care for a member. For State-Only members, an 834 Closure is required before entry for an EOC End Demographic.

 5 – Crisis/Short Start – Required for all crisis members. Used to begin a Crisis or Short Episode of Care.

 6 – Crisis/Short End – Used to end a Crisis/Short Episode of Care for a member

 9 – Correction – Used to enter a correction to a previous Demographic Like Members, Demographics can also have stages. Explanations of Demographic stages are as follows:

 1 – Provided: The Demographic needs to be modified by the Provider (usually because of errors that occurred when the enrollment was sent to the State)

 2 – Enrolling: CPSA has received and accepted the EOC Start Demographic for a member and it is in a queue to be submitted to the State.

 5 – Acitve: The member is currently in an Active Episode of Care. (Note: This used to be called the “Enrolled” stage)

 6 – Submitting Changes: After a change has been made to the Demographic and the record is put in a queue to be submitted to the State.

 7 – Submitting Closure: An EOC End Demographic has been entered and it has been place in a queue to be submitted to the State.

 8 – Disenrolled: The member has been disenrolled, either by the enrolling CSP, or by AHCCCS.

 9 – CPSA State Errors: The Demographic was transmitted to the State but had one or more errors preventing the Demographic transaction from being

entered into their system.

 10 – Waiting for State Response: Demographic has been transmitted to the State and CPSA is waiting for a response.

 11 – Archived: Used to Indicate that as Assessment has been archived for viewing purposes.

 12 – CPSA – Suspend: A stage manually set by the CPSA staff. Freezed workflow and indicates that the record need to be acted on by CPSA.

Member Workflow

AHCCCS Eligible Members are automatically enrolled in PACE with a stage of “Inactive”. This means a Referral and Intake are automatically generated for them by the PACE Enrollment File Process.

In order to start an Episode of Care for an AHCCCS Eligible Member, the CSP needs to submit a Referral. An Intake will be automatically generated and placed in the “Awaiting EOC” stage. At this point, the CSP needs to submit a Demographic to begin the Episode of Care.

AHCCCS Eligible Members can only be disenrolled by AHCCCS. When a CSP ceases an Episode of Care for an AHCCCS Eligible member, then they return to the “Inactive” stage.

State-Only Member

State-Only members are enrolled and disenrolled by a CSP through direct entry of a Referral and an Intake.

A Referral is required to be submitted and closed before an Intake can be entered, and an Intake must be entered before a Demographic can be submitted. However, a CSP may submit all of these forms in a single transaction, as long as the Referral and Intake are not rejected by CPSA for data validation issues. After creation of a Referral, the member is given a PACE ID, which is the primary identifier used to track the member in the PACE syste. The secondary method od identifying a unique member – used by the CSPs – is the Provider Client ID (a unique ID

CSP), and the Provider ID (the ID of the CSP the member was referred to). CSPs use this method, as they do not always collect and record the PACE ID in their own system. When a CSP ceases an Episode of Care for a State-Only member, then they become “Disenrolled”.

Once a member has been enrolled with the State either through AHCCCS (if they are AHCCCS Eligible) or through a RBHA (if they are State-Only) they receive a CISID, which is another way of locating a member. All AHCCCS Eligible members will have a CISID prior to the start of an Episode of Care; State-Only members may or may not – if a member have been enrolled in Arizona behavioral health care before, they should already has a CISID. This is determined by a search using the first letter of the member’s first name, first four letters of a member’s last name, date of birth, and gender. A unique member enrollment segment consists of their CISID and their EOC Start Date, as the member’s PACE ID will change if they transfer Providers.

Versioning

The PACE versioning logic is as follows:

State-mandated releases change the major version number – IE, if the current version is PACE 6.5.1, and the next release is a state-mandated release, the that woud be known as PACE 7.1. Major revisions that are not state-mandated change the minor version number – IE, if the current version is PACE 6.4, and the next relase adds new features (beyond simple bug fixed), then it would be known as PACE 6.5.

Finally, bug-fix releases change the bug fix version number – IE, is the current version if PACE 6.5, and the next release adds one or more bug fixes without any major new features, then it would be known as PACE 6.5.1.

Pace Member Roster

The PACE Member Roster is a compilation of the most recent information for all CPSA

members. It is provided, and used, in both a database-table and electronic file form. This roster is generated on a daily basis. A CSP specific roster is also generated daily for each CSP, and is placed in their FTP Folder.

4.0 Encounters

4.1 Overview

In order to streamline CPSA’s handling of encounter files and to improve our communications with providers regarding encounter file processing, the following requirements have been implemented.

