Business logics and rules Document of Olympus 2.

0 AR Workflow Management
Definition:

Create AR Workflow management as Olympus2.0 application.

Independent Data Base to be created for Olympus2.0 application.

User Role and management role will be linked with Olympus 1.0

Claim status and Eligibility run will be linked to Olympus 1.0

Screen-1 AR upload
 Templates and Data base

Manual Upload Template (AMD, MEDISOFT, CR) AR Report output Raw Files.

All the Raw file headers will be retained based on the projects.

Same will be shown in AR Upload screen table.

 Screen-1 AR Upload

Main Screen

Aging upload button- Click open.

Close button should change as Save

Project Drop Down – Username list.

Logic- List of projects mapped to the logged in user (DB Zoho)

S.NO Location Projects

1 BLR FFN

2 BLR CAN

3 BLR PIL

4 BLR YCS NY

5 BLR YCS NJ

6 BLR YCS CBS

7 BLR YCS Triumph

9 BLR GBS- HOI

10 BLR GBS - RGF

11 BLR OIWK
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 12 BLR PFHC

13 BLR AMSU

14 BLR HBABA

15 BLR QER

16 BLR CEC

17 BLR WESCT

18 BLR RTRUST

19 BLR CBCT

20 BLR AC 14

21 BLR ALS

22 BLR APC

23 BLR SSAC

24 BLR FBMH

25 BLR RICFA

26 CJB RSS

27 CJB KMN

28 CJB SOPED

29 CJB TBC

30 CJB PAC

31 CJB ARETE

32 CJB RCS

33 CJB ACT

35 CJB AWM4

36 CJB DR. A

37 CJB IMA

38 CJB CRL

39 CJB MMTX

40 CJB CND

41 CJB WFLD

42 CJB Azul

43 CJB T-WORKS

44 CJB BSP

45 CJB ROSPT

46 BLR Pulse

Upload File- Browse the Local folders/ Directories and select for upload.

Logic-
Validated mandatory fields are present in the file which is unique to the client – Respective managers should provide this at the time of Account set-up.
Validate the Project name between Input file and Selected Project in application.
Validate the Format structure for all the mandatory fields.
Required fields - Insurance type, primary, secondary, tertiary, In network, out of network

To set the file unique to the client – create drop down, to do one time set-up.
Drop down1 – Count of Headers
Drop down2 – Content of headers
Drop down3 – header1, 2, 3, 4,5
Drop down4 - content1,2,3,4,5
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Upload Supporting File formats.

 Excel Workbook (*.xlsx)

 Excel Binary Workbook (*.xlsb)
 Excel 97-2003 Workbook (*.xls)
 Comma delimited (*.csv)

Clicking on Save should show the records in Table and perform existing rule and exclusions before push the claims into AR
assignments tab.

Clicking on Close (cancel) should terminate the action.

Main screen Tables- Display the list of records loaded in Table.

 Need to display all the Columns set for the receptive projects.
 Each Column should have respective filed Search, Sort option, Filters (Multiple Selection Filters with Check box) within the table.
 Show entries.
 Upload All records from input file nothing to be excluded or removed.
 All the records need to be saved in the database before exclusion.
 Should create Column and headers specific project name and should be dynamic.
 Multiple file upload option to be provided for all projects.
 Need to update the Project name in the AR report. It needs to be validated with “Project name” selection while uploading in Olympus.
 Need to add the date and time stamp in the report after uploading (Need to Automate in Olympus)

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 Screen-2 Exclusions
Exclusion Tab

UI Screen to push the data (list of accounts) to excluding from AR assignment screen and from AR work queue.
Will be uploading the exclusion reports file based and exclude from the database according to the rule set for each.

1. Denial Report and Payment posting

Denial Report and Payment posting will be clubbed into one as both reports are the same.

Function- Click on Posting/Denial report should show.

a. View Posting/Denial Report
b. Option to Capture Denial – Refunds – Correspondence
c. Upload option to upload the data through excel (captured manually by ops) Format template by client.
d. Enable option to connect through ODBC/API if the permission exists to connect.

2. View Denial Report

Function -click on view denial report should open View denials screen.

3. View denials screen

View denials screen – items

A. Upload Posting report (including denials) button

B. Apply to AR Assignment by the system automatic not manual option to TL/AM/Management
C. Select user Drop down.
D. Assign button will enable option for TL assign accounts to the user.
E. Search and show entered (Min 20 Max 500)
F. Table showing the columns along with selection check option.

