2.04 820 Design Specifications

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820 Phase 2 Design Specif icat ions

California Depart ment of Healt h Care Services

820 Phase 2

Design Specif icat ions

Document Id:

Version: 1.3

Date: December 9, 2009

Project Ident i f ier: 820 Phase 2

DHCS Project Manager: Curt is Milberger


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Revision RecordDate Author Revision Change Reference

10-01-2009 Trinity TechnologyDevelopmentTeam

1.0 Creation

10-20-2009 Grant Stewart 1.1 Revised Introduction

11-09-2009 Orri Rail 1.2 Revised Business Objects

12-09-2009 Grant Stewart 1.3 Finalized Design documents andcomments

Review Record

Name Position/Title Date

O. Rail Lead Developer 10-15-2009

P. Smith Enterprise Architect 10-15-2009

G. Stewart Project Manager 10-20-2009

G. Stewart Project Manager 12-09-2009

Approval Record

Name Position/Title Date


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Table of Content s1 Introduction ................................................................................................................................... 52 System Context Diagram..............................................................................................................8

2.1 Level 1 Context Diagram ........................................................................................................82.2 Level 2 Context Diagram ........................................................................................................9

3 820 System Activity Diagram......................................................................................................114 Component Architecture.............................................................................................................13

4.1 Component Diagram.............................................................................................................134.2 Sequence Diagrams .............................................................................................................17

5 Orchestrations ............................................................................................................................205.1 ProcessAccounting ............................................................................................................... 205.2 ProcessPayment................................................................................................................... 225.3 ProcessCapition.................................................................................................................... 245.4 ProcessRemittanceAdvice.................................................................................................... 26

6 Business Objects........................................................................................................................296.1 PaymentMgmt....................................................................................................................... 296.2 ContractMgmt........................................................................................................................ 366.3 BeneficiaryMgmt ................................................................................................................... 416.4 ReportMgmt ..........................................................................................................................466.5 RemittanceAdviceMgmt ........................................................................................................576.6 InvoiceMgmt.......................................................................................................................... 596.7 CapitationMgmt..................................................................................................................... 80

7 Data Objects ...............................................................................................................................867.1 Contract Data........................................................................................................................877.2 Beneficiary Data....................................................................................................................887.3 Invoice Data ..........................................................................................................................89

8 Database ....................................................................................................................................898.1 Entity Relationship Diagram..................................................................................................898.2 Table Descriptions ................................................................................................................ 91

9 User Interface .............................................................................................................................939.1 Site Map................................................................................................................................939.2 Master Page..........................................................................................................................949.3 Master Page Layout..............................................................................................................949.4 Site Constraints.....................................................................................................................969.5 Invoice Search ...................................................................................................................... 969.6 Invoice Summary .................................................................................................................. 999.7 Pre Payment ....................................................................................................................... 1029.8 Beneficiary Search..............................................................................................................104


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9.15Contract Change.................................................................................................................1279.16Contract HCP......................................................................................................................1309.17Contract Disbursement Register.........................................................................................1339.18Contract Plan-Based Payments..........................................................................................1359.19Vendor Search .................................................................................................................... 1379.20Vendor Summary ................................................................................................................ 1399.21Vendor Payment History.....................................................................................................1429.22Report Search.....................................................................................................................1459.23Reference Table Search.....................................................................................................147

10 Network Requirements .............................................................................................................15010.1Solution Platforms...............................................................................................................15010.2Server Platforms ................................................................................................................. 15510.3Scalability, Load Balancing & Redundancy ........................................................................17410.4Security and Recovery........................................................................................................175

Appendix A Data Dictionary.........................................................................................................17810.5Table Details ....................................................................................................................... 17810.6User Permissions................................................................................................................236

Appendix B Process Model ......................................................................................................... 237


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1 IntroductionThe purpose of this document is to provide software-level and hardware-level architecturespecifications for the 820 Phase 2project. This document identifies the new applicationsbuilding blocks (software components) and their interdependencies. These are the detailedsoftware specifications that will be used by application developers to build the 820 Phase 2application. This document also serves as an 820 technical manual for architects anddevelopers to extend and maintain the system.

This document is divided into the following sections that define how the system will be builtfrom a Software Engineering perspective.

Software Architecture

Orchestrations

Business Objects

Data Objects

Database Model

User Interface

The document also contains sections from a Network Architecture perspective, including:

Solution and Server Platforms

Scalability

Security

Backup and Disaster Recovery

A draft of the System Administration Guide (as specified as part of this deliverable, has beencreated separately in the 820 SharePoint site; filename: Draft System Admin Guide), includes:

System Modifications and Maintenance

Release Management

Transition Management

Software and Hardware Upgrades


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Key artifacts gathered during the Analysis Phase were used to support the creation of theDesign Specifications Document included the identification of Use Cases and the creation ofthe 820 Phase 2 Level One Process Model below.


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The below table represents a traceability matrix from the Use Cases in the RequirementsSpecification Document to the technical sections defined in this document. The Use Caseanalysis was fundamental in guiding the design of the technical components detailed in thefollowing sections.

Use Case Design Specification Section

1.1 Receive and Process Enrol lment Data 2.1, 2.2, 3, 4.1, 4.2, 5.3

1.2 Calculate Capitation 2.1, 2.2, 3, 4.1, 4.2, 5.3, 6.6, 6.7

2.1 Generate Invoices 2.1, 2.2, 3, 4.1, 4.2, 5.3, 6.6, 7.2, 7.3

2.2 Review and Approve Invoices 2.1, 2.2, 4.1, 4.2, 6.6, 7.2, 7.3,9.1, 9.6

2.3 HIPP BCCTP Invoice Management 2.1, 2.2, 4.1, 5.3, 6.6, 7.2, 7.3, 9.6, 9.10

3.1 Process Payment Files Use Case 2.1, 2.2, 3, 4.1, 4.2, 5.1, 5.2, 6.1, 6.5

4.1 Beneficiary Management 2.1, 2.2, 4.1, 6.3, 7.2, 9.8, 9.9

4.2 Contract Management 2.1, 2.2, 4.1, 6.2, 7.1, 9.13, 9.14

4.3 Generate Reports 2.1, 2.2, 4.1, 6.4, 9.22

4.4 Reference Data 2.1, 2.2, 4.1, 9.23

4.5 HIPP BCCTP Beneficiary Management 2.1, 2.2, 4.1, 6.3, 7.2, 9.8, 9.9, 9.10

4.6 HIPP BCCTP Vendor Management 2.1, 2.2, 4.1, 9.19, 9.20

5.1 Process and Send 820 Transactions 2.1, 2.2, 3, 4.1, 4.2, 5.4, 6.5, 7.3,


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2 System Context DiagramThe System Context Diagramrepresents all external entities that may interact with the system.The diagram is the highest level view of the system and is a good starting point to representthe system.

