PROJECT Chiropractic Vendor Delegation

MODULE

FUNCTIONAL
SPECIFICATION
TEST DATE 2/7/2015
TEST
OBJECTIVE Prepare Test Plan for Chiro Project
PREPARED BY Sneha Goel

Testable / Non
TC# TEST SCENARIO / BR Requirement PRE-CONDITION
Testable
Horizon shall be required to send the in-
TC 1.1 scope Chiropractic pended claims file daily Testable
to Healthways.

A unique vendor pend shall be on the

TC 2.1 claim header level Testable

TC 2.2 Claims that are out of scope for Healthways Testable

TC 2.3 In-scope claims shall be sent to Healthways Testable

The unique vendor pend shall be the only

TC 2.4 edit on the claim when the claim is sent to Testable
Healthways (Simultaneous edits).

The vendor pended claims shall remain in a

A release date of the
pended status at Horizon until the
claim by HW has been
TC 2.5 recommendation from Healthways is Testable agreed upon by HW
received or until the agreed upon release
and Horizon
date has been met

HW recommends that
TC 3.1 If Healthways recommends that a claim/claim
Testable
line is Medically Necessary
the claim(MN
/ claim
or ASP
lineindicator), it should be
is Medically Necessary
 HW recommends that
the claim / claim line
TC 3.2 If Healthways recommends that a claim/claim
Testable
line is Not Medically Necessary, (NM or MR1 indicator), it sho
is Not Medically
Necessary

Horizon shall be required to send

Chiropractic rendering PAR and NON PAR
TC 4.0 Non Testable
provider’s data on file to Healthways
weekly

Healthways shall send one of the

TC 5.1 following recommendations on each claim
line review:

TC 5.2 The codes sent by Healthways shall be sent Testable

Claim lines received from Healthways with

a ‘MN indicator are considered medically
TC 5.3 Testable
necessary and shall follow the current
adjudication process at Horizon.

Claim lines received from Healthways with

TC 5.4 an ASP indicator are considered medically Testable
necessary and shall follow the current
adjudication process at Horizon

TC 5.5 Claims lines received from Healthways with Testable

TC 5.6 Claims lines received from Healthways with Testable

The recommendation values that were

sent by Healthways for a claim to Horizon
TC 5.7 Non Testable
should be stored as an audit trail for SLA
reporting purposes.

TC 5.8 Claim lines received from Healthways with aTestable

 If Healthways sends a CRR code for a claim
line, Horizon shall apply an indicator to the
TC 5.9 claim line to indicate that medical records Testable
have been requested in order to stop the
clock from prompt pay calculation.

TC 6.1 If Healthways does not receive medical records

Testable
and sends MR1 indicator to Horizon, Healthways will provide

TC 6.2 If Healthways determines a claim line / claimTestable

to be ‘Not Medically Necessary’ and sends NM indicator to Hor

If Healthways does not receive medical

records and sends MR1 indicator to
Horizon, Healthways will provide written
TC 7.1 notification to the member mentioning Testable
that medical records were not received
and the claim line / claim is recommended
to be ‘Not Medically Necessary’.

If Healthways determines a claim line /

claim to be ‘Not Medically Necessary’ and
sends NM indicator to Horizon, Healthways
TC 7.2 will provide written notification to the Testable
member mentioning that the claim line /
claim is recommended to be ‘Not
Medically Necessary’

All appropriate communications and

process flows shall be developed for this
TC 8.0 project and will be tracked separately in Non Testable
the communications plan.
DOCUMENT REFERENCES
TIME TAKEN

TEST STEPS TEST DATA EXPECTED RESULT

1. File a chiro claim. 2. Procss the claim. 3. If Claim Pend file should be sent to HW
the claim pends, send it to HW daily

1. File a chiro claim. 2. Procss the claim. 3. A unique vendor pend should be
Check the claim header level displayed on the claim header level.

1. File a non chiro claim. 2. process the Claim file should not pend with the
claim. 3. Check the claim header level unique pend created for this project

1. File a chiro claim with date of service after

the go–live date of the project 2. Process The claim should be sent to HW.
the claim. 3. If claim pends, send it to HW

1. File a chiro claim. 2. Process the claim 3. If Claim received by HW should be the
the claim pends send to HW same, except for the unique pend

1. File a chiro claim 2. Process the claim 3. If

the claim pends send to HW. 4. Check the
status of the claim before the 4. Claim should remain in pend status.
recommendation from HW has been 5. Claim should remain in pend status
received. 5. Check the status of the claim until the release date if
before the release date if the recommendation not received.
recommendation has not been released by
HW

1. File a in schope chiro claim 2. HW Claim should be sent to Carecore for

recommends claim is Medically Necessary the RVD review process
1, File an in scope chiro claim. 2. HW 1. Claim should not be sent to Carecore
recommend the claim is not medically for the RVD review process. 2. Claim
necessary lines should be denied at Horizon

NA NA

1. File a chiro claim. 2. Process the claim. 3.

Claim is sent to HW. 4. HW reviews claim Code sent by HW should be sent to
and sends appropriate code for the claim. 5. EDW for storage
Code is sent to EDW and stored.