Encounters are submitted in HIPAA 837 format using the guidelines provided by CPSA and the mapping documents provided in Appendix A. The input encounter file name is defined in section 4.2. It must be unique to all other file names submitted to CPSA by the Provider. Files are placed on CPSA’s FTP folder through the File Transfer function on CPSA’s web portal or using SSL FTP software (must be coordinated with the CPSA IT staff). Files are accepted at any time, but submissions are scheduled with CPSA’s IS Operations group to level out work load and provide quick turnaround of file processing. Submission schedules are described in Section 4.3. During translation processing, files will be immediately picked up by the CPSA inbound processes. An acknowledgement and summary report should be available within a few minutes from file being placed in the test folder. It is the provider’s responsibility to review acknowledgement and summary reports. Please note that if no summary report is received, providers should immediately contact the [email protected] for assistance.

After translation, if no errors occurred, the file will be imported into CPSA’s encounter system as an EDI file. If one or more encounters within the file cannot be imported into the system, a file import report will be generated and placed in the Provider’s folder on CPSA’s FTP site. An example Import Error Report can be found in Appendix B.

Monday through Friday, encounters are processed through CPSA’s encounter system and adjudicated. Accepted encounters are sent to the State each week. CPSA may also send additional files to the state as needed. Response files from the State are generated bi-monthly and imported back into CPSA’s encounter system where any rejects are converted to denials. Each Sunday, CPSA generates a Weekly Response File containing all encounters processed or changed during the previous week for each submitting Provider. The files also contain any encounter that is ‘in-process’ – that has not been fully adjudicated or has been pended by CPSA for further review. Year-to-date response files for each fiscal year are also produced once each quarter for each Provider. They are called the Quarterly Resync Files.

Each Sunday, CPSA also generates Encounter Summary Status (ESS) reports containing a fiscal year-to-date summary of all encounters received from the submitting Provider. Each report is accompanied by a HCFA and/or UB Denial Summary report for the fiscal year. Network Providers also receive an Encounter Member UB Summary (EMS) report that contains inpatient encounters for their members at facilities that directly report to CPSA. These reports are described in detail in Section 4.4 and sample reports are provided in Appendix B.

4.2 Encounter File Submission Schedule

Provides are required to establish an encounter submission schedule with CPSA’s Data

Processing Department. The schedule may be weekly, monthly, or bi-monthly. They must then submit files according to this schedule.

 Providers may submit more frequently than specified in the agreement.

 If a deadline is going to be missed, send an email notification to the CPSA Data Processing Department to explain the delay. The email address is

[email protected].

 If a deadline is missed and the provider has not contacted CPSA IS Operations, an email will be sent to the provider requesting an explanation – and when the file(s) will be received. An example follows:

 CPSA normally processes the submitted encounter files within three business days of receiving them, however, files will be processed in the order they are received. If there are any processing delays on CPSA’s side, a notice will be sent out to the providers.

From: Cynthia Brown Sent: Wed 04/23/2008 9:15 AM

To: Joanne Smith; ‘[email protected]’ Cc: [email protected]

Subject: ABC HEALTHCARE File Submission – Reminder Joanne,

According to CPSA’s encounter file submission schedule, ABC HEALTHCARE agreed to submit their monthly encounter files to CPSA on the fourth Wednesday of each month. Since the fourth Wednesday of the month has passed and we have not received your submission, please contact us immediately to explain why the file(s) have not been sent and when we can expect them.

Thank you, Cynthia Brown

Business Systems Analyst

4.3 Encounter Response Files & Reports

The proceeding reports in section 4.4 have a purge schedule and will be purged after 90 days. It is the responsibility of the Provider to make sure they have everything they need before the files are purged. CPSA will not recreate these files.

4.3.1 Weekly Response Files

CPSA generates Weekly encounter Response Files for each Provider that contains information on all encounters processed or encounters whose status have changed in the past week. They also contain all in-process encounters, encounter voids, and replacement encounters belonging to the submitting Provider. There are three files for each submitting Provider – one for each of the latest three fiscal years. A file is created for each Provider and each fiscal year regardless of whether encounters were processed the previous week.

The Weekly Response Files constitute CPSA’s acknowledgement that a Provider’s encounters have been processed. The timeline for denial correction and submission back to CPSA begins when the file is placed in the Provider’s Response folder. The information contained is based on what was submitted to CPSA, and is not intended to be used for financial reporting. Refer to the Provider Manual for denial correction timelines.

Note: To obtain information regarding Provider Claim Disputes, please refer to CPSA Provider Manual, Section 5.6. Timely filing due dates are set forth in the ADHS/CPSA Provider Manual, Section 6.2.

Frequency:

Weekly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First business day of the week. Notification:

Email notification is sent by CPSA to the Providers.

File Naming Convention:

WRF_ProviderName_FYxx_ccyymmdd.txt

WRF Weekly Response File ProviderName Submitting Provider Name

xx Fiscal Year

ccyymmdd Creation date of file (century, year, month & day)

File Description:

4.3.2 Quarterly Resync Files

Resync files are created each quarter (January, April, July, and October) for each submitting Provider. They contain the current year-to-date processing status of all encounters submitted for the fiscal year – as well as other encounter data as it exists in CPSA’s encounter system.