2.1 Level 1 Context DiagramThe Level 1 Context Diagram provides a high level view of the 820 Phase 2 system as a singleentity and shows the flow of all external entities in and out of the system.

Level 1 Context Diagram

MEDSwillsend a file containing beneficiary eligibility information for the current monthsinformation and 12 historical months.


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SCOwill send a file (CD102) summarizing all warrants (or payments) made out to a vendor.

Vendorwill receive an 820 Remittance Advice representing all invoice payments for a given

month.

2.2 Level 2 Context Diagram

The Level 2Context Diagram breaks the CapMan system down into smaller components, whilethe external entities stay the same. Data storage also becomes visible.

Capitation

MEDS

ManagedCare User

Non-ManagedCare User

PaymentRecipient

SCO

Accounting

Capitation File

CD102

CMS64

820

RemittanceAdvice

Contract/Invoices

Beneficiaries/Invoices

UserInterface

Payment

RemittanceGeneration

Beneficiaries InvoicesContracts

Reports


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Paymentrepresents the process of consuming files from Accountingand SCO. Which includesverification and matching of payment information with invoices and finally calling the 820Generation.

Remittance Generationrepresents creating the Remittance Advice (based on invoicesprocessed within Payment). This process also manages sending the 820 file to the appropriatelocation.

User Interfacerepresents any user interaction with managed and non-managed care users.Beneficiary, Contract and Invoice management falls under this process.

Reportsrepresent the process of creating reports from the Invoice data storage.


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3 820 System Act ivity DiagramThe 820 System Activity Diagramrepresents the workflow for the backend processing. Theflow represents the entire high level process and does not show any errors conditionprocessing. Error conditions will be addressed at a lower level in relation to the specificcomponent that handles the error. This Activity Diagram is based of the Level 1 ProcessModel (see Appendix B) from the Requirement Specification.


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Shape Description

Receive Capitation File The system will receive the capitation filecoming from MEDS.

Load into Staging Tables The capitation file will be parsed and loadedinto a staging table.

Calculate Capitation The parsed capitation data will be processedand calculations will be performed.

Generate Invoices Invoices will be generated based on thecalculations.

Approve Invoices Invoices will be approved (from the UI).

Wait for Payments Since approved invoices will be mailed to

accounting, the system will be an idle waitstage.

Receive CMS64 File The system will receive CMS64files comingfrom accounting.

Receive CD102 File The system will receive CD102 files comingfrom SCO.

Match Invoices To Payment Payment information coming from Accountingand SCO will be matched against invoices.

Create Payment Remittance Advice A payment remittance advice will created tosend to the vendors.


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4 Component ArchitectureThis section represents the components of the system. Components are high level pieces ofcode that can either be physical (i.e. DLL) or logical (interrelated groups of code).

4.1Component Diagram

The component diagram's main purpose is to show the structural relationships between thecomponents of a system.

The component diagram provides a high-level, architectural view of the system, which helpsdevelopers begin formalizing a roadmap for the implementation, and make decisions abouttask assignments and/or design. System administrators will find the component diagram usefulbecause they get a view of the logical software components that will be running on theirsystems.


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business layerInvoiceMgmt

business layer

PaymentMgmt

business layerCapitationMgmt

user interfaceManagedCareUI

orchestrationProcessCapitaion

orchestrationProcessPayment

orchestrationProcessAccounting

orchestrationProcessRemittanceAdvice

user interfaceNonManagedCareUI

business layerContractMgmt

business layerBeneficiaryMgmt

business layerReportMgmt

business layerRemittanceAdvice

Component Diagram

Component Type Description

InvoiceMgmt Business This component will be responsible forgenerating and approving invoices. Thegeneration part will include performingretroactive adjustments and generatingnet-changes from previous invoices. It willprovide calculations on a beneficiary level


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CapitationMgmt Business The Capitation component will beresponsible to process the beneficiary datacoming in from the monthly capitated file. Itwill handle the loading and pre-populatinginvoice data before performing thecalculations.

ProcessCapition Orchestration This orchestration will receive and process

the capitation file coming from MEDS. Thedata will be processed into a staging tableand then instantiate CapitionMgmttoprocess the data.

ProcessAccounting Orchestration This component will process the CMS64file coming from Accounting. This willinclude parsing and mapping the file into astructure which will be used to call into

PaymentMgmt.

PaymentMgmt Business This component manages the CMS64andCD102data coming from Accounting andSCO.

ProcessPayment Orchestration This component will process the CD102filecoming from SCO. Which includes parsing

and mapping the file into a structure whichwill be used to call into PaymentMgmt.

ProcessRemittanceAdvice Orchestration This component will start the process tocreate an 820 Remittance Advice when apayment file has been received. It will callinto RemittanceAdviceMgmt.

RemittanceAdviceMgmt Business This component will receive informationfrom ProcessRemittanceAdviceand createthe 820 Remittance Advice.

ContractMgmt Business This component manages contracts withinthe system. This will include versioning of

t t d k i i i li d ith


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NonManagedCareUI User Interface This will be a user interface componentcontaining all non managed care userinterfaces.

ReportMgmt Business This component will manage the creationof reports.

BeneficiaryMgmt Business This component will be part of nonmanaged care and will handle versioning ofbeneficiaries to invoices.


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4.2Sequence DiagramsSequence Diagrams show how components of the 820 Phase 2 System interact with eachother. They also represent lifeline and message calls between components.

4.2.1Invoice Generation

ProcessCapitation CapitationMgmt InvoiceMgmt

Calculate

Generate

ErrorInformation

This sequence diagram represents how invoices will be created. The ProcessCapitationcomponent will call Calculatein the CapitationMgmtcomponent; CapitationMgmt will then callGeneratein InvoiceMgmt. CapitationMgmtwill return any error information toProcessCapitation.


