Enhancement Functional Specification

Business Information System Project

Maintain Crosswalk Tables for TPA Claims
Processing

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Enhancement Functional Specification

Table of Contents
1 GENERAL INFORMATION ..........................................................................................................3
2 BUSINESS NEEDS & REQUIREMENTS ........................................................................................4
3 STARTING CONDITION / DEPENDENCIES ...................................................................................5
4 ASSUMPTIONS ........................................................................................................................5
5 PROCESS FLOW DIAGRAM .......................................................................................................6
6 DETAILED PROCESSING LOGIC & BUSINESS RULES ...................................................................6
7 FILE/PROCESS SPECIFICATIONS ............................................................................................11
8 SECURITY / AUTHORIZATION REQUIREMENTS..........................................................................11
9 TESTING SCENARIOS.............................................................................................................11
10 ERROR HANDLING, MONITORING, RECONCILIATION .................................................................11
11 EXTERNAL SYSTEM CONSIDERATIONS ....................................................................................12
12 DATA RETENTION REQUIREMENTS .........................................................................................12
13 INTERFACE TRIGGER / SCHEDULING REQUIREMENTS ..............................................................12
14 EXPECTED PERFORMANCE AND SERVICE LEVEL AGREEMENT REQUIREMENTS .......................... 12

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Enhancement Functional Specification

1 General Information
Title: (40 Character MAX)

Maintain Crosswalk Table for TPA Claim Processing

Short description:

Need to post the GL account, Fund, Functional Area and Cost

Center data while processing the TPA medical claims in BIS based
on the TPA claim information. TPA will provide the GL and Fund but
need to develop 2 crosswalk tables to support the Cost Center and
Functional Area mapping.

Process Definition Document

(PDD) Legend # / Item #
BIS Project Phase
Business Team:
Priority:
Module /Submodule Information
Complexity:

Type of Enhancement:

Is there an alternative in the

standard system?

Phase 1C

Phase 1B

Phase 2

BIS TPA Implementation

High/mandatory
Module: AP

Medium/recommended
Submodule:

High
Medium
UserExit
BADI
Custom transaction
Standard SAP program modification
Other (Specify) : Create Crosswalk table
Yes

Low/optional

Low

No

Description of alternative:
Reasons why alternative is not
acceptable:

Performance problems
Other (Specify) :

Complexity

SAP Transaction code:

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Enhancement Functional Specification

2 Business Needs & Requirements

Third Party Administrator (TPA) processes the California Correctional Health Care Services
(CCHCS) medical claims and need to process the claims into CDCR Business Information
System (BIS)/SAP. TPA will provide the BIS Fund and GL accounts in the file but we need to
maintain the crosswalk tables to convert the TPA location code to BIS Cost Center and TPA
PCA codes to BIS Functional Area.
CCHCS TPA Medical Invoice Process Diagram
CCHCS

Rejected
Claims,
Credit/Refunds

Web Based Portal

Interaction with CCHCS

Audit File Transmitted

Interface
TPA

SCO
Completed Warrants File

BIS Vendor Master

Records to TPA
Inmate Locator
Eligibility Interface

Processed Claims

Processed Claim
Schedules

Completed
Warrants

Rejected Claims File

Processed
Claims
BIS
(SAP)

CMD
Create Claim Schedules

TPA Interface Descriptions:

Inmate Locator Eligibility Interface

Interface with CDCR Inmate Locator for automated claim eligibility determinations.

Processed Claims Interface

Interface with CDCR Accounting for transmission of adjudicated claims to be processed for
payment.

Audit File Interface

TPA interfaces with California State Controllers Office (SCO) transmitting specific claim file
information for SCO pre-payment auditing purposes.

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Enhancement Functional Specification

BIS Vendor Master Records to TPA

File transmission of CDCRs medical vendor demographic information from the Accounting office.

Claim Schedule Creation

Accounting office generates the electronic claim schedules and paper Std218 for claims received
by TPA to be transmitted to SCO for payment.

Rejected Claims File

Submitted claims which are rejected by the Accounting office are transmitted to TPA for research,
correction and resubmission.

Processed Claim Schedules

Processed Claim Schedules transmitted in paper with wet signatures to SCO for processing.

SCO Completed Warrants Transmission

SCO transmits paid claim information with Warrant/payment information to CDCR Accounting.

Accounting Completed Warrants Transmission

Accounting transmits Warrant/payment information to TPA.

Web Based Portal Interaction with CCHCS

Web based portals with CDCR for claim reviews, credit/refund requests, and suspended claims.

