Functionality Checklist
IntroductionClaims processing systems are not cheap! They are expensive to purchase and expensive to maintain. They are also hard to evaluate. Each claims processing system vendor presents their products with a flurry of hype and promises. On the surface they may look good but when put into production many systems reveal serious shortcomings in critical areas.
The following functionality checklist is specific enough to compare apples to apples when evaluating systems. Feel free to use all or any part of it to build your own “system-features” comparison sheet. A good system can answer “yes” to all of the following.
General
? Can the software run on various hardware platforms and operating systems? Can it run on your hardware and operating system?
? Can the system efficiently support the number of workstations required by your operation?
? If you have a small operation, can the system be scaled down to support your
operation without the need for expensive operating systems and/or related support personnel such as a database administrator?
? Can the software effectively service remote users? Can these remote users expect decent response times using regular 24k modem connections?
? Is the system delivered with source code included? Don’t be fooled by “source-code-in-escrow” statements in your agreement. Can you access it there? Do you really own it?
? Do you receive updates monthly or more often? Will you always be running on a version that’s the same as all other users?
? Can a change be applied to any of your programs on-line and immediately? Can you expect immediate modifications to your system for critical enhancements?
? Could you ever expect to call your software vendor and have a program change made and placed into your system while still on the phone with the developer?
? Will the senior developers that wrote the original source code support you? If not, will you be guaranteed that your representative will be as accomplished as technicians of that caliber?
? Can you design your own data entry screens, choosing what data fields are important to you and eliminating those that aren’t?
Claim Processing Capabilities
? Can claims be received via EDI or from a scanned image using OCR or from a remote data entry operation as well as being keyed manually?
? Does the system support different claim data entry screens for HCFA, UB92, dental and vision claims? Is the proper screen automatically selected as each claim is displayed?
? Are all code fields automatically validated against a table of valid codes? Can these tables be maintained on-the-fly as long as the user has the proper security clearance?
? When selecting the provider record associated with each claim does the claim record automatically fill with all pertinent provider data, even data that may not be shown on the screen but exists in the claim record?
? Are there provisions to select the referring physician and facility in addition to the servicing physician on each claim?
? When selecting the patient’s record does the system automatically find the associated member if the patient is not the insured?
? Does the system automatically find the employer group by analyzing the patients enrollment record?
? Are there provisions to select other insured records in addition to the member and patient records?
? Can claims be controlled using a batch numbering system? Does this batch system track all of the claims in the batch as they proceed through your process? It this batch numbering system used during an EDI process? Is the batch system optional?
? Does the claim request data pertaining to employment or accident-related activities?
? Does it identify whether the patient has signed for release of information and to assign benefits to the provider?
? Does the claim screen identify documents that are attached to the claim such as Physical Therapy Reports, Emergency Room Reports, Medicare EOMB’s, etc?
? Does the claim system provide for unlimited adjustments and link them to the source claim? Can these adjustments be originated from a copy of the source claim record?
? Will these adjustments back out the original amounts and reflect the new amounts and remain mathematically correct for all accounting functions regardless of in which accounting period the adjustment was made?
Functionality Checklist
? Does the claim support an adequate number of service lines (100 service lines per claim)?
? Do these service lines capture all of the data on a HCFA, UB92 and ADA form in the arrangement of the data on each form?
? Do fields default to expected values, i.e., dates duplicated from one service line to the next, place of service default to office, type of service default to medical, etc.?
? Is there a provision for more than one modifier?
? Is there a provision to enter anesthesia minutes separate from the service units data?
? Is there a provision for unlimited notes to be attached to each claim?
? Can the system recognize interim bills and consolidate them with the final bills?
? Can your claim processors quickly navigate to all other claims in history for this patient without leaving this claim record? Can they also navigate to this patient’s enrollment records and any referrals, pre-authorizations or servicing records without leaving the claim?