1. File a chiro claim. 2. Process the claim. 3.

Claim is sent to HW. 4. HW reviews claim as Claim recommended by HW as MN
MN, sends code for the claim. 5. Claim should follow the current adjudication
follows the current adjudication process by process by Horizon
Horizon.

1. File a chiro claim. 2. Process the claim. 3.

Claim is sent to HW. 4. HW reviews claim as Claim recommended by HW as ASP
ASP,sends code for the claim. 5. Claim should follow the current adjudication
follows the current adjudication process by process by Horizon
Horizon.

1. File a chiro claim. 2. Process the claim. 3. Claim should be denied by Horizon.
Claim is sent to HW. 4. HW reviews claim as New EOB and EOP message should be
NM and sends code for the claim. sent for the claim denied

1. File a chiro claim. 2. Process the claim. 3. Claim should be denied by Horizon.
Claim is sent to HW. 4. HW reviews claim as New EOB and EOP message should be
MR1 and sends code for the claim. sent for the claim denied

NA NA

1. File a chiro claim. 2. Process the claim. 3. HW shall send one letter to the
Claim is sent to HW. 4. HW reviews claim as provider per claim to request for
CRR and sends code for the claim. medical records

1. File a chiro claim. 2. Process the claim. 3.
Claim is sent to HW. 4. HW reviews claim as
CRR and sends code for the claim.
1. File a chiro claim. 2. Process the claim. 3.
Claim is sent to HW. 4. HW reviews claim as
MR1 and sends code for the claim.
1. File a chiro claim. 2. Process the claim. 3.
Claim is sent to HW. 4. HW reviews claim as
NM and sends code for the claim.
1. File a chiro claim. 2. Process the claim. 3.
Claim is sent to HW. 4. HW reviews claim as
MR1 and sends code for the claim.
1. File a chiro claim. 2. Process the claim. 3.
Claim is sent to HW. 4. HW reviews claim as
NM and sends code for the claim.
NA
Horizon shall apply an indicator to the
claim line to indicate that medical
records have been requested in order
to stop the clock from prompt pay
calculation.
HW should provide written notification
to the provider mentioning that
medical records were not received and
the claim line / claim is recommended
to be ‘Not Medically Necessary’.
Healthways should provide written
notification to the provider mentioning
that the claim line / claim is
recommended to be ‘Not Medically
Necessary’
Healthways should provide written
notification to the member mentioning
that medical records were not received
and the claim line / claim is
recommended to be ‘Not Medically
Necessary’.
Healthways should provide written
notification to the member mentioning
that the claim line / claim is
recommended to be ‘Not Medically
Necessary’
NA
 RESULT (PASS /
ACTUAL RESULT COMMENTS
FAIL)

Claim 234R did go to HW PASS

Claim header level shows a

unique vendor pend PASS

Claim header level shows a

PASS
regular pend

Claim number 223 was sent to

PASS
healthways

Claim 433A was received by HW

with only one edit – the unique PASS
pend

Claim 343 remained in pend

status PASS

Claim is sent to Carecore for RVD

PASS
review process
Claim is not sent to Carecore, and
PASS
denied by Horizon BCBS

Code sent by HW is send to EDW PASS

Claim follows the current

PASS
adjudication process

Claim follows the current PASS

adjudication process

Claim is denied by Horizon.

Appropriate EOB and EOP PASS
messages sent

Claim is denied by Horizon.

Appropriate EOB and EOP PASS
messages sent

HW sends a letter to the provider

of the claim to request medical PASS
records.
Horizon applies an indicator to
the claim line to indicate that
medical records have been PASS
requested. The clock stops for
doing the prompt pay calculation.

HW sends a written notification to

the provider mentioning that
medical records were not
PASS
received and the claim line / claim
is recommended to be ‘Not
Medically Necessary’.

Healthways sends a written

notification to the provider
mentioning that the claim line / PASS
claim is recommended to be ‘Not
Medically Necessary’

Healthways sends written

notification to the member
mentioning that medical records
PASS
were not received and the claim
line / claim is recommended to be
‘Not Medically Necessary’.

Healthways sends written

notification to the member
mentioning that the claim line / PASS
claim is recommended to be ‘Not
Medically Necessary’