Rejected Claims, Credit/Refunds

SCO communicates to CDCRs Accounting rejected claim batches, questions and/or corrections
needed.

Completed/Processed Claims Data Transfer

TPA transmits finalized processed claims information to CCHCS.

3 Starting Condition / Dependencies

TPA processes the medical vendor claims and generates the daily claims file and send to BIS to
process as invoice. The claim file will be processed into BIS SAP as vendor invoices.

TPA Processes
Medical Invoice
Claims

TPA Generates
Daily Medical
Claims File

TPA Transmits
Claims file

BIS gets the

Claims File
(SAP XI)

BIS Automatically
Processes
Medical Claims

To process the medical claims by TPA, BIS vendor master must be exist in TPA system and
crosswalk value must be maintained in the mapping table to get the BIS accounting information
(Functional Area and Cost Center).

4 Assumptions
1. When a new location code is needed, the Cost Center crosswalk table must be
maintained prior to maintain in TPA system.

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Enhancement Functional Specification

2. When a new PCA code is needed, the Functional Area crosswalk table must be
maintained prior to maintain in TPA system.

5 Process Flow Diagram

The process flow diagram represents, at a high level, how the process is performed.
description of the process is included below the process flow.

Business Process

CCHCS TPA Implementation

TPA Processed Claims to BIS SAP

Business Process Owner:

Process Team: BIS CCHCS TPA Implementation
Created by:
Creation Date:

Legend:

Type of Activity/Other Process

...Manual

Activity

...SAP Transaction
Other Process

...computer based (non-SAP)

Process
Trigger and
Termination
Decision

On-page
Connector
Document
Off-page
Connector

Third Party
Administrator

TPA Processed Claims (Invoices) to BIS SAP

Process Medical
Invoice Claims

Generate Daily Medical

Claims File

Interface file to BIS SAP

CCHCS Error
Handling Unit

Via CPHCS Data Center

Review/Correct the
Error or Communicate
to TPA for Correction

BIS SAP

Yes

Get the Claims File

(SAP XI)

Automatic Process
Medical Claims

TPA Medical Claims

Posted

Error Exist?
No
Email notification for the
status of Medical Claims

TPA will process the medical vendor invoices and generate the processed claims file daily. The
file will be interfaced via SAP XI to BIS system to process as the vendor invoice. During the
invoice processing in BIS, the program will utilize the 2 crosswalk tables to identify the BIS Cost
Centers and BIS Functional Areas.

6 Detailed Processing Logic & Business Rules

To process the TPA Medical claims in BIS, TPA file should contain the BIS accounting coding
information such as GL accounts, fund, functional area or cost center. TPA medical claims file
will contain the BIS GL accounts and Fund not the functional areas or cost center. To post the
medical claims in BIS, we need to develop 2 crosswalk tables to convert the cost centers and
functional areas.
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Enhancement Functional Specification

Cost Center Crosswalk Table Layout

Location Code
MCSP
ASP
LAC
CVSP
RJD
HQTR
CCI
CMC
CCC
FSP
FWF
CMF
CRC
CIM
COR
CIW
SQ
SCC
CTF
DVI
VYCF
NAC
OHC
PINE
CAL
WSP
NKSP
CHCF
SAC
CCWF
PBSP
CEN
PVSP
ISP
SATF
SOL
KVSP

Location Code Name

Mule Creek State Prison
Avenal State Prison
California State Prison, Los Angeles County
Chuckawalla Valley State Prison
R. J. Donovan Correctional Facility
Hlthcare Inv Data &Prov Svs Br
California Correctional Institution
California Men's Colony
California Correctional Center
Folsom State Prison
Folsom Women's Facility
California Medical Facility
California Rehabilitation Center
California Institution for Men
California State Prison, Corcoran
California Institution for Women
California State Prison, San Quentin
Sierra Conservation Center
Correctional Training Facility
Deuel Vocational Institution
Ventura Youth Correctional Facility
N A Chaderjian Youth Correctional Facility
O H Close Youth Correctional Facility
Pine Grove Youth Conservation Camp
Calipatria State Prison
Wasco State Prison
North Kern State Prison
California Health Care Facility
California State Prison, Sacramento County
Central California Women's Facility
Pelican Bay State Prison
Centinela State Prison
Pleasant Valley State Prison
Ironwood State Prison
California Substance Abuse Treatment Facility
California StatePrison, Solano County
Kern Valley State Prison