? Can the system point to users that have experienced productivity levels of 500 and even 600 claims per day for a single operator?
? Does the system keep track of the operator time spent on each process (data entry, corrections, etc.) for later productivity reporting?
Automatic Processing Capabilities
? Does the system automatically determine the correct network, product and insurance plan from among the many choices that may be presented by the provider and
enrollment records?
? When assigning these networks and plans, does the system automatically consider PCP assignments, referral and pre-certification requirements if they are pertinent to the selection formula?
? Can the system automatically find the correct pre-certification or referral that fits the claim by analyzing any number and combination of diagnosis codes, ICD9 procedure codes, HCPCS codes, CPT4 procedure codes, dates of service, provider ID’s, DRG codes, revenue codes and bill type codes?
? Can the system automatically detect specific authorized services by analyzing CPT4 codes, diagnosis codes, DRG codes, HCPCS codes and revenue codes that are date driven and unique to each provider assigned to each pre-certification or referral?
? Can the system automatically assign a pre-negotiated price that was established by the review personnel during the generation of that pre-certification or referral?
? Can this price be service specific? Can this price be a complex formula? (Example, your review personnel sets up a pre-certification for a hospital stay and negotiates a per diem rate based on a series of DRG codes, revenue codes and HCPCS codes. When the claim is processed it should be priced according to the formula established by the review nurse.)
? Will the system summarize claim activity by diagnosis code and update the patient’s clinical history records?
? When processing electronic claims, can the system find the provider, patient, member and group master records by using a combination of data such as submitter ID’s, FTIN’s, names, addresses and social security numbers?
? If the master records are not found does the system repeatedly try the search again using different combinations of this data?
? If the master records are still not found, does the system automatically modify the data (use part of a name and/or address and/or FTIN) and continue searching?
? Are the search algorithms used to find these master records tuned specifically to your database contents? Can you modify them without additional programming?
? Can the system automatically detect physicians in authorized call-groups of PCP or gatekeeper providers and price and adjudicate the claim accordingly?
? Does the system keep a log of master record search attempts that were expended for each type of search so that continuous fine-tuning of the search algorithms is
possible?
? Does the system automatically find claim errors such as missing mandatory data, invalid codes or various edit failures and hold claims that fail any of these conditions? Is the hold-claim feature capable of retaining an unlimited number of hold reasons per claim?
? Can an unlimited number of messages be automatically attached to the claim that explain things like excluded services, denied benefits, missing information and edit errors? Can these messages appear on pricing sheets and EOB’s.?
Contract Management Capabilities
? Can the system support an unlimited number of facility contracts?
? Does the system handle complex facility contracts? When re-pricing these contracts does it consider factors such as the bill type, CPT4 codes, diagnosis codes, DRG codes, ICD9 procedure codes, the length of stay, procedure modifiers, the type of network,
Functionality Checklist
revenue codes, place of service, type of service, the patient sex, patient age and number of service units?
? Does this complex contract re-pricing vehicle also consider whether the claim was pre-certified, whether the service was pre-authorized, whether the provider was in or out of network, whether the services were inpatient or outpatient and whether the claim was a referral from another provider?
? Can situations that can be described by combinations of codes be pre-defined so that the code combinations need not be repeated in each contract that refers to that situation? (Example, infectious diseases may be defined as diagnosis codes 001 through 139.8. Perhaps a series of contracts refer to special re-pricing for services related to infectious diseases in young females for providers in three counties in California. Can a code be established that encapsulates these items so that they need not be repeated in every contract that uses them?)
? Are the contracts specified in a manner that is easy to read and understand by your personal?
? Is the contract formulation process totally unlimited? Can a contract be unlimited in complexity? Is the system guaranteed to handle your contracts?
? Can the contract formulation process call common formulas? (Example, can a contract call a common routine that checks for stop losses so that the stop loss logic does not have to be written in each contract?)