Note: To obtain information regarding Provider Claim Disputes, please refer to CPSA Provider Manual, Section 5.6. Timely filing due dates are set forth in the ADHS/CPSA Provider Manual, Section 6.2.

Frequency:

Quarterly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First Monday following the close of the quarter. Quarters are defined as July through September (Qtr 1), October through December (Qtr 2), January through March (Qtr 3) and April through June (Qtr 4).

Notification:

Email notification is sent by CPSA to the Providers.

File Naming Convention:

QRF_ProviderName_FYxx_ccyymmdd.txt

QRF Quarterly Resync File ProviderName Submitting Provider Name

xx Fiscal Year

ccyymmdd Creation date of file (century, year, month & day)

File Description:

The Quarterly Resync Files are created as text files, with comma separated fields. The file layout is the same as the Weekly Response Files and is provided in Appendix A.

4.3.3 Inventory Reports

Each week, CPSA generates a list of all files submitted to CPSA by each Provider who sends encounter files electronically. The list is provided in a Microsoft Excel spreadsheet with

separate worksheets for new encounter files, replacement encounter files, denial correction files and data validation files. The status of each file (processed, in inventory, returned, etc.) is also provided, with received dates, translation dates, import dates, and notes.

The Inventory report is created so that the Provider can validate their encounter file inventory with CPSA’s – and rectify any differences that are found.

Frequency:

Weekly. The report is posted to the Provider’s FTP Claims file folder. Schedule:

First business day of the week. Notification:

Email notification is sent by CPSA to the Providers.

Report Naming Convention:

ProviderName FYxx Encounter Inventory ccyymmdd.txt

ProviderName Submitting Provider Name

xx Fiscal Year

ccyymmdd Report creation date (century, year, month and day) Report Description:

A sample Inventory report is provided in Appendix B.

4.3.4 Encounter Submission Status by Service Month

The Encounter Submission Status by Service Month (ESS) reports are a monitoring tool which reports the status of the Provider’s service encounters that have been input into CPSA’s

encounter processing system for a fiscal year to date. This includes both electronic files and manual UB and HCFA claim forms submitted by the provider that have been keyed into the encounter system by the Claims Department.

Separate reports are provided for each of the last three fiscal years. An example ESS report is provided in Appendix B.

Frequency:

Weekly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First business day of the week. Notification of Report Availability:

Email notification is sent by CPSA to the Providers. Report Naming Convention:

ESS_Provider_ProviderID_YYYY_yyyymmdd.PDF Provider Submitting Provider Name ProviderID Submitting Provider ID YYYY Fiscal Year

yyyymmdd Date the report was generated

Report Description:

The report is broken into two distinct sections described below:

1. Summary of Submission Results (page 1)

This section of the report provides a percent of total records received by form type and by the status of the encounters.

 Accepted by CPSA  Rejected by CIS  Pended by CPSA  In Process by CPSA  Denied by CPSA

This portion of the report contains a sum of the Encounters (Count), their Billed Amounts and Allowed Amounts by Service Month. Information is accumulated in the following categories for each encounter by the processing status of the encounter:

 Month: Encounter Service Start Month

 Quarterly Summary: Sum of the data by Quarter 1, 2, 3, and 4.  Total Submission: Fiscal Year to date total for the status.

A separate page is produced for each Encounter Status. Explanations of the statuses are: Submitted to CPSA (page 1)

This category reports all the encounters that have been submitted by the Provider and entered into the CPSA encounter system. In addition to the Count, Billed Amounts, and Allowed Amounts, this portion of the report also contains the sum of the enrolled members for each service month. The column is titled Member Count. The Member Count is present on Network Provider’s report. The field will be blank for all other providers since they do not have CPSA members assigned to them.

Accepted by CPSA (pages 2-6)

This category reports all encounters that have been adjudicated and have passed all edits. There are five (5) sub-statuses within this category:

1. Accepted by CIS (page 2) – CIS is an acronym for the Department of Behavioral Health Services (DBHS) processing system, ‘Customer Information System.’ Encounters ‘Accepted by CIS’ have been submitted to DBHS and accepted by their system.

2. Submitted to State (page 3) – This is a status used by CPSA to manage the number of encounters that have been sent to DBHS, but CPSA is awaiting a response from DBHS as to their acceptance or rejection.

3. Waiting for Check Write (page 4) – This is an interim status used by CPSA to manage encounters that have passed the CPSA adjudication process, but have not been finalized through the ‘Check Write’ process. Until finalized, encounters cannot be sent to DBHS.

4. Check Write Complete (page 5) – This is an interim status used by CPSA to manage encounters that have passed the CPSA adjudication process and have been finalized through the ‘Check Write’ process, but have not yet been sent to DBHS.

