Functional systems analysis
Raup
FunctionalSpec_sample_2.docx
Georgia GAMMIS Claims Load to ECFMAS
Functional Design
Version 1.2.1
VSD-8466
July 26, 2018
TABLE OF CONTENTS
Revision Log 3
Sign-Off Log 4
System(s) Affected: 5
Business Requirements 5
Background/Objective Overview 5
Performance Requirements 5
Risks 5
Assumptions 5
Glossary of Terms 7
Open Questions 7
Design Characteristics or Problem Description 8
Revision Log
|
Revised by: Revision Date: 6/17/2018 |
Revision Description: Initial publication |
|
Revised by: Revision Date: 7/26/2018 |
Revision Description: Updated ECFMAS table and logic for accommodating negative unit and dollar amounts |
|
Revised by: Revision Date: |
Revision Description: |
|
Revised by: Revision Date: |
Revision Description: |
Sign-Off Log
System(s) Affected:
|
|_| AuthLetterConnect |
|_| EligibilityConnect |
|_| MBHP Checks |
|_| StaffConnect |
|
|_| BenefitConnect |
|_| FHC Purchasing |
|_| MemberConnect |
|_| TeamWorks |
|
|_| Benefits on Line (BOL) |
|_| FileConnect (ETS) |
|_| NetworkConnect |
|_| TeleConnect |
|
|_| CareConnect |
|_| FinanceConnect |
|_| OnDemand |
|_| Web Site |
|
|X| CAS |
|_| FL Health Partners |
|_| OnTrack |
|_| Web Training |
|
|_| ClaimConnect |
|_| GBA Fixed Assets |
|_| Oracle Financials |
|_| Other:___________ |
|
|_| Claims QuickView |
|_| HIPAA Letters |
|_| ProviderConnect |
|
|
|_| ClientConnect |
|_| HMS Time & Atten. |
|_| QualityConnect |
|
|
|_| CompuSet |
|_| Achieve Solutions |
|_| ReferralConnect |
|
|
|_| CPTS |
|_| IRIS |
|_| Scanning |
|
|
|_| E-Claims v2.1 |
|_| IVR (Old) |
|_| SecurityConnect (eSAR) |
|
|
|_|ElectronicClaimConnect |
|_| KnowledgeConnect |
|_| ServiceConnect |
|
Business Requirements
The Georgia Collaborative (GACO) has requested that claims paid externally by Medicaid be imported into a table or tables that are accessible by the new IDD portal.
Background/Objective Overview
Claims paid externally through the GAMMIS claims payment system shall be loaded to ECFMAS. Claims files are received weekly and shall be processed on a set schedule.
Performance Requirements
The following requirements shall be met.
1. The system shall import data from the original GAMMIS files into a new input table, GACLMIMP.
2. The system shall write good records from GACLMIMP to ECFMAS.
3. The system shall identify good records with a specific status code.
4. The system shall identify bad records with a specific status code, error code, and error message.
5. The system shall attempt to process bad records when a new file is received.
6. The system shall create an output report of errors.
7. The system shall send email notifications of successful job completion and distribute any error report(s) created during the job.
Risks
1. Copies of one or more files currently loaded to the data warehouse have not been made available for analysis. This functional specification was developed using the details found in the functional specification for loading files from GAMMIS to the data warehouse (VSD-6068).
Assumptions
1. GAMMIS claims will be loaded to the existing table, ECFMAS.
2. The same files currently processed by the data warehouse shall be made available to the external claims load process for importing into ECFMAS.
3. The files will be routed through FileConnect and delivered by FileConnect to a location accessible to this new program. Any decryption or unzipping will be performed by FileConnect prior to delivering the file to the input folder location.
4. The inbound files will be sent in compliance with the supplied layout.
5. There may be numerous input files, based on size, but they will all conform to the supplied layout. The category of service (COS) buckets below will each be in a separate file.
a. PRTF (020)
b. CMH (440)
c. CBAY (442)
d. NOW/COMP Waiver (680/681)
6. The data files will all be sent in a fixed-width format and will be consistent with agreed upon naming conventions.
7. The inbound file names will be:
a. COS 020: 300479_prtf_claims_YYYYMMDD.dat.gz
b. COS 440: 300479_cmh_claims_YYYYMMDD.dat.gz
c. COS 442: 300479_cbay_claims_YYYYMMDD.dat.gz
d. COS 680/681: 300479_now_comp_claims_YYYYMMDD.dat.gz
8. A user can identify the original inbound file for a specific record by looking at the Category of Service (SVCCAT) and Add Date (SYSDAT) in the Beacon tables.
9. As UNIX is case sensitive, the case of the inbound file names will always be what is listed above.
10. Numeric fields that contain a decimal will be sent with the explicit decimal within the data.
11. The date defined fields will be sent as MMDDYYYY only.
12. Numerically defined columns did not contain scale on the client supplied layout. Assuming a scale of 0 for all columns except amount columns, or as otherwise noted in the layout. Assuming a scale of 2 for any amount columns. Data for these columns should contain an explicit decimal (where applicable).