? Does the system handle any number of PPO price schedules and/or rate tables such as flat rates, RVS schedules, RBRVS schedules and U&C tables?
? Can the contract formulas look back into history to find other claims for this patient and/or provider and use data from those claims to effect the pricing and adjudication of this claim?
? Does the system come with pricing formulas already developed for major PPO’s such as CCN, Beachstreet/Capp Care, etc.? Is the system guaranteed to handle all others?
Plan of Benefits Design Capabilities
? Can the system support an unlimited number of plans of benefits?
? Can multiple employer groups share these plan definitions or can a plan be specific to a certain employer group as needed?
? Can each benefit maintain it’s own values for copay, coinsurance, out-of-pocket and deductible amounts? Are the actions to be taken when these amounts are reached completely parameter driven and unique to each plan?
? Can each benefit maintain it’s own set of limitations? Can these limitations be based on benefits received, allowed amounts, deductible taken, coinsurance reserved or out-of-pocket dollars?
? Can they also be based on accumulated units, visits or length of stay?
? Can these limits be exclusive to one benefit or intermixed with other benefits, plans, networks, carriers, products and employer groups, as specified by the plan document?
? Upon reaching these limits, can the plan deviate in its payment policies to any combination of payment percentages or other rule?
? Can copay amounts be limited to one copay per day or per service? Can copay amounts be different for each type of service or for each procedure code?
? Can the rules for applying benefit codes to each service line be unique to each plan or be shared by multiple plans?
? Are these rules unlimited in scope?
Auto-adjudication Capabilities
? Does the system guarantee that their auto-adjudication process will decipher any complex PPO re-pricing formula and accurate apply the correct allowed amount to each service line?
? Does the system guarantee that their auto-adjudication process will decipher any complex insurance plan of benefits and accurately apply the correct payment amount to each service line?
? Does the system determine PPO allowed amounts for inpatient stays on a service line basis, applying per diems, lab charges, excluded amounts, etc., to their appropriate services so that they can be channeled to the correct benefit during the payment phase of the adjudication process?
? Will the system automatically analyze all options and then select the proper network, product and plan even if the client and provider participate in many common networks and products?
? Does this network selection process consider such items as PCP assignments, provider participation rules, enrollment requirements, product importance rankings, network consolidations, and referrals?
Functionality Checklist
? Will the system automatically detect related pre-authorizations for each claim and apply the proper pricing and adjudication rules to each service depending upon
whether the pre-authorization is present or absent and whether its authorized values have been exceeded?
? Will the system analyze all claims that are processes electronically and channel them to the proper claim examiner for review if they are not complete to your
specifications? Can this workflow process be tailored to your operational requirements?
? Will the system recognize claims that have been misdirected to your operation, prior to the complete data entry process, and direct these claims back to the submitter, saving unnecessary data entry costs?
Premium Billing
? Will the system handle individual, group or consolidated group billing methods?
? Does the system support multiple billing modes, i.e., monthly, quarterly, etc.?
? Can the billing system support an unlimited number of products (medical, dental, vision, life, etc.)?
? Can the system automatically calculate retroactive adjustments?
? Does the system support any number of billing formats that are specific by group?
? Can the system be used to produce quotes or ad hoc bills?
? Can the system re-print any bill at any time?
? Can rates be based on age, sex, group, network, product, carrier, plan and rate tier?
? Can the system support an unlimited number of fees and premium components?
? Are billing rates accessible from the member or client maintenance screens?
? Can bills be immediately recalculated while viewing the invoice data on-line?
? Can the system automatically post payments according to your own rules?
? Does the system calculate a five-tier commission structure with unlimited breakdowns?
Member Information Capabilities
? Is there one integrated database that includes members, employees, other insured persons, patients and dependents so that all records can be found in a single search?
? Does this database contain industry standard codes for demographic data such as relationships, sex, marital status, Medicare status, COB status and student status?