5. CIS Rejects (page 6) – This is an interim status used by CPSA to manage encounters that have been sent to DBHS and rejected. CPSA must review these encounters and determine their final disposition. These encounters will either be denied back to the Provider or resubmitted to DBHS. Until then, the encounter is considered accepted. The sum of the five (5) sub-statuses are included in the ‘Total Accepted by Quarter’ and the ‘Total Accepted by CPSA’ on Page 6.

In Process by CPSA (pages 7-8)

This category reports all the encounters that have been entered into the CPSA encounter system but have not completed adjudication. There are two (2) sub-statuses within this category:

1. Pended by CPSA (page 7) – This status is used by CPSA to manage encounters that have been edited and require further review by CPSA to determine their final

disposition.

2. In Process by CPSA (page 8) – This status is used by CPSA to manage encounters that have been entered into the CPSA encounter system but have not yet been adjudicated. Normally these are encounters that were received at the time the report was produced.

The sum of the two (2) sub-statuses is included in the ‘Total In Process by Quarter’ and ‘Total In Process by CPSA’ on Page 8.

CPSA Denied (page 9)

This category reports all the encounters that have been denied back to the Provider. Details of these denials are reported on a companion report entitled ‘Denial Code by Deny Code Summary.’

4.3.5 Encounter Member UB Status by Service Month

Each week, CPSA generates Encounter Member UB Status by Service Month (EMS) reports for each of the Networks. Other Submitting Providers will not receive these reports. They are a monthly summary of inpatient encounters for the Network’s assigned members for all facilities that directly submit encounters to CPSA. Network Psychiatric Hospital Facilities (PHFs) that the Networks submit to CPSA for their members do not show in this report.

Separate reports are provided for each of the last three fiscal years. An example EMS report is provided in Appendix B.

Frequency:

Weekly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First business day of the week. Notification of Report Availability:

Email notification is sent by CPSA to the Providers. Report Naming Convention:

EMS_UB_Provider_ProviderID_YYYY_yyyymmdd.PDF Provider Submitting Provider Name

ProviderID Submitting Provider ID YYYY Fiscal Year

yyyymmdd Date the report was generated

Report Description:

The report is broken into two distinct sections described below:

1. Summary of Submission Results (page 1)

This section of the report provides a percent of total records received by form type and by the status of the encounters. However, UBs are the only form type updated with the following values:  Accepted by CPSA  Rejected by CIS  Pended by CPSA  In Process by CPSA  Denied by CPSA

This portion of the report contains a sum of the Encounters (Counts column), their Billed Amounts and Allowed Amounts by Service Month. Information is accumulated in the following categories for each encounter by the processing status of the encounter:

 Month: Encounter Service Start Month

 Quarterly Summary: Sum of the data by Quarter 1, 2, 3, and 4.  Total Submission: Fiscal Year to date total for the status.

A separate page is produced for each Encounter Status. Explanations of the statuses are: Submitted to CPSA (page 1)

This category reports all the encounters that have been submitted by the Provider and entered into the CPSA encounter system.

Accepted by CPSA (pages 1-3)

This category reports all encounters that have been adjudicated and have passed all edits. There are five (5) sub-statuses within this category:

1. Accepted by CIS (page 1) – CIS is an acronym for the Department of Behavioral Health Services (DBHS) processing system, ‘Customer Information System.’ Encounters ‘Accepted by CIS’ have been submitted to DBHS and accepted by their system.

2. Submitted to State (page 2) – This is a status used by CPSA to manage the number of encounters that have been sent to DBHS, but CPSA is awaiting a response from DBHS as to their acceptance or rejection.

3. Waiting for Check Write (page 2) – This is an interim status used by CPSA to manage encounters that have passed the CPSA adjudication process, but have not been finalized through the ‘Check Write’ process. Until finalized, encounters cannot be sent to DBHS.

4. Check Write Complete (page 2) – This is an interim status used by CPSA to manage encounters that have passed the CPSA adjudication process and have been finalized through the ‘Check Write’ process, but have not yet been sent to DBHS.

5. CIS Rejects (page 3) – This is an interim status used by CPSA to manage encounters that have been sent to DBHS and rejected. CPSA must review these encounters and determine their final disposition. These encounters will either be denied back to the Provider or resubmitted to DBHS. Until then, the encounter is considered accepted. The sum of the five (5) sub-statuses are included in the ‘Total Accepted by CPSA’ on Page 3.

In process by CPSA (page 3)

This category reports all the encounters that have been entered into the CPSA encounter system but have not completed adjudication. There are two (2) sub-statuses within this category:

1. Pended by CPSA – This status is used by CPSA to manage encounters that have been edited and require further review by CPSA to determine their final disposition.