13. During the load, errors may be encountered. The errors will be handled as described below. When there are data type errors, those records will not be loaded (see below). Valid records will be loaded. This means that BHO will be able to perform partial data loads.
14. As long as there is at least one valid record, the load will be considered successful.
15. Any errors generated from the load of the data, i.e. data type mismatch, missing data elements, or length inconsistencies will cause the record to not load to ECFMAS. The record will be marked as an error and considered a completed transaction. Errored records will not be processed any further during any subsequent load to ECFMAS. Once the program has recorded an error, the program will continue to process the next record. Any resolution of bad data will be handled by the data warehouse team as part of their existing processes whereby they have GAMMIS resubmit corrected records.
16. Given the error logic outlined below, any one record would only ever encounter one error condition before the program will stop processing the record. Therefore, the table design only includes one error code and related error message.
17. For missing files, the Georgia Engagement Center will follow up with the FileConnect team to see if the file(s) was received within BHO. If not, they will reach out to the client to inquire about the status of the file. If BHO did receive the file, then the FileConnect team will need to research why the file has not been forwarded to the proper location for loading.
18. This load has been designated as a Medicaid Behavioral Health (DBHDD) Paid Claims data import. Medical (Professional/Physician and Institutional) and Pharmacy Claims will be not be loaded as part of this project.
19. The Connects applications that currently display data from ECFMAS will not be modified. Any new fields added to ECFMAS to accommodate this project will not be available for display in the Connects.
Glossary of Terms
Throughout the document, references may be made to various entities, as defined below:
· GACO – Georgia Collaborative; Beacon parent code for GA
· GAMMIS – The Medicaid information system used for, among other functions, paying claims for Medicaid members
· COS – Category of Service; GAMMIS designation for different types of services for which they pay claims; Categories of Service can be correlated to funding sources within the Beacon system
Open Questions
|
|
Issue |
Need Response From |
Status |
Resolution/Notes |
|
1 |
How do we need to configure routing so that the same files going to the DWH are sent to this new ECFMAS process? |
Beacon |
Open |
|
|
2 |
|
|
|
|
|
3 |
|
|
|
|
|
|
|
|
|
|
Georgia GAMMIS Claims Load to ECFMAS
Functional Design
1
8/28/2019 v1.0
5 of 26
Design Characteristics or Problem Description
1. The existing screen, AO3121, will be used to execute the GA External Claims Load program
1.1. Menu Path
1.1.1. Managed Health System- Option 1
1.1.2. Add On Menu – Option 20
1.1.3. Claims – Option 3
1.1.4. External Claims Upload – Option 12
1.1.5. External Claims Upload – Option 1
1.2. Job Parameters
1.2.1. Client Group: GACO
1.2.2. Load Claims?: Y
1.2.3. Load Notes?: N (not functional)
1.2.4. Build Accumulators?: N (not functional)
1.2.5. Printer: P6 (not functional)
ACTION: P ENTER ACTION CODE
+----------------------------------------------------------------------------+
| SC0000 01 091108 EXTERNAL CLAIMS UPLOAD AO3121 |
+----------------------------------------------------------------------------+
P . . . . . . . . PROCESS
This screen will submit a job that will upload External
Claims to MHS.
SELECTIONS: Client Group ........ GACO
Load Claims? ........ Y (Y/N)
Load Notes? ......... N (Y/N)
Build Accumulators? . N (Y/N)
Printer ............. P6
CMD:1=Place On JOBQ, 7=Exit
1.3. The AO3121 program will process all files in input folder
1.3.1. Dev: \\vo-dca-edi\c$\ValueOptions\Scheduled\Georgia\GAGammisExternalClaimsImport\Input
1.3.2. Prod: TBD
1.4. Once a file has been processed, the program will remove the file from input folder and place a copy in archive folder
1.4.1. Dev: TBD
1.4.2. Prod: TBD
2. The AO3121 program will map the data from each input file to EDIGACO.GACLMIMP as outlined the Table Mapping section below.
2.1. If a record includes at least one value that is not in the expected format per the table design of GACLMIMP,
2.1.1. Populate GACLMIMP.STATCD with ‘D’
2.1.2. Populate GACLMIMP.ERRCD1 with ‘001’ and ERRMSG1 with value from CWKMAS as outlined in the table mapping section below (e.g., Bad data. Record not loaded).
2.1.3. Do not load record to ECFMAS
3. The program will look up the Beacon Member Number for each incoming record where STATCD is not ‘D’ and populate GACLMINP.MEMBNO with AMXMAS.MEMBNO
Table aliases:
amx = AMXMAS
imp = GACLMIMP
3.1. Find distinct amx.MEMBNO where
amx.ALTNUM = imp.MEMMED and
amx.PARENT = ‘GACO’ and
amx.REASCD = ‘MCD’ and
amx.EFFDAT <= imp.SVCDAT and
amx.EXPDAT >= imp.SVCDAT
3.2. If no match found,
3.2.1. Populate GACLMIMP.STATCD with ‘E’
3.2.2. Populate GACLMIMP.ERRCD1 with ‘002’ and ERRMSG1 with value from CWKMAS as outlined in the table mapping section below (e.g., Member Medicaid ID not found).