? Does this database contain alternate ID codes for synchronizing downloads of enrollment data from various employer groups?
? Does this database allow the modification of social security numbers and yet retain the connection between the member’s record and all related claims and other data?
? Does this database include home and work phones as well as e-mail addresses?
? Does this database allow enrollment with any number of employer groups with simultaneous or overlapping time periods without creating duplicate member demographic records?
? Do these enrollments specify any number of PPO networks, products and insurance plans for each group, with effective and termination dates?
? Can these enrollments be restricted to exclude or include specific situations based on items such as patient age, patient sex, bill types, provider county, provider city, provider specialty, provider degree, provider zip code, provider FTIN, specific provider, diagnosis codes and DRG codes?
? Can a dependent’s enrollment be different and independent from the insured member?
? When adding a new member, does the software provide a rapid method to automate enrollment by using a cafeteria menu of available plans for each employer?
? Can the system record unlimited PCP assignments to each network and plan and track them by effective and termination dates? Can a member have different PCP’s for different networks, products, or plans? Can PCP assignments be tracked through history on an unlimited basis?
? Does the database allow the recording of clinical data for each patient pertaining to such items as family illnesses, medical history, surgical history, employment conditions, medication history, vaccination record, symptomatic considerations, allergy
considerations and life style factors?
? Can this clinical data be viewed and maintained during case management and claim processing functions?
? Can this clinical data be used to automatically effect pricing and adjudication
formulas, such as recognizing that a patient at high risk for breast cancer is allowed more mammograms than one that is not at high risk?
? Is there a provision for unlimited notes to be attached to each member?
Claim Processing Software
Functionality Checklist
Provider Information Capabilities? Is there one integrated database that contains data on physicians, hospitals, clinics, laboratories, rehabilitation facilities, nursing homes, legal organizations and medical supply organizations?
? Can this database receive downloads from a variety of sources, such as CCN, Capp Care and First Health, and retain their individual pricing formulas without creating duplicate demographic records for each source?
? Will your existing database be cleaned-up, eliminating duplicates and erroneous
provider records that have been created in your old system through various downloads and data entry processes?
? Does this database contain demographic data such as degree codes, multiple specialty codes, office hours, contact names, voice/fax/modem phone numbers, e-mail
addresses, universal PIN numbers, EDI submitter numbers and alternate ID’s for mapping to external data sources?
? Can this database handle multiple provider service addresses?
? Can these multiple service addresses share common billing addresses?
? Can the services in these multiple addresses be assigned to different networks and be re-priced differently from one another and/or share common re-pricing policies?
? Does this database allow for multiple provider FTIN’s that are all active during an FTIN search?
? Does this database contain PPO re-pricing information that allows the provider to subscribe to any number of PPO’s, reflecting different products and policies within these networks?
? Are these network assignments date-specific?
? Can these network assignments be restricted to exclude or include specific situations based on items such as patient age, patient sex, bill types, provider county, provider city, provider specialty, provider degree, provider zip code, provider FTIN, diagnosis codes and DRG codes?
? Can a provider act as a PCP in some networks and not others? Can they be a referral physician in some networks and not others? Can they be a PCP or referral provider only under certain circumstances, e.g., urgent only or for currently enrolled members only?
? Does this database support physician “on-call” situations (groups of doctors that can cover for a PCP physician)? Are they unlimited in size?
? Can a provider belong to different on-call physician groups in each network or for each product within each network? (Perhaps Dr. Jones belongs to both the ABC and XYZ Networks but expects a different group of physicians to cover for him for patients in each of these two networks.) Can these call-groups be date specific? (Perhaps Dr. Jones goes on extended leave and uses one on-call group to cover for him during the first half of his leave and another during the second.)
? Is there a provision for unlimited notes to be attached to each provider record? Can these notes be specific for each providers network?
? Does the database include integrated credential information such as hospital
privileges, board certifications, education history, insurance issues, state licenses and legal issues? Do these credential records all contain effective and termination dates?