2. In Process by CPSA – This status is used by CPSA to manage encounters that have been entered into the CPSA encounter system but have not yet been adjudicated. Normally these are encounters that were received at the time the report was produced. The sum of the two (2) sub-statuses is included in the ‘Total In Process by CPSA.’

CPSA Denied (page 4)

This category reports all the encounters that have been denied back to the Provider. Details of these denials are reported on a companion report entitled ‘Denial Code by Deny Code Summary.’

4.3.6 Denial by Deny Code Summary (for HCFAs)

CPSA generates Denial by Deny Code Summary (DEN_MC) reports for all denials received year-to-date for each Provider who submits professional encounters (HCFAs) to CPSA. The report includes both encounters submitted on electronic files and on paper. It is used to identify edits that need to be created in the Provider’s encounter system and denials that need to be worked by the Provider.

This report is used in conjunction with the Encounter Submission Status by Service Month (ESS) report. It details the denial reasons for the encounters totaled on Page 9 of the ESS report

described in Section 4.4.4. It should also be used in conjunction with the ‘Denial Code

Resolution’ document provided by the CPSA Claims Department in the FTP Common file folder and in Appendix C.

Separate reports are provided for each of the last three fiscal years. An example DEN_MC report is provided in Appendix B.

Frequency:

Weekly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First business day of the week. Notification of Report Availability:

Email notification is sent by CPSA to the Providers. Report Naming Convention:

DEN_MC_Provider_ProviderID_YYYY_yyyymmdd.PDF Provider Submitting Provider Name

ProviderID Submitting Provider ID YYYY Fiscal Year

yyyymmdd Date the report was generated

Report Description:

The report is comprised of one section which includes the following fields: 1. Deny Code: CPSA denial reason code.

2. Description: Denial reason code description.

3. Count: Sum of the encounters that were denied for denial reason code.

4. Billed Amount: Sum of the Billed Amounts for the encounters denied for the denial reason code.

5. Allowed Amount: Sum of the Allowed Amount determined during the adjudication of the encounter. In some cases the Allowed Amount will be zero if the encounter could not be priced.

4.3.7 UB Denial by Deny Code Summary

CPSA generates the ‘UB Denial by Deny Code Summary’ (DEN_HC) reports for all denials received year-to-date for each Provider who submits inpatient and outpatient encounters (UBs) to CPSA. The report includes both encounters submitted on electronic files and on paper. It is used to identify edits that need to be created in the Provider’s encounter system and denials that need to be worked by the Provider.

This report is used in conjunction with the Encounter Submission Status by Service Month (ESS) report. It details the denial reasons for the encounters totaled on Page 9 of the ESS report

described in Section 4.4.4. It should also be used in conjunction with the ‘Denial Code

Resolution’ document provided by the CPSA Claims Department in the FTP Common file folder and in Appendix C.

Separate reports are provided for each of the last three fiscal years. An example DEN_HC report is provided in Appendix B.

Frequency:

Weekly. The report is posted to the Provider’s FTP Response file folder. Schedule:

First business day of the week. Notification of Report Availability:

Email notification is sent by CPSA to the Providers. Report Naming Convention:

DEN_HC_Provider_ProviderID_YYYY_yyyymmdd.PDF Provider Submitting Provider Name

ProviderID Submitting Provider ID YYYY Fiscal Year

yyyymmdd Date the report was generated

Report Description:

The report is comprised of one section which includes the following fields: 1. Deny Code: CPSA denial reason code.

2. Description: Denial reason code description.

3. Count: Sum of the encounters that were denied for denial reason code.

4. Billed Amount: Sum of the Billed Amounts for the encounters denied for the denial reason code.

Sum of the Allowed Amount determined during the adjudication of the encounter. In some cases the

4.3.8 Industry Lag Report

The CPSA Industry Lag report is used by CPSA Business Operations’ staff as well as CPSA’s direct contracted providers and Comprehensive Service Providers (CSP) to monitor CSP encounter submission behavior. Monitoring is necessary to ensure compliance by CSPs with contracted timely filing requirements according to the CPSA Provider manual, Section 6.2.7A. Encounter submission behavior also affects the Comprehensive Service Provider’s ability to meet its quarterly and annual required encounter value thresholds according to Section IX - Encounter Submission of the CPSA Provider Finance Guide. Consequently, the monitoring of submissions through the use of the Industry Lag Report helps CPSA, the CSPs, and the direct contracted providers to meet timely filing and encounter withhold requirements.

The CPSA Industry Lag Report shows the overall length of time, in units of months, from when member service is rendered until the respective service encounters are received by CPSA. The Industry Lag Report provides a comprehensive “at-a-glance” reference and auditing tool for submitted encounters. The reports distinctly reveal encounter submission behavior and can indicate whether a CSP is up-to-date or falling behind on its submission schedule. The report additionally reveals where submissions are late for specific service months. By comparing service month to submission month, the Lag Report can be used to pinpoint where delays are occurring and suggest whether or not the CSP is fulfilling its contractual obligation regarding timely claim submissions. As such, the reports are a critical tool used for analysis and discussion by CPSA’s Business Operations representatives and the Comprehensive Service Provider billing staff.