3.2.3. Do not load record to ECFMAS
3.3. If more than one distinct MEMBNO found,
3.3.1. Populate GACLMIMP.STATCD with ‘E’
3.3.2. Populate GACLMIMP.ERRCD1 with ‘003’ and ERRMSG1 with value from CWKMAS as outlined in the table mapping section below (e.g., More than one unique Beacon Member ID found)
3.3.3. Do not load record to ECFMAS
3.4. If one distinct MEMBNO found, continue to next step.
4. The program will look up the Beacon Provider/Vendor combination for each incoming record where STATCD is not ‘D’ and populate GACLMINP.PROVNO with AMXMAS.PROVNO and GACLMPIMP.VENDOR with AMXMAS.VENDOR
Table aliases:
prx = AMXMAS
imp = GACLMIMP
4.1. Find distinct prx.PROVNO, VENDOR combination where
prx.ALTPRV = imp.PRVMED and
prx.PARENT = 'GACO' and
prx.IDTYPE = ‘ENT’ and
prx.EFFDAT <= imp.SVCDAT and
prx.EXPDAT >= imp.SVCDAT
4.2. If no match found,
4.2.1. Populate GACLMIMP.STATCD with ‘E’
4.2.2. Populate GACLMIMP.ERRCD1 with ‘004’ and ERRMSG1 with value from CWKMAS as outlined in the table mapping section below (e.g., Provider Medicaid ID not found)
4.2.3. Do not load record to ECFMAS
4.3. If more than one match found,
4.3.1. Populate GACLMIMP.STATCD with ‘E’
4.3.2. Populate GACLMIMP.ERRCD1 with ‘005’ and ERRMSG1 with value from CWKMAS as outlined in the table mapping section below (e.g., More than one unique Beacon Provider ID found)
4.3.3. Do not load record to ECFMAS
4.4. If one distinct PROVNO/VENDOR combination found, continue to next step
5. The program shall load records where GACLMIMP.STATCD is not ‘D’ or ‘E’ from EDIGACO.GACLMIMP to MHSFLO.ECFMAS.
5.1. Records successfully loaded into ECFMAS will be deleted from GACLMIMP
5.2. If any programming errors occur when loading data to ECFMAS, a job failure email will be generated. Please see the Email Notifications section below for details
Rationale: The purpose of reprocessing records (Step 7, below) is to allow a user to make corrections to the Member Medicaid ID, and/or Provider/Vendor Medicaid ID configuration and have the errored records successfully processed in a subsequent job. It is not a requirement to track the history of errored records so as records are reprocessed, they can be deleted from GACLMIMP. GACLMIMP will only store the most recent error status for any one claim.
6. The program reprocess records from the most recent prior job where GACLMIMP.STATCD is ‘E’
6.1. The program shall select records where GACLMIMP.STATCD = ‘E’
6.2. The reprocessed records shall be processed as if new
6.2.1. The reprocessed records will be subject to the conditions outlined in steps 2 through 5 above
6.2.2. The reprocessed records will be written to GACLMIMP with a new record identifier (GACLMIMP.ID)
6.3. If a record is reprocessed, the original error shall be deleted from GACLMIMP
Field Mapping: Incoming file to GACLMIMP
The table below details how the incoming GAMMIS file will be mapped to GACLMIMP
|
GAMMIS Field Name |
GAMMIS Field Description |
Length |
Type |
GACLMIMP Target Field |
Type |
Length |
Programming notes |
|
|
|
|
|
ID |
N |
10 |
Sequentially-assigned record identifier |
|
|
|
|
|
TRNID |
N |
15 |
Sequentially-assigned EDI job identifier |
|
|
|
|
|
STATCD |
A |
1 |
S = Successful import E = Error D = Data Error
If a record has an invalid data format as outlined in the Programming Notes in this table, set status to ‘D’. Records with status of ‘D’ will not be reprocessed in a subsequent job.
If status is ‘D’, stop processing record and move to next record in file.
If a record meets an error condition as outlined in the Programming Notes in this table, set status to ‘E’. Records with status of ‘E’ will be reprocessed in a subsequent job.
