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VA Code in Flight Submission - Purchased Care Projects (X12 attachments/Authorizations Compliance/Claims Compliance) Draft SDDs and RSDs (docs only)
Please use this identifier to cite or link to this publication: http://hdl.handle.net/10909/11159
Submitted by OI&T EPMO Lean Systems Engineering Open Source Coordination Office on 11-23-2015.
The Chief Business Office Purchased Care (CBOPC) assesses the impact of healthcare regulatory requirements on VHA Electronic Data Interchange (EDI) health care claims processing and designs the use cases to illustrate the reengineered business process flows associated with technology changes. The office continuously monitors and participates in meetings of industry EDI standards-setting organizations. As the business process owner and Subject Matter Expert (SME) for industry health care EDI mandates, Purchased Care (PC) defines business needs that necessitate VHA EDI health care claims system software development. The office designs the maintenance and iterative updates to the EDI enterprise tool used to pay healthcare providers for service connected care provided to Veterans and family members. PC develops partnerships with other Federal agencies and trading partners to support EDI processing and verify compliance; they test software, train users on the use of revised software, and provide help desk support for end users. The EDI transactions processes are utilized to pay nearly $6B in projected claims annually. The development work done under the scope of PC is inextricably linked to providing Veterans the medical care they have earned and deserve.

The HAPE EDI portfolio delivers IT products and services to the Chief Business Office (CBO).

The X12 Attachments Compliance project will create a mechanism for requesting supporting documentation for Health Care Claims and Health Care Services Reviews via EDI transactions. In addition, this enhancement will develop the necessary systems for receiving, storing, and retrieving healthcare claims and healthcare services attachments, whether submitted in response to a Request for Information (RFI) or unsolicited.

The Claims Compliance Project will create processes and modify the relevant systems for handling all data contained in incoming 837 transactions to comply with the operating rules. Secondarily, the enhancement work will modify the affected systems to process denied and unauthorized Claim through generation of 835 transactions and producing tracking reports.

The PC Authorizations Compliance project will create new processes and systems to receive incoming requests for healthcare services review (278) and produce corresponding response transactions (278). Over time, this enhancement should significantly reduce manual methods (e.g., responding to telephone calls to VA Medical Centers (VAMCs) using EDI transactions for treatment authorizations and pre- certifications.

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