Test Claims - Batch

Client-Driven Bulk Claim Test

For a PBM user, there may be a need where a newly designed Plan or modified plan needs to be tested with multiple claims to make sure that the setup works for all use cases.

Users can navigate to Customers Services -> Claim Submission Tool, to submit test claims. The claim submission tool is useful for quick tests, also users can submit only one claim at a time. To submit the next claim, either a different template has to be created/used or data needs to be modified.

This document provides a comprehensive guide for users to conduct bulk claim testing efficiently. By following the outlined steps, users can process bulk claims and receive detailed reports on claim outcomes.

Overview

• In this process, Users have to create an input file with the data required for claim submission and the expected outcome that needs to be validated.
• The input file will be processed and a detailed test report & claim details file will be generated. 

Step 1: Create Data Management Job Configuration

• This is a one-time process. The job configuration instructs the system to process the claim data as test claims and export the reports.
• Navigate to the Administration / Data Management menu. Create a new job configuration with the following details:
  • Job Type: Claims
  • Job Criteria: Process
  • Process As: Test Claims (Option for Live Claims will be available in the future)
• Save and activate the job configuration.

Step 2: Prepare Input Files Build input files based on the provided layout. Ensure the file name follows the specified format containing the keyword '_CLAIM_PROCESS_'

Step 3: Upload Input Files

• Option 1: If the file size is 5MB or less: Upload the input file through the user interface. Select the ellipsis icon of the job configuration and choose the Upload File option. 
  

• Option 2: If file size exceeds 5MB: Place the input file in the AWS S3 bucket. The S3 input file path can be referred from the job configuration. 

• Once the file is placed/uploaded, the system will validate the file name and format. After successful validation, the files will be staged.
• Verify the status of the file before triggering the job to process claims. Click on the ellipsis icon and select the View Input Files option.

Step 4: Run Claim Processing Job Choose the Run/Load Now option to process the claims.

Step 5: View Statistics Select 'View Job Execution Details' to access statistics. Review statistics including:

• Total Claims: Number of claims in the input file.
• Passed: Number of tests passed (Considered passed when all the given expected data matches the actual data)
• Failed:  Number of tests failed (Considered failed when one or more of the expected data does not match the actual data)
• Invalid: Number of claims not processed due to missing data or other issues.

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Step 6: Download the Test Report and Claim Details Report

Download the test report and claim report from the provided download option or S3 folder path. Users can analyze results and compare expected and actual outcomes. The reports can be pushed to an external FTP if necessary. Contact the support team to set up the FTP connectivity.

Multiple rows will be displayed if multiple input files are staged during the process. However, the results of all the input files staged and processed together will be combined and displayed in all the output files. Users can identify the source file of each claim by referring to the filename column in the test report.

Note:

• The download option will be displayed only when the output file size is less than 5MB.

• If the file size exceeds 5MB, users should retrieve the file from the provided S3 file path.

Input File

• The input file should be provided in the below layout.
• The input file should be an excel file.
• The input file should follow a specific naming format. For Eg., CVS_CLAIM_PROCESS_FILE or ACMEPBM_CLAIM_PROCESS_FILE. The file name should contain *_CLAIM_PROCESS_*
• The keyword _CLAIM_PROCESS_ is case-sensitive, and the system accepts uppercase only.

Field	Description
R	Required / Mandatory
O	Optional
S	Situational

A sample input file is attached to this document.