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4.2.2Approving Invoices

ManagedCareUI InvoiceMgmt ReportMgmt

Set Status

Get Invoice Report

Invoice Report

This sequence diagram represents how invoices will be approved. The ManagedCareUIwillcall into InvoiceMgmtwith an invoice status, in this case Approved. The ManagedCareUIretrieves the invoice by calling ReportMgmt.

4.2.3Generate Remit tance Advice

ProcessAccounting PaymentMgmtProcessPayement

ProcessCMS64

ProcessCD102

ProcessRemittanceAdvice

Call ProcessRemittanceAdvice

RemittanceAdviceMgmt

CreateRemittanceAdvice

InvoiceMgmt


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This sequence diagram represents how the 820 Remittance Advice will be generated. TheProcessAccountingcomponent will call into PaymentMgmtto process the CMS64file. TheProcessPaymentcomponent will also call into PaymentMgmtto process the CD102file.

Subsequently ProcessPaymentwill call ProcessRemittanceAdvicecomponent to initiate the820 Remittance Advice process. A call into RemittanceAdviceMgmtwill then gather paidinvoices from InvoiceMgmtand create an 820 Remittance Advice.


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5 OrchestrationsOrchestrations control the workflow for a business process. An example of an orchestrationcould be receiving and parsing a file and then calling logic to complete a business process.The following sections are design details for the orchestration types defined in the componentdiagram (section 4.1).

5.1ProcessAccount ingThe ProcessAccountingOrchestration will be responsible for receiving and logging the receiptof the CMS64 file from accounting and archiving the file. The orchestration will also parse theCMS64 file to match the invoice numbers within the file to the unpaid invoices within the 820Phase 2 system.


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5.1.1Activit y Diagram

Archive

SFTP

Receive CMS64 File

Log CMS64 File Receipt

Map CMS64 File Contentsagainst Unpaid Invoices

Update Unpaid Invoice Statuseswith Claim Schedule Information

Archive CMS64 File

Activity Description

Receive CMS64 FileReceive CMS64 File from external interface, instantiating aninstance of the orchestration.

Log CMS64 File Receipt Log receipt of CMS64 File in 820 Phase 2 event log.BizTalk Map that extracts invoice information for only the 820


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5.2ProcessPaymentThe ProcessPayment Orchestration will be responsible for receiving and logging the receipt of

the CD102 file from SCO and archiving the file. The orchestration will parse the CD102 file andmatch the claim schedule numbers to any unpaid invoices.

The orchestration will enter an exception state given the following conditions:

If any unpaid invoices have yet to receive claim schedule numbers If there are any unpaid invoices with claim schedule numbers that are not matched with

the CD102 file If any invoice amounts are inconsistent

If all unpaid invoices are matched correctly, then the orchestration will start the Process820orchestration.


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Receive CD102 FileReceive CD102 File from external interface, instantiating aninstance of the orchestration.

Log CD102 File Receipt Log receipt of CD102 File in 820 Phase 2 event log

G t Li t f U id I i P ll th 820 Ph 2 t t t ll id i i


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Exception: Invoices Do NotMatch

System enters an exception state if invoice information isincomplete for unpaid invoices in the 820 Phase 2 system.The exception is reported to the system administrator and theorchestration instance is suspended awaiting further review.

Update Invoice Statuses andInformation

For all 820 Phase 2 invoices matched, update invoice withwarrant information and status to CD102 received.

Archive CD102Archive the CD102 physical file to the pre-determined archivelocation.

Begin Process820Begin the Orchestration to process the 820 file for all unpaidinvoices that have received the CMS64 and CD102 file.

5.3ProcessCapit ionThe ProcessCapitationOrchestration will be responsible for receiving and logging the receiptof the MMCD Capitation files from MEDS and archiving the MMCD file. The orchestration willinvoke the business layer to create invoices based upon the beneficiaries in the capitation

file. This orchestration is a singleton, so only one instance of the ProcessCapitationorchestration will be run at the same time.


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Receive MMCD File

Receive MMCD File from external interface, starting theorchestration. The orchestration receipt also validates theformat of the MMCD File.

Log MMCD File Receipt Log receipt of MMCD File in 820 Phase 2 Event Log.Persist MMCD File intoStaging Table

Contents of the MMCD File are persisted into staging tables inthe 820 Phase 2 database


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5.4ProcessRemit t anceAdviceThe ProcessRemittanceAdvice Orchestration will be responsible for creating the 820

Remittance Advice file upon receiving a list of paid warrants from the Process PaymentsOrchestration. This will generate XML-Formatted 820 files which are then processed by theXEngine interface to validate and transform the XML files to X12 5010 820 EDI files. TheX12 5010 820 EDI Files are then processed and sent to the external SFTP Interface to bedelivered to clients.

820 Ph 2 D i S ifi t i


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Receive List of Paid InvoicesA list of paid invoices is received from the ProcessPaymentsorchestration.

Map Paid Invoices to 820 FormatThe List of Paid Invoices is mapped to multiple 820 files in XMLFormat.

Translate 820 Paid Invoices to EDIFormat

The 820 XML Files are sent to the XEngine interface to bevalidated and transformed to a 5010 820 Remittance AdviceEDI File.

Log XEngine ErrorsAny XEngine errors (SNIP) that occur during translation arereturned and persisted the 820 Phase 2 Event Log.

Archive 820 EDI File The 820 EDI File is archived to the file system.

Send 820 Files to ClientsAll 820 Files are sent to the SFTP Interface where they arethen forwarded to the corresponding recipients.



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6 Business Obj ectsThe Business Objectswill define business logic and rules. The objects are designed followingObject Oriented Design methodologies (OOD. Both the user interface layer and orchestrationlayer call into the business layer. The following sections are design details for the businesstypes defined in the component diagram (section 4.1).

6.1Payment MgmtThe PaymentMgmtcomponent will handle the processing of the two distinct payment files for820 Payment Processing, CMS64and CD102.

CMS64 processing entails matching approved invoices with an incoming CMS64 file. For amatching invoice, a Claim Schedule Numberwill be persisted with a new status ofCMS64Processed.

CD102 processing entails matching CMS64 processed invoices with the incoming CD102 file.For a matching invoice, a warrant numbers will be persisted with a new status of Paid.

All errors will be logged in an XML error document.