Otherwise, set to ‘S’ |
|
|
|
|
|
ERRCOD |
A |
3 |
If Record Status = ‘D’, populate with ‘001’
If Record Status = ‘E’, populate with appropriate error message given the details outlined in this document. |
|
|
|
|
|
ERRMSG |
A |
50 |
Find CWKMAS.TRGTVL||TRGTTVL2 where SRCSYS = GAEXTCLM and TBLNUM = ‘001’ and PARENT = ‘GACO’ SRCVAL = ERRCOD |
|
NUM_ICN |
Number assigned to a claim processed in the system; used for control purposes. |
A |
17 |
CLAMNO |
A |
15 |
|
|
ID_MEDICAID |
Identification number assigned to the member within Medicaid system. This is the member receiving services. |
A |
13 |
MEMMED |
A |
15 |
|
|
|
|
|
|
MEMBNO |
A |
15 |
See section 3 above for details |
|
ID_PROV_RENDER |
Identifies an individual provider who rendered a service to a member. |
A |
15 |
PRVMED |
A |
15 |
|
|
|
|
|
|
PROVNO |
A |
15 |
See section 4 above for details |
|
|
|
|
|
VENDOR |
A |
15 |
See section 4 above for details |
|
DTE_PAID |
Paid claim: the date all paid detail lines were paid. Format MMDDCCYY |
N |
8 |
PAYDAT |
D |
7 |
Reformat to CYYMMDD
If date is not a valid calendar date, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
NUM_DTL |
The detail line number on a claim record. |
N |
4 |
LINENO |
A |
6 |
If value is not numeric, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
DTE_FIRST_SVC |
Date on which the statement period on the claim began. Format MMDDCCYY |
N |
8 |
SVCDAT |
D |
7 |
Reformat to CYYMMDD
If date is not a valid calendar date, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
DTE_LAST_SVC |
Date on which the statement period on the claim ended. Format MMDDCCYY |
N |
8 |
ENDDAT |
D |
7 |
Reformat to CYYMMDD
If date is not a valid calendar date, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
SIGN_1 |
Indicates the subsequent field (Units Billed) is positive or negative value. |
A |
1 |
SIGN01 |
A |
1 |
|
|
QTY_UNITS_BILLED |
Detail Line Item Submitted Units. Format is 999999999. Leading zeroes apply if applicable. |
N |
9 |
UNITBL |
N |
9 |
Leading zeroes will be trimmed when writing to GACLMIMP
If value is not numeric, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
CDE_PROC |
Code identifying the detail line service performed for a member. |
A |
7 |
SVCCOD |
A |
8 |
|
|
CDE_PROC_MOD_1 |
The first Procedure Code Modifier used to further define a procedure provided. |
A |
2 |
MODCOD |
A |
2 |
|
|
CDE_PROC_MOD_2 |
The second Procedure Code Modifier used to further define a procedure provided. |
A |
2 |
MODCD2 |
A |
2 |
|
|
CDE_PROC_MOD_3 |
The third Procedure Code Modifier used to further define a procedure provided. |
A |
2 |
MODCD3 |
A |
2 |
|
|
CDE_PROC_MOD_4 |
The fourth Procedure Code Modifier used to further define a procedure provided. |
A |
2 |
MODCD4 |
A |
2 |
|
|
CDE_CLM_STATUS_DETAIL |
Indicates if the claim was paid or denied at the detail. |
A |
1 |
CLMSTA |
A |
1 |
|
|
PRIOR_AUTH_NUM |
The number assigned by the PA unit to a Prior Authorization request. The PA number is associated with a detail line item. |
A |
12 |
ATHNUM |
A |
12 |
|
|
SIGN_2 |
Indicates the subsequent field (amount paid) is positive or negative value. |
A |
1 |
SIGN02 |
A |
1 |
|
|
AMT_PAID |
Amount paid is the amount paid - Amount State Share. Format is 9999999999.99. Leading zeroes apply if applicable. |
N |
13 |
PAYAMT |
D |
9,2 |
Leading zeroes will be trimmed when writing to GACLMIMP
Assuming scale 2 and explicit decimal. Format 9999999.99.
If value is not numeric, set STATCD to ‘D’ and ERRCD1 to ‘001’
If decimal is missing, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
SIGN_4 |
Indicates the subsequent field (amount billed) is positive or negative value. |
A |
1 |
SIGN04 |
A |
1 |
|
|
AMT_BILLED |
Amount requested by provider for services rendered on a detail line item. Format is 9999999999.99. Leading zeroes apply if applicable |
N |
13 |
CLAAMT |
D |
9,2 |
Leading zeroes will be trimmed when writing to GACLMIMP
Assuming scale 2 and explicit decimal. Format 9999999.99.
If value is not numeric, set STATCD to ‘D’ and ERRCD1 to ‘001’
If decimal is missing, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
CDE_COS |
The Category of Service |
A |
3 |
SVCCAT |
A |
3 |
If field is blank, set STATCD to ‘D’ and ERRCD1 to ‘001’ |
|
SIGN_6 |
Indicates the subsequent field (units paid) is positive or negative value. |
A |
1 |
SIGN06 |
A |
1 |
|
|
QTY_UNITS_PAID |
Quantity allowed for payment for services rendered. The quantity allowed is for a detail line item. Format is 9999999.99. Leading zeroes apply if applicable. |
N |
9 |
UNITPD |
N |
9,2 |
Leading zeroes will be trimmed when writing to GACLMIMP
If value is not numeric, set STATCD to ‘D’ and ERRCD1 to ‘001’
|
|
|
|
|
|
SYSDAT |
26 |
Z |
Default to SYSDAT |
|
|
|
|
|
USERAD |
10 |
A |
Default to ‘VSD8466’ |
|
|
|
|
|
LSTCHG |
26 |
Z |
Default to SYSDAT |
|
|
|
|
|
USERID |
10 |
A |
Default to ‘VSD8466’ |
Field Mapping: GACLMIMP to ECFMAS
The table below details how GACLMIMP will be mapped to ECFMAS.