CPSA Industry Lag Reports are produced for two form types: Medical (HCFA / 837P) and Hospital (UB / 837I) claims and encounters.

Please refer to the following documents for further information:

 CPSA Encounter Submission of the CPSA Provider Finance Guide – Section IX.  CPSA Provider Manual for submission timelines (Section 6.2) Submitting Claims &

Encounters to the RBHA, for further information.

Frequency:

Weekly. The report is posted to the Providers FTP Remits file folder. Schedule:

First business day of the week.

Notification of Report Availability:

Report Naming Convention:

Report: Type_ProviderName_ProviderID_FYxx_ccyymmdd.pdf

Report Type LAG_MC (for HCFA / 1500 OR 837P medical claims) LAG_HC (for UB04 / 837I hospital claims)

Provider Name Provider Name (CSP)

Provider ID Provider Identifier (CPSA Assigned 2 Digit Identifier) FYxx Fiscal Year

ccyymmdd Report creation Date (century, year, month, & day) PDF File extension (.PDF)

Example: LAG_MC_ABC_31_2010_20091206.pdf Availability:

The CPSA Industry Lag Reports are distributed into each CSP’s and direct contracted provider’s respective FTP folder under their Remits directory. The reports can also be retrieved using the CPSA Connect Web portal from the File Transfer Menu. From this window, the reports can be found under the CSP’s “Response File” folder option.

Report Description:

The CPSA Industry Lag Report is displayed in cross tab format. Each report displays for a given Comprehensive Service Provider and Fiscal Year, all submitted original encounters (electronic and paper) as of a designated date in time. Fiscal year-to-date accumulated submission counts are displayed in a tabular fashion by received month that is displayed across the table’s header columns and by service month, which is shown running down the rows of the table’s left most column. Each “Received” month column has a total value displayed at the foot of that month’s column. Similarly, each service month has a total value displayed in its right-most column. A grand total is additionally displayed at the rightmost bottom corner of the table. Given that submissions throughout a fiscal year lag into subsequent months, an additional set of columns, qualified by month name post-fixed with the word “Next” display late submitted encounters for corresponding service months. See examples in Appendix B:

1. Header:

Each report displays the submitting provider name across the top of the report. A sub-title displayed below the submitting provider name identifies the form type, fiscal year, and “As Of” date that the report reflects.

Example: HCFA Encounter LAG Report for FY 2009 as of 12/06/2009 2. Rows:

 Rows 2 thru 12 represent the SERVICE Months of the reported FISCAL YEAR, (JULY - JUNE), for which Services were rendered as stated on the submitted Claim.  Each row is comprised of 23 columns representing the months in which encounters

and claims were received by CPSA - RECEIVED MONTH. o Column 1 is the Service Month.

o Column 22 represents the post withhold period.

o Column 23 reflects the total encounters for columns 1 through 22.

 Row 13 contains Totals for each of the 20 “RECEIVED” Months as labeled on the column headings.

3. Columns:

 Column 1 represents the SERVICE MONTH. The left most rows of this column lists the twelve (12) SERVICE MONTH row headings, in FISCAL YEAR order, starting with July and ending in June.

 Columns 2 thru 13 represent twelve (12) RECEIVED MONTHS which comprise the specified Fiscal Year months in which encounters and claims were received by CPSA.

 Columns 14 thru 21 represent eight (8) additional RECEIVED MONTHS (JULY thru FEB), which account for the pay period to complete the Fiscal Year’s submissions. Numbers found in these columns represent encounters occurring during Fiscal Year of the Report, but were not submitted to CPSA until after the Fiscal Year ended.  Column 22 is Post Withhold, representing encounters received after the close of the

Fiscal year rollup.

4.3.9 Subcontractor Lag Report

The CPSA Subcontractor Lag report is used by CPSA’s Comprehensive Service Providers (CSP) and CPSA’s Business Operations’ staff to monitor CSP encounter submission behavior by CSP site and by the CSP’s subcontracted providers. Monitoring is necessary to ensure provider compliance with contracted timely filing requirements according to the CPSA Provider manual, Section 6.2.7A. Encounter submission behavior also affects the CSP’s ability to meet its quarterly and annual required encounter value thresholds according to Section IX - Encounter Submission of the CPSA Provider Finance Guide. Consequently, the monitoring of CSP’s and their subcontractor submissions through the use of the Subcontractor Lag Report helps CPSA, the CSP’s and their subcontractors meet timely filing and encounter withhold requirements. Because the submission of encounters by subcontractors to their CSPs affects timely filing, a lower level lag report is required to help monitor and pinpoint lagging submissions by CSP site and subcontractor.