Cost Center
Number
0250000000
0260000000
0270000000
0280000000
0300000000
0424100000
0540000000
0560000000
0680000000
0710000000
0710000000
0760000000
0790000000
0800000000
0840000000
0860000000
0950000000
0990000000
1010000000
1060000000
1350000000
1430000000
1430000000
1430000000
1780000000
1800000000
1820000000
1900000000
2840000000
3810000000
3940000000
4030000000
4350000000
4440000000
5870000000
6740000000
9150000000
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Enhancement Functional Specification

Location Code
VSPW
HDSP
SVSP

Location Code Name

Valley State Prison for Women
High Desert State Prison
Salinas Valley State Prison

Cost Center
Number
9190000000
9340000000
9360000000

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Enhancement Functional Specification

Functional Area Crosswalk Table Layout

PCA Code
20302
20303
20304
20305
20306
20307
20309
20310
20311
20312
20313
20314
20316
20401
20402
20601
20602
20603
20604
20605
20606
20607
20608
23190
23290
23390
50200
50300
96001
96002
96003
96004
96005

PCA Description
Med/Surg. Acute-Comm
Med/L.T. SubAcute
CTC-SubAcute
OHU-Multiple Svcs.
OHU-HIV
OHU-Long Term
Ambul. Surg. Svcs.
Med. Outpatient
Med. Outpt.-Obstetrics
Med. Reception Ctr.
Emergency Svcs.
Inpatient Services (CDCR Hospital
Facility)
Med. Outpt.-Gynecology
Dental Outpatient
Dental-Rec. Ctr.
Psych Acute
CTC-Psych Crisis
OHU-OPP (CMF)
Psych Outpatient
Psych Rec. Ctr.
Psych CCCMS
OHU-EOP
PSU (SAC & PBSP)
Medical Juvenile Contract
Dental Juvenile Contract
Mental Health Juvenile Contract
Dental Service Adult
Mental Health Adult
Cardiology
Dental Lab
Dermatology
Endocrinology
Gastroenterology

Functional
Area
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010090
5010010
5020010
5020010
5030010
5030010
5030010
5030010
5030010
5030010
5030010
5030010
2310010
2320010
2330010
5020090
5030090
5010010
5020010
5010010
5010010
5010010
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Enhancement Functional Specification

PCA Code
96006
96007
96008
96009
96010
96011
96012
96013
96014
96015
96016
96017
96018
96019
96020
96021
96022
96023
96024
96025
96026
96027
96028
96029
96030
96031
96032
96033
96034
96100
96101
96102

PCA Description
Oncology/Chemotherapy
Laboratory
Neurology
Pathology
Physical Therapy
Ophthalmology
Optometric
Orthopedics
ENT - Otorhinolaryngology
Pharmacy
Podiatry
Pulmonary / Respiratory Therapy
Radiology-Diagnostic
Nuclear Med. / Radiation Therapy
Rheumatology
Urology
Internal Medicine
Medical Transport
Nephrology/Dialysis
Infectious Disease
General Surgery
Recreation Therapy
Occupational Therapy
Speech Therapy
Sleep Studies
Audiology
Hematology
Vascular Medicine
Allergy/Immunology
Central Svcs.&Supp.
Cont. & Ext. H.C. Sv
Dietary

Functional
Area
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010
5010010

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Enhancement Functional Specification

7 File/Process Specifications
N/A

8 Security / Authorization Requirements

Need new transaction codes to maintain the tables and display tables

Maintain Cost Center Crosswalk Table

Display Cost Center Crosswalk Table

Maintain Functional Area Crosswalk Table

Display Functional Area Crosswalk Table

9 Testing Scenarios
Normal Functionality - test cases that ensure the conversion requirement, as it should.
ID
1
2
3

Description
Maintain new mapping records for Cost Center
Maintain new mapping records for Functional Area

Exception - special logic or exceptions

1
2

Remove a Cost Center Mapping and process the claims

Remove a Functional Area mapping and process the claims

10 Error Handling, Monitoring, Reconciliation

The error handling, monitoring, reconciliation section identifies a step by step list of instructions
to mitigate errors encountered during the development of enhancement in SAP.
If an error occurs during the TPA medical claims processing in BIS due to the missing mapping
records for Cost Center or Functional Area, the CCHCS exception handling group needs to
communicate to BIS MDU (Master Data Unit) to maintain the crosswalk tables.

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Enhancement Functional Specification

11 External System Considerations

TPA system

12 Data Retention Requirements

N/A

13 Interface Trigger / Scheduling Requirements

N/A

14 Expected Performance and Service Level Agreement Requirements

BIS Support Unit will maintain the crosswalk tables.

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