|
GACLMIMP Source Field |
Type |
Length |
ECFMAS Target Field |
ECFMAS Field Description |
Length |
Type |
Programming notes |
|
CLAMNO |
|
|
CLAMNO |
Claim Number |
15 |
A |
|
|
LINENO |
N |
4 |
LINENO |
Line Number |
6 |
A |
|
|
|
|
|
GRPNUM |
Group Number |
10 |
A |
Default to ‘GACO01’ |
|
MEMBNO |
A |
15 |
MEMBNO |
Member Number |
15 |
A |
|
|
MEMMED |
A |
15 |
MEMMED |
Member Medicaid ID |
15 |
A |
New Field |
|
PROVNO |
A |
15 |
PROVNO |
Provider Number |
25 |
A |
|
|
VENDOR |
A |
15 |
VENDOR |
Vendor Number |
25 |
A |
|
|
ATHNUM |
A |
12 |
ATHNUM |
Authorization Number |
30 |
A |
|
|
|
|
|
PATNUM |
Patient/Invoice Number |
10 |
A |
Leave Blank |
|
|
|
|
HOLDC1 |
Hold Code 1 |
6 |
A |
Leave Blank |
|
|
|
|
HOLDC2 |
Hold Code 2 |
6 |
A |
Leave Blank |
|
|
|
|
HOLDC3 |
Hold Code 3 |
6 |
A |
Leave Blank |
|
|
|
|
HOLDC4 |
Hold Code 4 |
6 |
A |
Leave Blank |
|
|
|
|
UNITCT |
Unit Count |
3,2 |
D |
Leave Blank |
|
SIGN01 UNITBL |
A |
10 |
UNITBL |
Units Billed |
1 9 |
A |
May be negative New Field |
|
SIGN06 UNITPD |
A |
10 |
UNITPD |
Units Paid |
1 9 |
A |
May be negative New Field |
|
SIGN04 CLAAMT |
N |
11v2 |
CLAAMT |
Claimed Amount |
9,2 |
D |
May be negative |
|
|
|
|
ALWAMT |
Allowed Amount |
9,2 |
D |
Leave Blank |
|
|
|
|
COPAMT |
Copay Amount |
7,2 |
D |
Leave Blank |
|
|
|
|
COIAMT |
Coinsurance Amount |
7,2 |
D |
Leave Blank |
|
|
|
|
WTHAMT |
Withhold Amount |
7,2 |
D |
Leave Blank |
|
|
|
|
DEDAMT |
Deductible Amount |
7,2 |
D |
Leave Blank |
|
|
|
|
COBAMT |
Coordination of Benefits Amount |
7,2 |
D |
Leave Blank |
|
|
|
|
NONAMT |
Non-Covered Amount |
9,2 |
D |
Leave Blank |
|
|
|
|
DSCAMT |
Discount Amount |
7,2 |
D |
Leave Blank |
|
SIGN02 PAYAMT |
N |
11V2 |
PAYAMT |
Payment Amount |
9,2 |
D |
May be negative |
|
|
|
|
PAYFLG |
Payment Code |
1 |
A |
Leave Blank |
|
|
|
|
FORMCD |
Form Code |
1 |
A |
Leave Blank |
|
|
|
|
DIAG1 |
Diagnosis Code 1 |
8 |
A |
Leave Blank |
|
|
|
|
DIAG2 |
Diagnosis Code 2 |
8 |
A |
Leave Blank |
|
|
|
|
DIAG3 |
Diagnosis Code 3 |
8 |
A |
Leave Blank |
|
|
|
|
DIAG4 |
Diagnosis Code 4 |
8 |
A |
Leave Blank |
|
|
|
|
POSCOD |
Place of Service Code |
2 |
A |
Leave Blank |
|
|
|
|
TOSCOD |
Type of Service Code |
2 |
A |
Leave Blank |
|
SVCCOD |
A |
5 |
SVCCOD |
Service Code |
6 |
A |
|
|
MODCOD |
A |
2 |
MODCOD |
Service Modifier Code |
2 |
A |
|
|
MODCD2 |
A |
2 |
MODCD2 |
Service Modifier Code 2 |
2 |
A |
New Field |
|
MODCD3 |
A |
2 |
MODCD3 |
Service Modifier Code 3 |
2 |
A |
New Field |
|
MODCD4 |
A |
2 |
MODCD4 |
Service Modifier Code 4 |
2 |
A |
New Field |
|
CLMSTA |
A |
1 |
CLMSTA |
Claim Detail Line Status |
1 |
A |
New Field |
|
SVCDAT |
S |
8 |
SVCDAT |
Date of Service |
7,2 |
D |
Reformat to CYYMMDD |
|
ENDDAT |
S |
8 |
ENDDAT |
Ending Service Date |
7,2 |
D |
Reformat to CYYMMDD |
|
PAYDAT |
S |
8 |
PAYDAT |
Pay Date |
7,2 |
D |
Reformat to CYYMMDD |
|
|
|
|
ENTDAT |
Entry Date |
7,2 |
D |
Leave Blank |
|
|
|
|
LOADDT |
Load Date |
7,2 |
D |
Leave Blank |
|
|
|
|
ADMDAT |
Admission Date |
7,2 |
D |
Leave Blank |
|
|
|
|
DISDAT |
Discharge Date |
7,2 |
D |
Leave Blank |
|
|
|
|
BENCOD |
Benefit Code |
10 |
A |
Leave Blank |
|
|
|
|
BILCOD |
Bill Type Code |
3 |
A |
Leave Blank |
|
|
|
|