6.1.1UseCase 3.1 Receive and Process Payment Files

Requirement Specification

The Process Payments process focuses on the receipt and reconciliation of the CMS64 andCD102 payment files received from the Accounting Office. The System matches the invoices tothe Claim Schedule Numbers on the CMS64 on a weekly basis, and then reconciles the ClaimSchedule Numbers to the Warrant Numbers on the CD102 file, which is received on a monthlybasis. Once the invoices have been reconciled to the payment data (CD102 File), the invoicesare ready to for the next process of going on an 820 transaction.

Process Model



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6.1.1.1Use Case Except ions

o If the format or structure is incorrect then system logs an error and haltsprocessing of file (CMS64).

o If the vendor number from the CMS64 file does not match with theCAPMAN vendor number, System updates Invoice status to CMS64Payment Error. System generates the following payment errornotification:CMS64 Payment Error Vendor Number [##] in systemDoes Not Match Vendor Number [##] on CMS64 file for Invoice Number[##]. Accounting must re-submit a corrected Claim Schedule. Else, ifwarrant has already been issued for original Claim Schedule, user mustenter a payment error adjustment.

o

If the invoice amount from the CMS64 file does not match with theCAPMAN invoice amount, System updates Invoice status to CMS64Payment Error. System generates the following payment errornotification:CMS64 Payment Error Invoice Amount [$$] Does NotMatch Amount [$$] on CMS64 file for Invoice Number [##]. Accountingmust re-submit a corrected Claim Schedule. Else, if warrant hasl d b i d f i i l Cl i S h d l t t



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g p

resume further processing once the invoice status becomes CMS64Received.

o If the total dollar amount of the invoices within a Claim Schedule does

not match the Warrant Amount on the CD102, system updates thestatus of all invoices on that Claim Schedule to CD102 Payment Error.System generates the following payment error notification for eachinvoice with status of CD102 Payment Error:CD102 Payment Error Sum of Invoice Amounts [$$] for Claim Schedule [##] is not equal to theWarrant Amount [$$] on CD102 File. User must enter a payment erroradjustment.

o If the number of warrants associated with the Claim Schedule Number

does not equal the number of unique vendor codes for the all invoiceswithin the Claim Schedule, then system updates the status of allinvoices to CD102 Payment Error. System generates the followingpayment error notification for each invoice with status of CD102Payment Error:CD102 Payment Error Number of Warrants [##] onCD102 for Claim Schedule Number [##] is not equal to Number ofVendors [##] for the Claim Schedule in System. User must enter apayment error adjustment.



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6.1.2Class Diagram

6.1.2.1PaymentService

The PaymentServiceclass will be used to retrieve invoices that will either be a) Approvedorb) CMS64Processed. The class will also provide services to retrieve the vendor number foran invoice The ProcessCD102 and ProcessCMS64 classes will use this class



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Parameters Type Description

invoiceStatus enumStatus Either enum64 or enumCD102

status

Output Description

IList List of Invoiceobjects

Method Description

GetVendorNumber Retrieve the Vendor number for an invoice.


invoiced int The invoice id

Output Description

String The invoice number

6.1.2.2ProcessCMS64

The ProcessCMS64class will be used to process a CMS64file. After retrieving a list ofinvoices with the status of CMS64Processed(using PaymentService), matching of eachinvoice will occur against the CMS64file. Any matching errors will be generated in an XMLerror log.

Method Description

Process This method will start the process of matching invoicesagainst the CMS64 file

Output Description

bool Success or Failure.

Method Description

GettErrorXml Retrieve the list of errors if Processfails.

Output Description



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6.1.2.3InvioceMatch

The InvoiceMatchclass will be a helper class to keep track of any issues matching theincoming CMS64 file invoices with the existing invoices in the database. Any issues will belogged.

Property Description

Invoice The invoice matched from the CMS64 file. .

Output Description

OHC820.Data.Invoice The Invoice object coming from the Data objects.


CMS64 A single CMS64 record coming from the CMS64 file

Output Description

CMS64Record An object representing the CMS64 record.


Log A log entry when a failure happens.

Output Description

XmlDocument An xml representation of a a failure

6.1.2.4ProcessCD102

The ProcessCD102class will be used to process a CD102file. After retrieving a list of

invoices with the status of Paid(using PaymentService), matching of each invoice will occuragainst the CD102file. Any matching errors will be generated in an XML error log.

Method Description

Process This method will start the process of matching invoicesagainst the CD102 file

Output Description

bool Success or Failure.

Method Description

GettErrorXml Retrieve the list of errors if Processfails.

O t t D i ti



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6.1.2.5PaymentMatch

The InvoiceMatchclass will be a helper class to keep track of any issues matching theincoming CMS64 file invoices with the existing invoices in the database. Any issues will belogged.


Invoice The invoice matched from the CMS64 file. .

Output Description

OHC820.Data.Invoice The Invoice object coming from the Data objects.


CD102 A single CD102 record coming from the CMS64 file

Output Description

CD102Record An object representing the CD102 record.


Log A log entry when a failure happens.

6.1.2.6CMS64Record

This class will represent a single record in the CMS64 file.

Property Type Description

SequenceNumberField String The sequence numberScheduleNumberField String The schedule number

PaymentAmountField String The payment amount

InvoiceAmountField String The invoice amount

AdjustAmountField String The adjustment amount

AdjReasonCodeField String The adjustment reason code

ServiceNameField String The service namePayDateField String The pay date

CovdPeriodFromField String The coverage period from

CovdPeriodToField String The coverage period to



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ForeigncntryField String The foreign country

VendorzipField String The vendor zip code

VendorTypeField String The vendor type

InvoiceNumberField String The invoice number

ServiceCodeField String Sthe service code

6.1.2.7CDI02Record

Property Type Description

SqheduleNumberField String The schedule number

BeginWarrantNumberField String The start warrant number

EndWarrantNumberField String The end warrant number

WarrantDateField String The warrant date

FederalFiscalYearField String The federal fiscal year

AmountField String The amount field

6.2Contract MgmtThe ContractMgmtcomponent will be used with contract data. Contracts will be versioned forevery change made. There will be no deletion or updates. This component will also handle

HCPs, Aid Code Group and Aid Codes. Both ManagedCareUIand InvoiceMgmtcomponentswill interact with it.