A. Upload denial button- Logic

Should browse local files and take input. (FORMAT Template TO BE PROVED FROM OPS).
Applicable for Existing and New Records- If the Account Last work date is within 30 days from today will be excluded from AR assignment, AR
work queue. (Last work date column will be from AR assignment, AR work queue and input file).
Uploaded/selected denials will be available for Denials assignment.

Update the logic to create a denial queue as a separate queue do not map to Denial to AR assignment to exclude worked denials

B. Select user Drop down - Logic- Should show the list of users with skill mapped to the project.
C. Assign button – Logic Clicking on Assign should assign the list of selected account from table to the user selected in Select user drop down.

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 4. Capture denials.

Function -click on Capture denial report should open Capture denial screen.

5. Capture a denial screen.

Capture denials screen – items.

Manual entry table Grid to manual input data. (Input fields/columns to be provided by ops)

System should auto group the denials based on the CARC/RARC codes.
Steve to provide the CARC/RARC code list and category and subcategory to match,
Enable the option for agent to change the category and subcategory at the time of work.

D. Close/Cancel button.
Should prompt the confirmation screen.
Clear the grids and close or cancel (back to Create denials screen with no changes).

6. Global issues report

Clicking on Global issues report should open the rules control screen.

List of fields to shown

1. Rule Title (Free text up to 50 characters)- (Additional Field)

2. Facility (DD based on the list in DB)
3. Provider name (DD based on the list in DB)
4. Insurance name- (DD based on the list in DB)
5. Primary/ Secondary/Tertiary (FIXED DD) (Additional Field)
6. From DOS- (DD based on the list in DB)
7. To Dos- (DD based on the list in DB)
8. Billed amount - (Range)
9. Balance Amount- (DD based on the list in DB)
10. Diag.Code-1- (DD based on the list in DB)
11. CPT-1- (DD based on the list in DB)
12. Last billed date- (DD based on the list in DB)
13. Category - (DD based on the list in DB)
14. Sub-Category- (DD based on the list in DB)
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 15. Action Code - (DD based on the list in DB)
16. Responsibility - (DD based on the list in DB)
17. Tickler date – (Let user to select the Future date)
18. Notes Field- (Free text)
Note: Account# and agent name is removed as requirement

A. Close/Cancel button.
Should prompt the confirmation screen.
Clear the grids and close or cancel (back to Create denials screen with no changes).
B. Click on save.
Should expand the new grid below.
Logic- Based on the combinations of the field selections list to be should show list of account from AR assignment and AR work queue in the below table.
Logic – If duplicate rule created or exist, user should get a prompt.

C. Confirm and send for Managers approval. (New button to be added in below grid)
Logic- Rule combination will be sent for manger approval.

D. Close/Cancel button.
Should prompt the confirmation screen and back to grid with no changes.
E. Tickler date.
Once the date is set for the rule created and approved, Accounts related to rule will be behind the screen.
Once date is met notification should be sent and accounts shall move to AR assignment with the notes stating account are in Global issue.

View created rules (Screen to show the created rules and status)

Logics-
 Approve, Edit, and delete button to be provided in view rule screen for the rules created.
 Only managers will have access to approve and create and save a rule.
 No approval required for Supervisor-2 Created rules.
 Only supervisor-1 and supervisor-2 can create a rule.
 Any Edited and deleted should be again sent for manger approval.
 Based on primary and secondary logic.
If the grid selected is primary - Last billed should never show date less than 30 days and should not have option to enter.
If the grid selected is secondary - Last billed should never show date less than 45 days and should not have option to enter.

F. Approve Button
Once manger Approve the Rules –
Logic- Based on the combinations of the filed selections in the RULE Accounts should be excluded from AR assignment and AR work queue in the
below table.
 If the rule is approved for editing, related accounts to the rule should be revalidated and related accounts changes to be applied.
 If the rule is approved for deleted, related accounts to the rule should brought back to the assignment.
 Applied rule and the changes should be shown on the supervisor screen.

G. Edit button.
Should allow team lead and managers/Supervisor to edit the rule set.
All the changes should be sent to supervisor-2 approval.
H. Delete
Rule needs to be removed from screen (need to maintain internal logs)
All the changes should be sent to supervisor-2 supervisor approval.

7. Client Exception report (Discarded) as we will link the tasking tool to apply the same logic.

Client exception needs to be removed as we are already moving the account from AR queue and AR assignment to the client exception
bucket through creating task.