The CPSA Subcontractor Lag Report shows the overall length of time, in units of months, from when member services are rendered until the respective service encounters are received by CPSA. The Subcontractor Lag Report provides a comprehensive “at-a-glance” reference and auditing tool for submitted encounters. The reports distinctly reveal encounter submission behavior and can indicate whether a CSP and its subcontractors are up-to-date or falling behind on their submissions. The report additionally reveals where submissions are late for specific service months. By comparing service month to submission month, the Subcontractor Lag Report can be used to pinpoint where delays are occurring, and suggest whether or not the CSP and their subcontractors are fulfilling their contractual obligations regarding timely claim submissions.

Please refer to the following documents for further information for timely submission rules.  CPSA Encounter Submission of the CPSA Provider Finance Guide – Section IX.  CPSA Provider Manual for submission timelines (Section 6.2) Submitting Claims &

Encounters to the RBHA, for further information.

Frequency:

Weekly. The report is posted to the Providers FTP folder. Schedule:

Subcontractor Lag Report Layout: Report Title:

Each report displays provider name across the top of the report. A sub-title displayed below the submitting provider’s CSP name identifies the form type, fiscal year, and “As Of” date that the report reflects.

Example: HCFA Encounter LAG Report for FY 2009 as of 12/06/2009

The subcontracted provider name and assigned AHCCCS ID are also displayed and aligned on the left edge of the report underneath the report title region.

Example: Subcontractor / AHCCCS ID CASAVERDE - 7654321 Rows:

 Rows 2 thru 12 represent the SERVICE Months of the reported FISCAL YEAR, (JULY - JUNE), for which Services were rendered as stated on the submitted Claim.

 Each row is comprised of 23 columns representing the months in which encounters and claims were received by CPSA - RECEIVED MONTH.

o Column 1 is the Service Month.

o Column 2 through 21 represent the received months. o Column 22 represents the Post Withhold period.

o Column 23 reflects the total encounters for columns 1 through 22.

 Row 13 contains Totals for each of the 20 “RECEIVED” Months as labeled on the column headings.

Columns:

 Column 1 represents the SERVICE MONTH. The left most rows of this column lists the twelve (12) SERVICE MONTH row headings, in FISCAL YEAR order, starting with July and ending in June.

 Columns 2 thru 13 represent twelve (12) RECEIVED MONTHS which comprise the specified Fiscal Year months in which encounters and claims were received by CPSA.  Columns 14 thru 21 represent eight (8) additional RECEIVED MONTHS (JULY thru FEB),

which account for the withhold period to complete the Fiscal Year’s submissions. Numbers found in these columns represent encounters occurring during Fiscal Year of the Report, but were not submitted to CPSA until after the Fiscal Year ended.

 Column 22 is Post Withhold, representing encounters received after the close of the Fiscal year withhold period.

Summary Report Page

The Subcontractor Lag Report CSP Summary page mirrors the layout of the Industry Lag. The summary sheet has been included to: (1) permit balancing with the CSP’s CPSA’s Lag Report; and (2) demonstrate that the prior subcontractor lag reports balance accordingly. Refer to the layout specifications for the HCFA Industry Lag Report for further explanation of this summary sheet.

Summary Report – Subcontractor Encounter Count Summary Page(s)

The Subcontractor Encounter Count Summary Page displays encounter counts by subcontractor ID and name. The format simply lists in ascending order by subcontractor/site name each subcontractor site’s encounter counts. The grouping helps the reader quickly identify which subcontractors contributed the most and the least encounters year-to-date for the CSP in question.

4.4 Web-based Claims Entry

4.4.1 Overview

The CPSA Web-based Claim Entry application is designed to allow CPSA’s contracted providers a means for entering their HCFAs and UBs into a form-based system that produces a

HIPAA-compliant 837 file for importing into CPSA’s claim system. The entry screens mimic the look and flow of their paper counterparts – the CMS-1500 for professional encounters and the UB-04 for inpatient encounters. It is not a substitute for a medical management system and it will not adjudicate the data entered into the forms. It will, however, validate that the data entered is complete, free from illegal characters, and capable of creating a viable electronic data file. It also allows the user to edit their claims and print out a hardcopy.

This document serves as a training guide for users of this system. It contains instructions for:  applying for access to the system,

 logging into the system,  changing your password,  retrieving a forgotten password,  creating a batch of claims,

 handling special functions within the entry forms,

 correcting errors for which the system produces warnings, and  coordinating with CPSA for batch submissions

This document does not provide instructions for entering valid data into the CMS-1500 or UB-04 forms. Specific instructions for that are provided by the CPSA Claims Department.