6.2.1UseCase 4.2 Cont ract Management

Requirement SpecificationThis Use Case describes the process for Users to view, add and update Contracts,Amendments, Change Orders and Disbursement Register for Managed Care Plans..

6.2.2Use Case - 2.1 Generat e Managed Care Invoices

Requirement SpecificationThe Process Invoices process begins with the generation of all Managed Care invoices for the



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invoice(s). The invoices are now ready for payment reconciliation, which is described in thenext section: Process Payments.

Process Model



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6.2.3Class Diagram

Data.Contract

ContractService

+IdentifyEffectiveCurrentContracts()+LoadContractSupplementalData()

+GetApplicableContract()

-HcpToContractMap-HcpToSupplementalMap

ContractMgr

+GetContracts()+UpdateContract()+GetContractById()+GetRelatedContracts()

interface

IContractService

InvoiceMgmt

CapitationMgmt

ManagedCareUI

6.2.3.1IContractService

The IContractServiceinterface will define methods to retrieve and save contract information.This interface will be used by the ManagedCareUIcomponent.

Method Description

GetContracts Get all contract related data. This includes HCP, AidCode groups and Aid codes.


IncludeDetails Bool Flag indicated if all contractrelationships should be loaded



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contractNumber String The contract number

healthCarePlanTypeId Int The health care plan type

countyCodeTypeId Int The country code type id

contractTypeId Int The contract type id

effectiveFrom DateTime Effective from date

effectiveTo DateTime Effective to date

Output Description

Contract[] An array of Data.Contract objects

Method Description

UpdateContract Update conctract information. This will create a newversion of all contract data.


Contract Data.Contract The contract values to update.

Method Description

GetContractById Get all contract related data. This includes HCP, AidCode groups and Aid codes.

Parameters Type DescriptionIncludeDetails Bool Flag indicated if all contract

relationships should be loaded

contractId Int The contract id



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Method Description

GetRelatedContracts Get all contact version tied to a specific contract


IncludeDetails Bool Flag indicated if all contractrelationships should be loaded

contractId Int The contract id

Output Description

Contract[] An array of Data.Contract objects

6.2.3.2ContractMgr

The ContractMgrclass will be used by the InvoiceMgmtcomponent to retrieve the applicablecontract information to perform invoice calculations on beneficiaries.

Method Description

LoadContractData Loads all contracts from the database

Method Description

IdentifyEffectiveCurrentContracts Itentifies the contracts matched for beneficiaryinformation


Beneficiary Data.Beneficiary The beneficiary to matchwith a contract

Output Description

Contract The matching contract

Method Description

LoadContractSupplementalData Load the supplemental contract information


supplementalAidCodeType Data AidCodeType The supplemental aid code



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hcpId Short The id of the health careplan

serviceMonth DateTime The applicable servicemonth

payType Short The applicable paymenttype

Output DescriptionList A list of Data.Supplemental objects


HcpToContractMap Dictionary mapping an HCP to contracts

Output Description

Dictionary A dictionary keyed on hcp id with a list ofapplicable contracts


HcpToSupplementalMap Dictionary mapping an HCP to supplementaldata

Output Description

Dictionary

A dictionary keyed on hcp id with a list ofsupplemental data

6.3BeneficiaryMgmtThe BeneficiaryMgmtcomponent will be used to manage beneficiaries and their associatedentities. This will include retrieval for both non-managed and managed care beneficiaries. Formanaged care only, adding risk factor and supplemental information, and for non-managedcare only, creating new beneficiaries with associated coverage. This component will bereferenced by ManagedCareUIand NonManagedCareUI, and will be reference the Datacomponent



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.

6.3.2Use Case 4.5 HIPP and BCCTP Benef iciar y ManagementRequirement SpecificationThis Use Case describes the steps for adding, updating and viewing HIPP, BCCTP, and GHPPBeneficiary information in the 820 Phase 2 System via the user interface.

6.3.3Class Diagram

Data.Beneficiary

BeneficiaryService

+GetBeneficiaries()+SaveBeneficiary()+InsertAdjustment()+InsertCoverage()

interfaceINonMCBeneficiaryService

ManagedCareUI

NonManagedCareUI

+GetBeneficiaries()+InsertRiskFactor()+UpdateSupplementalInformation()+InsertSupplementalEligibility()

interfaceIMCBeneficiaryService

6 3 3 1 IMCBeneficiaryService



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M th d D i ti

Method Description

GetBeneficiaries Retrieve beneficiaries


CIN String The CIN number of abeneficiary to retrieve

firstName String First Name

lastName String Last Name

dateOfBirth DateTime The date of birth

alienStatus String The alien status

healthCarePlanId Int The health care plan id

primaryEligibilityId Int The primary eligibility id

supplementalEligibilityId Int The supplemental eligibility id

supplementalEligibilityFromDate DateTime The from date of thesupplemental eligibilityinformation

supplementalEligibilityToDate DateTime The to date of the supplementaleligibility information

Output Description

Beneficiary[] An array of Data.Beneficiary objects



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Contract Data.Contract The contract values to update.

Method Description

InsertRiskFactor Insert Risk factor for a beneficiary.


beneficiaryId Long The beneficiary id

riskFactor Decimal The risk factor

Method Description

InsertSupplementalEligibility Insert supplemental information for a beneficiary


beneficiaryId Long The beneficiary id

supplementailAidId Long The supplemental id code id

diagnosis String The diagnosis code

6.3.3.2INonMCBeneficiaryService

The INonMCBeneficiaryServiceinterface will define methods to retrieve and save beneficiaryinformation. This interface will be used by the NonManagedCareUIcomponent.



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Method Description

SaveBeneficiary Save a single beneficiary

Method Description

GetBeneficiaries Retrieve beneficiaries


CIN String The CIN number of abeneficiary to retrieve

firstName String First Name

lastName String Last Name

dateOfBirth DateTime The date of birth

alienStatus String The alien status

healthCarePlanId Int The health care plan id

primaryEligibilityId Int The primary eligibility id

supplementalEligibilityId Int The supplemental eligibility id

supplementalEligibilityFromDate DateTime The from date of thesupplemental eligibilityinformation

supplementalEligibilityToDate DateTime The to date of the supplementaleligibility information

Output Description

Beneficiary[] An array of Data.Beneficiary objects



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6.4Report MgmtThe ReportMgmtcomponent will be used manage and create reports. Reports will be initiated

from the user interface and will either be formatted for Excelor AdobeReader. TheManagedCareUIand NonManagedCareUIcomponents will use it. This component willreference the Datacomponent.