RCVDAT |
Received Date |
7,2 |
D |
Leave Blank |
|
|
|
|
ADJDAT |
Adjudication Date |
7,2 |
D |
Leave Blank |
|
|
|
|
CHKNUM |
Check Number |
10,2 |
D |
Leave Blank |
|
|
|
|
CHKINF |
Check Information |
10 |
A |
Leave Blank |
|
|
|
|
PARENT |
Parent/Client Code |
4 |
A |
Default to ‘GACO’ |
|
SVCCAT |
|
|
ITMCOD |
Fund Code |
3 |
A |
|
|
|
|
|
FEDNUM |
Federal Tax Identification Number |
15 |
A |
Leave Blank |
|
PRVMED |
A |
15 |
PRVMED |
Provider Medicaid ID |
15 |
A |
|
|
|
|
|
ALTPRV |
Alternate Provider Number |
15 |
A |
Leave Blank |
|
|
|
|
PRVLST |
Provider Last Name |
20 |
A |
Leave Blank |
|
|
|
|
PRFRST |
Provider First Name |
15 |
A |
Leave Blank |
|
|
|
|
PRVMID |
Provider Middle Initial |
1 |
A |
Leave Blank |
|
|
|
|
MLADR1 |
Provider Address Line One |
25 |
A |
Leave Blank |
|
|
|
|
MLADR2 |
Provider Address Line two |
25 |
A |
Leave Blank |
|
|
|
|
MLCTY |
Provider City Name |
16 |
A |
Leave Blank |
|
|
|
|
MLSTAT |
Provider State Code |
2 |
A |
Leave Blank |
|
|
|
|
MLZIP |
Provider Zip |
10,2 |
D |
Leave Blank |
|
|
|
|
MEMLST |
Member Last Name |
20 |
A |
Leave Blank |
|
|
|
|
MEMFRT |
Member First Name |
15 |
A |
Leave Blank |
|
|
|
|
MEMID |
Member Middle Initial |
1 |
A |
Leave Blank |
|
|
|
|
ADRLN1 |
Address line 1 |
25 |
A |
Leave Blank |
|
|
|
|
ADRLN2 |
Address Line 2 |
25 |
A |
Leave Blank |
|
|
|
|
CITYCD |
City |
16 |
A |
Leave Blank |
|
|
|
|
STACOD |
State Code |
2 |
A |
Leave Blank |
|
|
|
|
ZIPCOD |
Zip Code |
10,2 |
D |
Leave Blank |
|
|
|
|
BTHDAT |
Member Birth Date |
7,2 |
D |
Leave Blank |
|
|
|
|
AJTDAT |
Adjustment Date |
7,2 |
D |
Leave Blank |
|
|
|
|
COBSVG |
COB Savings |
9,2 |
D |
Leave Blank |
|
|
|
|
INTCTL |
Internal Control # |
16 |
A |
Leave Blank |
|
|
|
|
PHYLIC |
Physician License # |
15 |
A |
Leave Blank |
|
|
|
|
PRVCPY |
Provider Capacity Code |
2 |
A |
Leave Blank |
|
|
|
|
REDAMT |
Reduction Amount |
9,2 |
D |
Leave Blank |
|
|
|
|
ATHTYP |
Authorization Type |
6 |
A |
Leave Blank |
|
|
|
|
PAYTOF |
Pay to flag |
6 |
A |
Leave Blank |
|
|
|
|
CGRPNO |
Client Group Number |
15 |
A |
Leave Blank |
|
|
|
|
ADJCOD |
Adjustment Code |
6 |
A |
Leave Blank |
|
|
|
|
CLMCAR |
Claims Carrier |
6 |
A |
Leave Blank |
|
|
|
|
CLMADJ |
Claim Adjustor Code |
10 |
A |
Leave Blank |
|
|
|
|
CHKTYP |
Check type |
10 |
A |
Leave Blank |
|
|
|
|
LBNCOD |
Legacy benefit Code |
10 |
A |
Leave Blank |
|
|
|
|
BENTYP |
Benefit Type |
10 |
A |
Leave Blank |
|
|
|
|
PLNNBR |
Legacy Plan Number |
20 |
A |
Leave Blank |
|
|
|
|
CLINF1 |
Claim Info Field 1 |
30 |
A |
Leave Blank |
|
|
|
|
CLINF2 |
Claim Info Field 2 |
30 |
A |
Leave Blank |
|
|
|
|
LGPPRV |
Legacy System Payment Provider ID |
20 |
A |
Leave Blank |
|
|
|
|
LGSPRV |
Legacy System service Provider ID |
20 |
A |
Leave Blank |
|
|
|
|
CLMTYP |
Claim Type |
2 |
A |
Leave Blank |
|
|
|
|
SYSDAT |
System Add Date |
7,2 |
D |
Default to SYSDAT |
|
|
|
|
USERAD |
User ID of person who added record |
10 |
A |
Default to ‘VSD8466’ |
|
|
|
|
LSTCHG |
Last Change Date |
7,2 |
D |
Default to SYSDAT |
|
|
|
|
USERID |
Last User to Change record |
10 |
A |
Default to ‘VSD8466’ |
Email Notifications
7. Once the job has completed, a notification will be sent to email addresses where EMAMAS.PROCID = ‘GAMMISCLM’.