Type	Attribute	R/O/S	Field Format / Valid values	Comments
Input	BIN	R		Currently, we are not validating the "Bin" field. Per current design this field must contain a value.
Input	PCN	O		Processor Control Number
Input	Service Provider ID Qualifier	O	12 - DEA  07 - NCPDP 01 - NPI	If not provided, defaulted as 01 - NPI
Input	Service Provider ID	R		Pharmacy Service provider id
Input	Product Service ID Qualifier	O	00 - Not Specified 03 - NDC	If not provided, defaulted as 03
Input	Product Service ID	R		Drug product service ID
Input	Group ID	R		External Group ID
Input	Quantity	O		Defaulted to 30 if not provided
Input	Days Supply	O		Defaulted to 30 if not provided
Input	U&C Submitted	O		Defaulted to 999999.99 if not provided
Input	Date of Service	O	YYYYMMDD	Defaulted to system date if not provided
Input	Cardholder Id	O / S		Cardholder ID If not provided, the system will assign random cardholder ID for test. Note - Cardholder ID cannot be left blank when testing commercial claim as the ID should match with the member's cardholder ID in the system.
Input	First Name	O / S		Note - First Name cannot be left blank when testing commercial claim as the name should match with the member's name in the system if the name is used in the Member identification rules
Input	Last Name	O /S		Defaulted to “LN" if not provided. Note - Last Name cannot be left blank when testing commercial claim as the name should match with the member's name in the system if the name is used in the Member identification rules
Input	Date of Birth	O / S	YYYYMMDD	Defaulted to system date less 30 years if not provided Note - DOB cannot be left blank when testing commercial claim as the DOB should match with the member's DOB in the system as DOB is used in the Member identification rules
Input	Gender Code	O / S	U , M , F	Defaulted to U if not provided Gender Code may be used in Member Identification rules, so it cannot be left blank when testing a commercial claim.
Input	Person Code	O / S		Person Code may be used in Member Identification rules, so it cannot be left blank when testing a commercial claim.
Input	Patient Relationship	O	1 - Cdh 2 - Spouse 3 - Dependents 4 - Other 5 - Student 6 - Dis 7 - AD Dep
Input	Ingredient Cost Submitted	O		Defaulted to 777777.77 if not provided
Input	Dispensing Fee Submitted	O		Defaulted to 0 if not provided
Input	Gross Amt Due Submitted	O		Defaulted to 888888.88 if not provided
Input	Flat Sales Tax Amount Submitted	O		Defaulted to 0 if not provided
Input	Percentage Sales Tax Amount Submitted	O		Defaulted to 0 if not provided
Input	Percentage Sales Tax Rate Submitted	O	Sample value - 4.5 10
Input	Percentage Sales Tax Basis Submitted	S		Required if “Percentage Sales Tax Amount Submitted” is provided
Input	Prescription Service Reference Number Qualifier	O	1 - Rx 2 - Service 3 - Non-Rx	Defaulted as 1 - Rx if not provided
Input	Prescription Service Reference Number	O		system generates random number if not provided
Input	Date Prescription Written	O	YYYYMMDD
Input	Fill Number	O		Defaulted to 1 if not provided
Input	Number Of Refills Authorized	O
Input	Dispense As Written / Product Selection Code	O		Defaulted to 0 if not provided
Input	Prescriber ID	R
Input	Prescriber ID Qualifier	O		If ID starts with number, it will automatically set to “01” if not provided If ID starts with 2 alpha characters,  it will automatically set to “12” if not provided
Input	Prescriber Name	O
Input	Prescriber Last Name	O
Filler	Filler1	O		These fields are not used by the system, these are fillers which can be used by users for any purpose. For eg., Unit Price, AWP and Discount can be entered in order to calculate the expected ingredient cost in the input file with formula's
Filler	Filler2	O
Filler	Filler3	O
Expected	Claim Status	R	PAID REJECTED
Expected	Adjudicated Group ID	O	External Group ID
Expected	Expected Reject Code	O		Reject code(s) needs to be provided. Use pipe , if there is more than one reject code For eg 75 | 54
Filler	Filler4	O		This field can be used by customer to note down the reject code description. This field is not used for validation
Expected	Total AWP	O
Expected	Ingredient Cost	O
Expected	Dispensing Fee	O
Expected	Sales Tax Amount	O
Expected	Incentive Amount	O
Expected	Other Amount	O
Expected	Member Paid Amount	O
Expected	Plan Pay Amount	O
Expected	Basis of Reimbursement	O	0-24
Expected	Basis of Cost Code	O		Code Needs to be provided For eg : A or WAC or UC
Expected	Amount Applied to Periodic Deductible	O
Expected	Amount Attributable Coverage Gap	O
Expected	Amount Attributable to Processor Fee	O
Expected	Amount Attributed to Product Selection/Brand Drug	O
Expected	Amount Attributable Product Selection Brand Non Preferred Formulary	O
Expected	Amount Attributable Product Selection Non Preferred Formulary	O
Expected	Amount Attributable Provider Network	O
Expected	Amount Exceeding Periodic Benefit Maximum	O
Expected	Amount Attributable Coinsurance	O
Expected	Amount Attributable Copay	O
Expected	Incentive Fee (Member)	O
Expected	Other Service Fee (Member)	O
Expected	Cardholder ID	O
Expected	Member First Name	O
Expected	Member Last Name	O
Expected	Member Person Code	O
Expected	Member DOB	O	YYYY-MM-DD
Expected	Brand Class Priced	O	Generic Single-Source, Generic Multi-Source, Brand Single-Source, Brand Multi-Source
Expected	Brand Class PBM	O	Generic Single-Source, Generic Multi-Source, Brand Single-Source, Brand Multi-Source
Expected	Formulary Status	O	1,2,3,4
Expected	Formulary Compliance Code	O	F / FP / FN / NF / NP / NN / 1X / 1P / 1N
Expected	Preferred Status	O	XP / NP / P#

Output Files

Upon completion of the bulk claim testing process, two output files are generated - Test Report and Claim Details Report.

Test Report

This document presents the outcome of the claims - Test Pass or Fail. The report provides comprehensive information on expected and actual values, allowing users to analyze discrepancies.

Claim Details Report

This report is generated to provide each claim detail to the user for review. The format of this report is similar to the format when you extract claims data from the system. Please refer to this page for more details Procella Claim Extract Fields V5.1

Limitations

• Compound claims testing is not supported in this process. Currently, only Single-Ingredient claims can be tested.

• Claim Reversals cannot be tested

• A raw claim (D.0 claim) is not prepared from the customer input file. We do not use Switch in this process. We build the request from the input file and send it to Transaction Engine for processing. So this test process cannot be used to check Switch validation. So if you provide incorrect data in the input file, the claim cannot be processed. The claim status will be Invalid for such claims.

• This test process can be performed within a PBM. Testing across the PBM is not supported.