6.4.1UseCase 4.3 Generat e Repor t s

Requirement SpecificationThis use case describes the process for users to generate, view, print and export reports viathe user interface.

.

6.4.2Class Diagram

+GetAvailableReports()

ReportManager

Reports

+Generate()+SetFormat()+SetDateFilter()

Report

1*

1

*

IList

CapitationReport

PACEClaimScheduleReport

ExpendituresByFundingSourceReport

EnrollmentReport

ExpendeturesByWaiverAuthorityReport

PlanPaymentHistoryReport

PermReport

HealthPlanPaidInvoiceReport

RateSheetReport

ContractEncumbranceAndExpenditureReport



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6.4.2.1ReportManager

The ReportManagerclass will be the managing class within this component. It will used toaccess all available reports.

6.4.2.2Reports

The Reportsclass will implement System.Collections.Generic.IListand will contain a list ofReportobjects. The list will be strongly typed and each object can be accessed by index.

6.4.2.3Report

The Reportclass will be an abstract class containing methods that are common across reportobjects within the system.

Method Description

SetFormat Set the format of the report to either PDF or Excel

Parameters Type DescriptionformatType enumFormat {excel,

pdf}An enumerator of eithervalue defining either excelor pdf

Method Description

GetAvailableReports Get a list of available reports

Output Description

Reports A list of Report objects

Method Description

Generate Generate the report based on a date filter.

Output Description

Reports A list of Report objects



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1.1.1.1

6.4.2.4EnroEnllmentReport

The EnrollmentReportclass will represent Beneficiaries grouped by County and Aid CodeGroup. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuseswill be Pending through 820 Sent.

6.4.2.5CapitationReport

The CapitationReportclass will represent Beneficiaries grouped by Aid Code Group, HCP,

Rate, Term date and County. Invoice Types will be both Medi-Cal Only and Medicare Part D.The invoice statuses will be Pending through 820 Sent.

Method Description

SetDateFilter Set the to and from date filter

Parameters Type DescriptiondateFrom DateTime The date from

dateTo DateTime The date To



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6 4 2 6 E di B F di S R


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6.4.2.6ExpendituresByFundingSourceReport

The ExpendituresByFundingSourceReportclass will represent Amounts paid, broken downby State Fiscal Year and Quarter of Payment Date, HCP and Model Type, for Funding

Sources:Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will bePending through 820 Sent.

6.4.2.7ExpendeturesByWaiverAuthorityReport

The ExpendeturesByWaiverAuthorityReportclass will represent Waiver Amounts paid perState Fiscal Year and Quarter, broken down by HCP, Claim Sch. Number, Payment Type,Funding Source and Aid code group for each waiver. Invoice Types will be both Medi-CalOnly and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

6.4.2.8PermReport

The PermReportclass will represent expenditures by HCP, Aid Code Group, Aid Code, Rate,



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6.4.2.9PlanPaymentHistoryReport

The PlanPaymentHistoryReportclass will represent expenditures by Month of Payment orMonth of Service/. Invoice Types will be both Medi-Cal Only and Medicare Part D. Theinvoice statuses will be Pending through 820 Sent.

6.4.2.10 ContractEncumbranceAndExpenditureReport

The ContractEncumbranceAndExpenditureReportclass will represent expenditures byContract Invoice Types will be both Medi-Cal Only and Medicare Part D The invoice



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6.4.2.11 OMCAndPHPClaimScheduleReport

The ContractEncumbranceAndExpenditureReportclass will represent Payments by Date ofPayment. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice

statuses will be Pending through 820 Sent.



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6.4.2.12 PACEClaimScheduleReport

The PACEClaimScheduleReportclass will represent Payments by Date of Payment(Hierarchy: Program Type, Managed Care Plan Name, Funding Source, Quarterly). Invoice

Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pendingthrough 820 Sent.


6 4 2 13 RateSheetReport


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6.4.2.13 RateSheetReport

The RateSheetReportclass will represent Payment Rates per Aid Code Group (orSupplemental Payment Rate), per HCP, and per current Effective Date(s). Invoice Types will

be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through820 Sent.

6.4.2.14 HealthPlanPaidInvoiceReport



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6.4.2.15 BeneficiaryPaymentHistorySummaryReport

The HealthPlanPaidInvoiceReportclass will represent a summary of payment history perBeneficiary. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoicestatuses will be Pending through 820 Sent.



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6 5 Remit t anceAdviceMgmt


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6.5Remit t anceAdviceMgmtThe RemittanceAdviceMgmtcomponent will handle the internal processing of gatheringinvoices from the system and generating and 820 Remittance Advice. The invoices should

have the status of Paid, meaning that Accounting and SCO have paid out the invoices to theVendor. The component will then transform the invoice data into an 820 Remittance AdviceXML document suitable for processing in XEngine to produce the actual 820 EDIdocument.

6.5.1UseCase 5.1 Process and Send 820 Transact ions

Requirement SpecificationThe Process and Send 820 Transactions process produces HIPAA-compliant 820 transactions

that show the beneficiary, invoice and payment data for Trading Partners to receive from anSFTP site..

Process Model

1.1.1.1 Use Case Except ions

o If the invoice payee is a beneficiary or a beneficiary representative, doNOT generate an 820 transaction for invoice.

o

If an 820 transaction does not pass SNIP validations, system haltsprocessing of the transaction and posts SNIP Error Report. Systemlogs an error for System Administrator.


6.5.2Class Diagram


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g

+Process()

RemittanceAdviceMgmt

+GetRemittanceAdvice()-InvoiceInfoList

Processed820

InvoiceMgmt

6.5.2.1RemittanceAdviceMgmt

The RemittanceAdviceMgmtclass will manage and start the processing of a new remittanceadvice file (the 820 EDI file). With a warrant number, invoices with the status of Paidwill beprocessed and sent into XEngineto create the EDI file.

Method Description

Process Starts the process the generating the remittance advice.


warrantNumber Long The warrant number to beprocessed against

Output Description

XmlDocument An XML document validated against the 820 XEngineSchema

6.5.2.2Processed820

Th P d820 l ill b d t th itt d i Th f t f th


Output Description


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XmlDocument An XML document validated against the 820 XEngineSchema

6.6 InvoiceMgmtThe InvoiceManagementcomponent will handle generation of all supported invoices. Thecomponent will be used by the capitation process and, invoice recalculation.