Create task will be converted to TASK and moved to supervisor-1 approval bucket (create approval bucket)
Once Supervisor-1 approves account will be moved to client buket

Other bucket/Department task will show in the respective bucket (coding/supervisor-1/posting) in the AR assignment
to send reminder.

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 Dr J signed off the requirements updated till this page-1 st phase
now complete document is signed off 2nd phase

Screen-3 RULES HUB

Rules hub

Clicking on Rules hub should show the option to select Create rules or mange rule.

List of fields to shown - ( All the fields should be Multiple select option enabled (Steve Kennedy)

1. Rule Title (Free text up to 50 characters)- (Additional Field)

2. Facility (DD based on the list in DB)
3. Provider name (DD based on the list in DB)
4. Insurance name- (DD based on the list in DB)
5. Payer Type (Primary/ Secondary/Tertiary) (FIXED DD) (Additional Fied)
6. From DOS- (DD based on the list in DB)
7. To Dos- (DD based on the list in DB)
8. Billed amount - (Range)
9. Balance Amount- (DD based on the list in DB)
10. Diag.Code-1- (DD based on the list in DB)
11. CPT-1- (DD based on the list in DB)
12. Last billed date- (DD based on the list in DB)
13. Category - (DD based on the list in DB)
14. Sub-Category- (DD based on the list in DB)
15. Status Code- (DD based on the list in DB)
16. Action Codem - (DD based on the list in DB)
17. Assign to - (Select user)
18. Assign priority. (High, Mid, Low)
19. TFL (Range 30-365)
20. Tickler date – (Let user to select the Future date)
21. Notes Field- (Free text)
Note: Account# and agent name is removed as requirement

I. Close/Cancel button.
Should prompt the confirmation screen.
Clear the grids and close or cancel (back to Create denials screen with no changes).
J. Click on save.
Should expand the new grid below.

Logic-
DOS- When Dos is selected less than 30days needs show pop warning and confirmation should send for manager approval.
Based on the combinations of the filed selections list to be should show list of account from AR assignment and AR work queue in the below table.
Color code for account based on TFL Selected.
TFL Logic- Counts (TFL date <>= Todays date)
IF TFL Greater 30 days and less than 60-day amber color based on dos
Lesser than 30 days will be red color based on dos.

K. Confirm and send for approval. (New button to be added in below grid)
Logic- Rule combination will be sent for manger approval.

L. Close/Cancel button.

 Should prompt the confirmation screen and back to grid with no changes.

M. Tickler date.

Logic-
 Once the date is set for the rule created and approved, Accounts related to rule will be behind the screen.
 Once date is met notification should be sent and accounts to move to AR assignment with the notes stating account were in global issues

View created rules (Screen to show the created rules and status)

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 Logics-
 Approve, Edit, and delete button to be provided in view rule screen for the rules created.
 Only managers will have access to approve and create and save a rule.
 No approval required for Manger Created rules.
 Only Tl and manager can create a rule.
 Any Edited and deleted should be again sent for manger approval.
 Based on primary and secondary logic.
If the payer type selected is primary - Last billed should never show date less than 30 days and should not have option to enter.
If the payer type selected is secondary - Last billed should never show date less than 45 days and should not have option to enter.

N. Approve Button
Once manger Approve the Rules –
Logic- Based on the combinations of the filed selections in the RULE Accounts should be excluded from AR assignment and AR work queue in the
below table.
Color code for account based on TFL Selected.
TFL Logic- Counts (TFL date <>= Todays date)
IF TFL Greater 30 days and less than 60-day amber color based on dos
Lesser than 30 days will be red color based on dos.
 If the rule is approved for editing, related accounts to the rule should be revalidated and related accounts changes to be applied.
 If the rule is approved for deleted, related accounts to the rule should brought back to the assignment.
 Applied rule and the changes should be shown on the supervisor screen.

O. Edit button.
Should allow team lead and managers to edit the rule set.
P. Delete button.
Rule needs to be removed from screen (need to maintain internal logs)

Note – Once manager approves the rule, system should show the confirmation of the set rules are applied. (Steve Kennedy)

SCREEN – 4 AUTO CLAIMS STATUS

AUTO CLAIMS STATUS

Clicking on AUTO CLAIMS STATUS should open AUTO CLAIMS STATUS Screen

LOGIC-
A. Once all the exclusion, rule set and exception tracker accounts are excluded, Remaining accounts will be shown here in this screen list.
B. TL should be able to apply the filter and select multiple accounts or all accounts from the table.

Claim status check.

Click on Claim status check.