? Can the database be used for provider channeling? For, example, can the system easily locate all providers with a certain specialty in a specific zip code that speak a certain language and have privileges at a certain hospital?
Employer (group) Information Capabilities
? Is there one integrated database that contains information pertaining to employer groups, divisions, agencies, payers or any other entities?
? Does this database provide a tiered organizational structure that can be used for enrollment and reporting? (Example; (1) Ford Motor Car Company, (2) Lincoln Division, (3) Sales Division, (4) Western Region, (5) California District, would require a five level coding structure.)
? Does this database contain contact names, voice/fax/modem phone numbers, e-mail addresses, multiple policy numbers, alternate ID’s and EDI submitter ID’s?
? Can an employer group subscribe to any number of PPO networks, products within these networks, insurance carriers and plans?
? Can these network/plan subscriptions be specific to those that require referrals and/or PCP assignment and those that don’t.
? Can these network/plan subscriptions be restricted to exclude or include specific situations based on items such as patient age, patient sex, bill types, provider county, provider city, provider specialty, provider degree, provider zip code, provider FTIN, specific provider, diagnosis codes and DRG codes?
? Are these network/plan subscriptions date specific and can the dates be overlapping?
? Do these network/plan subscriptions specify the PPO charges in effect for that client and that network at that time? (Example, ABC network may charge Ford Motor
Functionality Checklist
company, Lincoln Division 15% of savings for using their PPO network rates, but they may charge the Mercury Division $2.00 per claim for the same services. Then as of a specific date, these rates may change.)
? Do these network/plan subscriptions describe how and where to route the claim output, both paper and electronic pricing sheets and/or explanation of benefits?
? Is there a provision for unlimited notes to be attached to each group master?
Master File Searching Capabilities
? Can providers be located by various search arguments such as tax ID’s, names, degree codes, specialty codes, addresses, city and state names, zip codes and alternate ID’s?
? Can these searches be performed concurrently using one search command with multiple search arguments? (Example, find all acupuncturists in Minnesota with the last name of Brown.)
? Can these searches be performed successfully using partial search arguments and wild card characters? (Example, find all providers with the last name “Bro… ” and FTIN “40127??42” would be handy if part of the FTIN was illegible)
? Can the system find records even though the search argument was not completely accurate? (Example, FTIN 401274661 is entered as 402174661, can the record still be found? Or Brown is spelled Braun, can the record still be found?)
? Can searches find data anywhere within group and provider office name fields? (Example, find all providers that have the word “clinic” anywhere in their name field.)
? Can these same types of search functions be applied to the member database using member and/or dependents social security numbers, names, addresses, date’s of birth and alternate ID’s?
? Can these same types of search functions be applied to the employer group database using group codes, names, addresses, policy numbers and alternate ID codes?
? Can these same types of search functions be applied to the claim and case management databases, using fields pertinent to these files?
? Will the system handle these multiple key, multiple record retrieval searches, using large files (800,000 providers, for example) and still provide sub-second response times?
Care Management Capabilities
? Does the care management system handle referrals, certifications,
pre-authorizations, concurrent utilization reviews and large case management types of activities?
? Do the data screens for all of the above mentioned case types include fields to record the case status, resolution, effective and termination dates, patient, member and employer?
? Do the data screens include fields to record caller information such as who-called, the date, time and type of caller and the representative that took the call?
? Do the data screens include fields to record multiple diagnosis code ranges, DRG code ranges, type of service, place of service and information dealing with insurance
coverage?
? If the case is for an inpatient stay, does it include fields to record the room type, the requested and actual admission dates and who requested the admission?
? Does the case allow unlimited notes? Are these notes protected from view and/or modification based on the user’s security code? Are these notes time stamped to record who made each entry?
? Can the case be changed from one type to another without re-entering all of the data? (Example, a referral may change to a utilization review that may change to a large case management record over time.)