All supported invoices can be grouped in three logical groups: capitation invoices, supplemental

invoices, and adjustment invoices. Though all these invoices generate same kind of output,each group has different source of input data. The caller of the component has to load requiredinput data.

6.6.1UseCase 2.1 Generat e Managed Car e Invoices

Requirement SpecificationThe Process Invoices process begins with the generation of all Managed Care invoices for the

current enrollment month based on the completion of processing the Beneficiary Enrollmentfile. The invoices are then made available for review and approval by the Managed CareDepartment. They are then manually printed by the user and provided to the DHCS Accountingdepartment. Additionally, HIPP/BCCTP Department staff manually creates invoices and printthem out for the DHCS Accounting Department. Contract and Beneficiary Adjustments are alsoavailable for the user in this process, which will ultimately be shown on the appropriateinvoice(s). The invoices are now ready for payment reconciliation, which is described in thenext section: Process Payments.

Process Model

820Phase2

System

1.2CalculateCapitation

CAPMANDatabase

RetrieveCurrentMonth

CapitationData

IdentifyInvoiceType

Systemwithholds

7% forSacramentoGMC Dental

PopulateAdvance

Payments &Advance

Adjustments

Set InvoiceStatus to

Pending & MakeAvailable on

User Interface

2.2 Reviewand Approve

Invoices

PopulateCurrentMonth

CapitationInformation

Populate TotalCapitationAmounts &

FundingBreakdown

PopulateHeader and

FooterInformation

PopulateQuarterly

RateAdjustmentAmounts

PopulatePreviiousQuarter

CapitationInformation


6.6.1.1Use Case Except ions


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o If Rate Adjustment is Negative, refer to Business Rule 2.1.21 for 25%Recoupment Cutoff logic.

o If a Rate Adjustment or Adjustments apply to a Service Month prior tothe 12 previous service months (but no earlier than 24 months prior tocurrent month), system creates a separate invoice apart from the 13-month capitation invoices. Invoices are generated based on StateFiscal Year, Contract Number, HCP, and Invoice Type.Invoice format and calculations are the same as described in Steps 2and 3, except Service Months do not include the current service monthor the 12 prior service months.

o

Rate Adjustments for Beneficiary-Based Supplemental Payments arecalculated for service months up to 2 years prior to current month.


6.6.2Class Diagram


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+GetInvoiceTypeRange() : InvoiceTypeRange

interfaceIInvoiceManagement

datatypeEnumInvoiceTypes

+StartRange : EnumInvoiceTypes+EndRange : EnumInvoiceTypes

structInvoiceTypeRange

+GetInvoiceDataByBene() : InvoiceInfoList+GetExpectedInvoices() : InvoiceInfoList+CalculateNewInvoices() : InvoiceInfoList#LoadApplicableContracts()+SaveInvoices()+UpdateInvoiceStatus()+ApplyAdjustments() : InvoiceInfo+PerformRateAdjustmentBeyondCapPeriod() : DateTime+RecalculateInvoice() : int

-ContractList : ContractDataList

InvoiceManagerService

+ServiceDate : DateTime+hcpId : short+AidCodeId : short+PaymentTypeId : short

struct

BeneEligibilityInfostructInvoiceInfo

InvoiceInfoList

*

1

+ApplyAdjustments() : InvoiceInfoList

CapitationInvoice

#GetAdjustedRate() : decimal#GetSupplementalAidType() : short#LoadApplicableBeneficiaries()

SupplementalInvoices

AidsInvoice AgnewsInvoice CraigBontaInvoiceMaternityInvoice

-LoadAdj()

-Adjustment

GmcDentalReleaseInvoice

SavingsSharingInvoice

AdvancePaymentInvoice

refines

structContractData

ContractDataList

*

1

refines

6 6 2 1 IIn oiceManagement


Output Description


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InvoiceTypeRange Start and end value of an invoice type range.

6.6.2.2InvoiceManagerService

The InvoiceManagerServicewill be an abstract base class. It will contain business logic thatis common for all types of invoices.

Method Description

GetInvoiceDataByBene Provides historical invoices for a list of beneficiaries.


BeneficiariesId List A list of beneficiary Ids whosehistorical invoices are needed.

LatestDate DateTime The end date for historicalinvoices date range (oftencapitation date).

MonthsInHistory Integer Count of historical months forwhich the data is needed.

Range InvoiceTypeRange A range invoice types thatshould be extracted.

Output DescriptionInvoiceInfoList A list of historical invoices.

Method Description

GetExpectedInvoices Provides a list of expected invoices based on providedeligibility information of a beneficiary and already loadedapplicable contract information.


CapitationDate DateTime Capitation date.


HistoricalCapitationData InvoiceInfoList List of historical capitation data,it will be required for


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it will be required forsupplemental invoices.

Output Description

InvoiceInfoList A list of expected invoices.

Method Description

CalculateNewInvoices Using provided lists of historical and expected invoices,provides a list of actual invoices that should to be saved

in the database.Parameters Type Description

HistoricalInvoices InvoiceInfoList A list of historical invoices.

ExpectedInvoices InvoiceInfoList A list of expected invoices.

Output Description

InvoiceInfoList A list of actual invoices that should be saved.

Method Description

LoadApplicableContracts This method will be a protected abstract method; henceevery derived class should provide its implementation.



Output Description

None However the method populates applicable contract datain ContractListdata member.

Method Description

SaveInvoices This method will be a public virtual method. It will savethe provided data (as input parameter) intb_invoice_detail and tb_invoice tables. ApplyAdjustment


InvoicesToBeSaved InvoiceInfoList List of InvoiceInfo records thatneeds to be saved.


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needs to be saved.


Output Description

None However the method will throw exceptions and the calleris expected to handle it.

Method Description

UpdateInvoiceStatus This method will be a public method; It will save Pendingtb_invoice_status records for invoices of a specificcapitation date and invoice type range.



range InvoiceTypeRange Type of invoices whose statusneeds to be saved.

Output Description


Method Description

ApplyAdjustments This method will perform Adjustment on every invoice thatis getting saved.


InvoiceInfoRecord InvoiceInfo An invoice detail data that needsto be saved.