7.1. Preferred format
GACO External Claims Import – [ORIGINAL FILE NAME]
Job Status: [FAIL or SUCCESS]
RUN DATE: 103015 JOB NAME: [TBD] USER NAME: V1HUDSOG JOB NUMBER: 518504
This email has been system generated and is intended to be informational only.
Please do not reply.
Please contact your manager if you have any questions.
7.2. If errors are generated as part of the current job, the email will include an error report as an attachment. Please see the reporting section below for details.
Error Report
8. If errors are encountered, the program shall produce a report in the format outlined below. The report shall be sent as an attachment to the successful job completion email. The error report shall only include errors for the current TRNID.
8.1. Error Report Sample
Below is a sample of the error report
|
CLAMNO |
MEMMED |
PRVMED |
ERRMSG |
SYSDAT |
|
123456 |
123456 |
123456 |
Member Medicaid ID not found |
2018-06-11-09.52.34.051496 |
|
876543 |
766435 |
987687 |
Provider Medicaid ID not found |
2018-06-11-09.52.34.053459 |
8.2. Error Report Field Mapping
|
Column Label |
Type |
Length |
GACLMIMP Source Field |
Field Description |
Programming notes |
|
CLAMNO |
A |
15 |
CLAMNO |
GAMMIS (external) Claim Number |
|
|
MEMMED |
A |
15 |
MEMMED |
Member Medicaid ID |
|
|
PRVMED |
A |
15 |
PRVMED |
Provider Medicaid ID |
|
|
ERRMSG |
A |
50 |
ERRMSG |
Error Message |
|
|
SYSDAT |
Z |
26 |
SYSDAT |
Date record added to GACLMIMP |
|
EDI Logging
9. The sections below outline the details for logging incoming files in the existing EDI logging tables.
9.1. Update EDI File Log (SECFLA/EDIFILELOG)
|
Field Name |
Description |
Field Len |
Data Type |
Req’d |
Programming Notes |
|
FILEID |
FILE log ID |
15 |
N |
Y |
PK – EDIFILELOG System generated incrementing number to uniquely identify the file process. MINVALUE 1 MAXVALUE 999999999999999 |
|
DTCREATED |
Date/Time Created |
14 |
A |
Y |
Format: YYYYMMDDHHmmSS |
|
FILENAME |
The name of the incoming or outgoing file |
50 |
A |
Y |
‘GAEXTCLM’ |
|
RECORDCT |
Record count contained in file |
9 |
N |
Y |
Total record count |
|
JOBID |
ID of last JOB to touch the file |
15 |
N |
Y |
Should map to valid secfla.edijoblog.jobid record. System Generated |
|
TRANID |
ID of last TRANSACTION to touch the file |
15 |
N |
Y |
Should map to valid secfla.editranlog.tranid record. System Generated |
|
FILTYP |
Either ‘I’ or ‘O’ depending on Inbound or Outbound |
1 |
A |
Y |
In this case “O” |
|
PARENT |
Parent Code for import or extract |
4 |
A |
Y |
In this case “GACO” |
9.2. Create EDI Transaction Reference Table Entry (SECFLA/EDITRNREF)
|
Field Name |
Description |
Field Len |
Data Type |
Req’d |
Programming Notes |
|
TRNTYPID |
Transaction Type Identification |
10 |
A |
Y |
‘GAEXTCLM’ |
|
PARENT |
VO Parent Code |
4 |
A |
Y |
‘GACO’ |
|
OWNER |
Transaction owner |
15 |
N |
|
Links to SECFLA.EDIOWNERS.OWNERID |
|
SOWNER |
Secondary Transaction owner |
15 |
N |
|
Links to SECFLA.EDIOWNERS.OWNERID |
Insert into SECFLA.EDITRNREF values (‘GAEXTCLM’, ‘GACO’, **, **) the owner and secondary owner need to be identified, and their associated ownerID will need to be used for the last two fields.