? Can the case be transferred to another case and retain the constant data from the originating case?
? Can the case records be retrieved by a variety of search arguments, such as patient social security number, patient name, type of case, status of event and the name of the nurse responsible for the case?
? Can letters be generated from the case using an industry standard word processing tool such as MS Word®? Does this tool use mail merge keywords to insert data from the case onto the letter?
? Can an unlimited number of providers be assigned to the same case?
? Can these provider assignments be date specific and procedure specific? (Example, can Dr. Brown be assigned to a case between Jan 10 and Jan 20 but only for claims with diagnosis codes 940 through 949.5 and only for procedures 13122 through 13152?)
? When recording a provider that is the “referred-from” physician, does the system prompt the user by showing the patients PCP assignments?
Functionality Checklist
? Can the date and procedure parameters controlling a provider’s activities be unlimited in quantity? Can they be negative parameters (can’t be procedures 13122 through 13152)?
? Can separate notes be attached to each provider assigned to a claim?
? Does the system provide for the recording of clinical information such as blood cholesterol, blood pressure, percent body fat, glucose blood, glucose urine, hemoglobin, height and weight, pulse, etc.
? Are these recording’s date and time stamped?
? Can a member’s entire master file, including their enrollment and clinical history be reviewed while in the case record? Can other related cases be reviewed while in this case record?
? Can case records be automatically generated by the claim processing operation when certain conditions apply? (Example, when certain diagnosis codes, procedure codes, providers, etc., appear on a claim, it may indicate a situation that should be tracked by the review personnel. If a case does not already exist for this situation, will the system automatically create one?)
Member Service Capabilities
? Does the system record and track member service calls and inquiries?
? Do the data screens for member service tracking include fields to record the call reason, call status, importance of issue, resolution, effective and termination dates, patient, member and employer? Can you modify these screens to fit your needs?
? Do the data screens include fields to record caller information such as who called, the date and time and type of caller and the representative that took the call?
? Can the call be assigned to another service representative and record the assignment time and date?
? Can unlimited notes be assigned to each call? Are these notes protected from view and/or modification based on the user’s security code and time stamped to record who made each entry?
? Can the call be changed from a member service record to a care management record without re-entering all of the data?
? Can the call record be transferred to another call record and retain the constant data from the originating call? (This provides unlimited call tracking for related incidences.)
? Can the call records be retrieved by a variety of search arguments, such as patient social security number, patient name, status of call and the name of the customer service representative responsible for the call?
? Can letters be generated from the call using an industry standard word processing tool such as MS Word®?
? Can an unlimited number of providers be referenced in the same call issue?
? Can separate notes be attached to each provider referenced in a call?
? Can a member’s entire master file, including their enrollment and clinical history be reviewed while in the call record? Can related care management records be reviewed while in this call record?
External Interface Capabilities
? Can the system launch third party software such as Microsoft Word®, Microsoft Access, Microsoft Excel, Lotus Approach, e-mail and a connection to the Internet?
? Can files be extracted from the member, provider, group and claim databases in multiple formats such as ODBC compatible, comma delimited text and fixed field text? Is this extract process parameter driven to select only those records wanted? Can it be run concurrent with other processing?
? Does the system include a common file import facility? Can it handle any data pertaining to claims, providers, members and groups, using common formats such as comma separated value files easily produced by spread sheet programs like Excel?
Database Backup, Security and Optimization Capabilities
? Does the database retain a history of activity on major data files? Can these history records be retrieved individually by record? (Can you restore one member master record to the way it looked last week, for example). Can this be performed during production processing?
? Can all records in the database be restore to a specific point in time? (Example, if a file was damaged at 4 p.m. yesterday, can you restore that file alone to the way it looked at 3:59 p.m. yesterday?)
? Does the system allow security codes that control data access to the program level? The file level? The field level?