4.4.2 Applying for Access to the System

To gain access to CPSA’s Web-based Claim Entry system, each user will need to complete CPSA’s WEB SERVICE APPLICATION SETUP FORM. This form may be obtained by calling CPSA’s IT Department at 520-784-5339 or going to CPSA’s web portal:

https://CPSAConnect.org. Follow the instructions attached to the form with the following change: In the Application Name column, check the “File Upload/Download Capabilities” box. In that same box write “Claims Entry System.” This will let the IT department know that a profile for this application needs to be created.

Fax the form back to CPSA using the number provided on the form. Once your profile has been completed, CPSA’s IT staff will contact you with your user name and password. Other

instructions will also be provided to you by the CPSA Data Processing Department concerning file submission requirements.

The first time that you log into the system, you will be required to change your password. You will also be required to select a security question and its answer. The question and its answer will be used as additional security in retrieving your password if you happen to forget it.

4.4.3 Logging into the System

To access the Web-based Claims Entry system you will need to go to the application’s URL address. That will be provided to you with your user name and password upon completing your web access security form.

The initial login section is used to enter your user name and password.

4.4.4 Successful Login

Upon successfully logging in, CPSA’s main homepage will display. On the main homepage, to access the Claims Entry system the user will need to select the Claims Entry link under the Claims menu.

4.4.5 Unsuccessful Login

If a login attempt is not successful, the following message shown in red will be displayed.

If you need to have your password emailed to you, the “Forgot password?” link can be used.

4.4.6 Help with Login Problems

The inability to login can be caused by these conditions:

1. Your account does not exist. If you have submitted a request for a web login account and it has not yet been setup, or if you are using the wrong login name, this condition might exist. Contact the CPSA IT Help Desk.

2. Your password is not correct.

If the password you have entered does not allow you to login, you may not be using the correct password. Make sure that your caps lock is not turned on. Your password is case-sensitive, so this would cause the system to fail your login. If this isn’t the case, select the ‘Forget password?’ link to have a new password emailed to you.

3. Your account is locked.

If you attempt to login with the wrong password too many times, your account will lock. If it does, you will have to contact the CPSA IT Help Desk to have it unlocked.

4.4.7 Changing your Password

To change your password by clicking on the “Change Password” link in the login area, or the system enforcement of a password change on your first login, or if the password has been reset by a CPSA admin, the password change form is displayed:

On this form, the current password and the new password must be entered. Upon selecting CHANGE PASSWORD, the following form displays indicating your password has been changed. The user will need to select CONTINUE to return to the initial login screen.

4.4.8 Important Security Measures

The Web-based Claim Entry System has incorporated security measures in order to ensure compliance with HIPAA standards. These measures are listed below:

1. A user name and password are required to access the system.

Passwords must be at least 7characters in length and contain at least 1 non-alphanumeric character.

2. Passwords must be unique for all accounts within an organization. The system will not allow you to create or change your password to one which is currently being used by another account in your organization.

3. Any accounts which have not been accessed for a period greater than 60 days will be disabled.

4. Your login password can be emailed to you automatically if you forget it. For this feature to work correctly, it is important that CPSA has your correct email address stored in the system.

5. When changing your password, it will be required that you select a security question and provide a response answer in order to be able to retrieve your password.

4.4.9 Retrieving a Forgotten Password

The “Forget Password?” link on the initial login screen allows the user to retrieve a forgotten password. When selected, the link will first display an entry screen where you must input your username:

After entering the user name and clicking on the SUBMIT button, a form is displayed which will query you for your password retrieval answer. The password retrieval question and answer information are created by the user the first time they log into the system.

If the correct answer is provided and the SUBMIT button is clicked, then a confirmation form is displayed notifying you that your password has been emailed to you:

The password will be emailed to you in a text message format like this example:

Please return to the site and log in using the following information. User Name: cpsa_user1

Password: GoodP@ssword

No link to the website will be included in the email. This is intentional and has been done for security reasons.

4.5 Creating a Batch of Claims

After successfully logging into the application, the “Control Values Selection” page is displayed (as seen below). The user will need to enter a Provider Acronym, Batch Type, Fiscal Year and File Status to begin the process of creating a batch of claims.

The Provider Acronym is a three character acronym that uniquely identifies the submitting providers associated with the user’s login. It is used in the name of the outbound file generated by the system and in the file itself. In most cases, only one acronym will be available per user. The Batch Type represents the type of claims that are going to be entered. “837p” is the HIPAA-compliant file format associated with professional claims (HCFAs). It is the default. “837i” is the HIPAA-compliant file format associated with inpatient claims (UBs).

The Fiscal Year for CPSA begins July 1st and ends June 30th. When creating batches of claims for submission to CPSA, the dates of service for those encounters cannot cross fiscal years. By selecting a Fiscal Year from the drop-down list, the user is indicating that all claims in that batch