1. Select account should be sent for Availity (Link with existing Olympus 1)
2. Un selected will be moved to AR assignment directly.

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Claims status output – Response from Availity input. (Steve Kennedy)
Following claims status should be excluded from the AR assignment

1. 0-30 shall be excluded from sending the auto claims status

2. Send the 31+ days from the DOS claims for auto status check.
3. In-process status – set auto tickler date for after 15 days.
4. Partial/denied status – Goes to AR assignment (Skill will be decided based on the complexity of denial)
5. Paid status claims – Goes to AR assignment (skill level -1)
6. Eligibility related issues (Details of eligibility related issues category will be shared) Move this claims to Eligibility verification (Skill level 1).
7. Claims with in-process status but not worked within last 15 days claims shall send to auto claims status check.

Note: Need to prioritize the phase of Auto Run and Run Now of claims status.

Bulk upload

Logic-
A. Will be not linking any 2.0 AR module features.
B. Only TL and above uploads external input file and gets the claims status from Availity.

SCREEN – 5 Real time Eligibility Verification

Upload file – List of appointments
 New
 Established

Output:
Successful verification – apply the status to the AR assignment and update the notes.

Unable to verify – Allocate to the level 1 users for manual verification

 Invalid/missing member id
 Invalid/missing patient /subscriber name
 Invalid/missing DOB
 Invalid/missing provider id
 Unable to respond at the current time

Missing pVerify Id –
 Allocate to level 1 user for manual verification
 Notify the supervisor to work with pVerify team to add the missing payer.

Existing AR accounts – Select and verify the eligibility and repeat the output process mentioned below.

Successful verification – apply the status to the AR assignment and update the notes.

Unable to verify – Allocate to the level 1 users for manual verification

 Invalid/missing member id
 Invalid/missing patient /subscriber name
 Invalid/missing DOB
 Invalid/missing provider id
 Unable to respond at the current time

Missing pVerify Id –
 Allocate to level 1 user for manual verification
 Notify the supervisor to work with pVerify team to add the missing payer.

SCREEN – 6 Insurance guide

Need to create the Screen.

Filing/Appeal limit by insurance table with time stamp

Insurance Plane Financial Filing Limit Appeal limit from First Insurance Phone
Name Name Class State from DOS denial Number
             
             
             

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 SCREEN – 7 Excluded queue
Show all the list of the excluded data with all the field at the account level. Along with the titles of excluded reasons with time stamp

SCREEN – 8 Duplicate queue

All the duplicate entries of previous upload will be saved in one screen for a reference.

SCREEN – 9 AR Assignment

Set Aging Plan

Priority-1,2,3,4 Select from drop
etc down
Facility/Locations Criteria

FC’s like – Medicare, Medicaid, BCBS,

ACU (Aetna, Cigna & United
Healthcare), Other Federal
(CHAMPVA, Tricare), HMO’s, Generic
Commercial & WC/Auto
Facility-1
Facility-2 High Dollar Accounts >=$500
Facility-3 Timely filing within 30 days to 60 days.
Facility-4 Low balance < $100

Save Plan

Aging plan logic under AR assignment screen

Allocation of Accounts by Skill/competency mapping (Mapping to be provided) Need to add a dropdown to select a skill, based on the skill selected users list
should be shown to assign.

Combination for callable and non-callable by mapping the aging categories will be shared

Following columns needs to be added

Date last worked
# of touches (# of dates the comments added and saved).
Insurance type – Primary, secondary, tertiary
Coverage type – In-network, out of network.

Should link the claims in tasking and AR Assignment to view the status of the task and enable access to pull back the task as required with Time stamp.

SCREEN – 10 User Profile

Same as the snapshot below and no edits required

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 Role assignment

Role CLIENT - Name

             
  Department
Payment Charge
Credential AR/Denial Coding Quality
  posting entry
             
  ROLES
Client Client Client Client Client Client Client
Director/VP/Sr.VP Leadership Leadership Leadership Leadership Leadership Leadership
AGM/DGM/GM Supervisor-3 Supervisor-3 Supervisor-3 Supervisor-3 Supervisor-3 Supervisor-3
AM/OM/CSM Supervisor-2 Supervisor-2 Supervisor-2 Supervisor-2 Supervisor-2 Supervisor-2
SME/TL Supervisor-1 Supervisor-1 Supervisor-1 Supervisor-1 Supervisor-1 Supervisor-1
Production Executive Executive Executive Executive Executive Executive

Dr J signed off the complete document is signed off

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