9.3. Update EDI Transaction Log (SECFLA/EDITRNLOG)
EDITRNLOG (EDI Transaction Logging Table) - Record Details
|
Field Name |
Description |
Field Len |
Data Type |
Req’d |
Programming Notes |
|
TRNID |
Specific Transaction ID |
15 |
N |
Y |
PK; auto incrementing numeric field that uniquely identifies a specific instance of a transaction. |
|
TRNTYPID |
The type of Transaction |
10 |
A |
Y |
Maps to the SECFLA.EDITRNREF.TRNTYPID created for this process (GAEXTCLM) |
|
JOBTYPID |
The current Job (or last job) executing for this transaction. To be updated after each job is run. |
10 |
A |
Y |
Maps to the SECFLA.EDIJOBREF.JOBTYPID of the current job being executed. Initial value is the first job of the transaction. In this case, (GAEXTCLM) |
|
DTSTART |
Date/Time that the Transaction started. This will be equivalent to the starting of the first JOB in the transaction |
14 |
A |
Y |
Date Time: YYYYMMDDHHmmSS |
|
DTEND |
Date/Time that the Transaction completed. This will be equivalent to the ending of the last JOB in the transaction. |
14 |
A |
N |
Date/Time: YYYYMMDDHHmmSS |
|
STATID |
Current Status of the transaction. |
1 |
A |
Y |
· “I”nprogress · “P”ending · “C”ompleted · “E”rror |
9.4. Create EDI Job Reference Entry (EDIJOBREF)
|
Field Name |
Description |
Field Len |
Data Type |
Req’d |
Programming Notes |
|
JOBTYPID |
Unique ID for jobs/programs |
10 |
A |
Y |
GAEXTCLM |
|
DESCRPT
|
Job type description |
30 |
A |
Y |
GA External Claims Import |
|
PGMLOC |
Program location |
30 |
A |
Y |
AO3121CL |
The number of Jobs (and therefore job reference records) will be determined by the developer. . In this case, there is only a need for ONE job for the transaction.
Insert into SECFLA.EDIJOBREF values (‘GAEXTCLM’, ‘GA External Claims Import‘, ‘AO3121CL‘)
9.5. Update EDI Job Log (SECFLA/EDIJOBLOG)
EDIJOBREF (EDI Job Reference File) – Record Details
|
Field Name |
Description |
Field Len |
Data Type |
Req’d |
Programming Notes |
|
JOBID |
Specific Job ID |
15 |
N |
Y |
PK; auto incrementing numeric field that uniquely identifies a specific instance of a job. |
|
FILEID |
The FileId of the file being processed by this job |
15 |
N |
Y |
Maps to specific SECFLA.EDIFILELOG.FILEID record for this job. |
|
TRNID |
The parent Transaction for this Job |
15 |
N |
Y |
Maps to SECFLA.EDITRNLOG.TRNID |
|
JOBTYPID |
The Type of Job as defined in SECFLA.EDIJOBREF |
10 |
A |
Y |
This will vary depending on how many Jobs are needed for the transaction. In this case, only the one “GAEXTCLM” |
|
DTSTART |
Date/Time that the Job started. |
14 |
A |
Y |
Date Time: YYYYMMDDHHmmSS |
|
DTEND |
Date/Time that the Job completed. |
14 |
A |
N |
Date/Time: YYYYMMDDHHmmSS |
|
USERID |
For auditing purposes, this is the Job’s executing User |
10 |
A |
Y |
Value is the actual user executing the job |
|
PARMS |
Job Parameters, this is usually a delimited list coming from the executing screen |
200 |
A |
N |
Parent=*PARENT*, StartDate=*STARTDATE*, Type=*MEMBERORHISTORY*, etc… Comma delimited, all taken from the screen |
|
JOBNO |
OS400 Job number |
30 |
A |
Y |
Job number provided by the operating system during run time |
|
TOTRECS |
Total number of records evaluated |
7 |
N |
Y |
Default 0 where needed |
|
ERRMSG |
Error message, where applicable. Default spaces. |
30 |
A |
Y |
|
Appendix A: External Claims Load Crosswalk Tables
|
SRCSYS |
TBLNUM |
Client |
Table Description |
SRCVAL |
SRCVAL2 |
SRCVAL3 |
SRCVAL4 |
TRGTVL |
TRGTVL2 |
Comments
|
|
GAEXTCLM |
001 |
GACO |
Claim Import Error Codes |
Error Number |
|
|
|
Error message description |
Error desc continued |
Descriptions populate GACLMIMP.ERRMSGx and Import Error Report |