Output Description





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Output DescriptionNone However the method will throw exceptions

and the caller is expected to handle it.

Method Description

RecalculateInvoice This method will be a public method; It will save Pendingtb_invoice_status records for invoices of a specificcapitation date and invoice type range.


InvoiceId integer Invoice that needs to berecalculated..

Output Description


6.6.2.3CapitationInvoice

The CapitationInvoicewill be a class used by capitation process to generate capitationinvoices. It must be derived from InvoiceManagerServiceand IInvoiceManagement. Most ofthe business logic required for generation of capitation invoice will exist inInvoiceMethodServicebase class. Any logic specific to capitation invoices should be

implemented in this class.

Method Description

LoadApplicableContracts Override this inherited method to extract contracts thatare applicable for capitation invoices.



Output Description

None However the method populates applicable contract datain ContractListdata member.


GetExpectedInvoices Override this method to identify expected capitationinvoices. The expected capitation invoices can be


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identified by locating applicable contract for a beneficiary.No historical invoice information will be needed here.



EligibilityInfo BeneEligibilityInfo Provides a beneficiaryseligibility information includingthe service month for which the

expected invoices will beidentified.

HistoricalCapitationData InvoiceInfoList Ignore this parameter.

Output Description


Method Description

ApplyAdjustments This method will apply adjustments that are required forcapitation invoices. It includes GM Dental Withhold,Advance Payment, and Recoupment Balance. Note thatthe adjustments are applicable to only capitation invoices.Any applicable adjustment should be applied on therelated invoice.



Invoices InvoiceInfoList List of invoices that should besaved in the database.

Output Description

InvoiceInfoList. List of adjusted invoices that should be saved in thedatabase.


CalculateNewInvoices Override this method only to apply the adjustment oncapitation invoices. The methods should call basei l i f h h d d f h ll


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implementation of the method and output of the callshould be sent as parameter to ApplyAdjustment method.

The output of the ApplyAdjustment should be returned tothe caller.




Output Description

InvoiceInfoList A list of actual adjusted invoices that should be saved.

6.6.2.4SupplementalInvoice

The SupplementalInvoicewill be an abstract base class for all supplemental and adjustmentinvoices. It will be derived from InvoiceManagerService, so that all common business logic ofinvoice generation can be utilized. Every class derived from SupplementalInvoiceshould alsoinherit IInvoiceManagement.

Method Description

LoadApplicableBeneficiary Provides supplemental eligibility information of a list ofbeneficiaries for a date range.


StartServiceDate DateTime Start date of date range.

EndServiceDate DateTime End date of date range.

BeneficiaryIds List A list of beneficiary ids whosesupplemental eligibility isrequired.

Output Description


GetAdjustedRate This method will be a protected abstract method. Everyderived class should provide its implementation. Theim l m t ti h ld id dj t d t f th


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implementation should provide adjusted rate for theapplicable supplemental eligibility of a beneficiary.


SupplementalRate Decimal Effective supplemental rate.

CapitaionPaid Decimal Capitation amount that was paidto the beneficiary.

Output Description

adjustedRate Adjusted Rate that should be saved in the database.

Method Description

GetSupplementalAidType This method will be a protected abstract method. Everyderived class should provide its implementation. Theimplementation should provide type of supported

supplemental eligibility.Parameters Type Description

none

Output Description

supplementalType Type of supported supplemental eligibility.

Method Description

LoadApplicableContracts Override this inherited method to extract contracts thatare applicable for supplemental invoices. Sincesupplemental eligibility has its own applicable contractdata, use GetSupplementalAidTypemethod in thiscommon implementation to identify type of supplementaleligibility whose contract data needs to be loaded.




GetInvoiceTypeRange Define this method as abstract, so that every non-abstractderived class must provide its implementation.


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None

Output Description

InvoiceTypeRange Returns range of the applicable invoice types.

Method Description

GetExpectedInvoices Override this method to identify expected supplementalinvoices. The expected supplemental invoices can beidentified by locating applicable contract for a beneficiaryand the related capitation eligibility.



EligibilityInfo BeneEligibilityInfo Provides a beneficiaryseligibility information includingthe service month for which theexpected invoices will beidentified.

HistoricalCapitationData InvoiceInfoList List of historical capitation data.

Output Description


6.6.2.5AidsInvoice

The AidsInvoicewill be a class used by processes to generate invoices for Aids. It must bederived from SupplemetalInvoiceand IInvoiceManagement. Most of the business logicrequired for generation of this invoice will exist in InvoiceMethodServiceandSupplementalInvoicebase classes. Any logic specific to aids invoices should be implementedin this class.




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Output Description


Method Description

GetSupplementalAidType Provide specific implementation for this protected abstractmethod.


none

Output Description


Method Description

GetInvoiceTypeRange Implement this interface method.


None

Output Description


6.6.2.6AgnewsInvoice

The AgnewsInvoicewill be a class used by processes to generate invoices for Agnews. Itmust be derived from SupplemetalInvoiceand IInvoiceManagement. Most of the businesslogic required for generation of this invoice will exist in InvoiceMethodServiceandSupplementalInvoice base classes Any logic specific to Agnews invoices should be





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Output Description


Method Description



none

Output Description


Method Description



None

Output Description


6.6.2.7MaternityInvoice

The MaternityInvoicewill be a class used by processes to generate invoices for Maternity. Itmust be derived from SupplemetalInvoiceand IInvoiceManagement. Most of the businesslogic required for generation of this invoice will exist in InvoiceMethodServiceand





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Output Description


Method Description



None

Output Description


Method Description



None

Output Description


6.6.2.8CraigBontaInvoice

The CraigBontaInvoicewill be a class used by processes to generate invoices forCraigBonta. It must be derived from SupplemetalInvoiceand IInvoiceManagement. Most ofthe business logic required for generation of this invoice will exist in InvoiceMethodService


LoadApplicableBeneficiary Override implementation of this virtual method. Thisimplementation should provide Craig Vs. Bonta eligibilityinformation of a list of beneficiaries for a date range.


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Parameters Type DescriptionStartServiceDate DateTime Start date of date range.


BeneficiaryIds List A list of beneficiary ids whose

supplemental eligibility isrequired.

Output Description

SupplementalInfoList A list that contains supplemental eligibility information ofall beneficiaries whose id was provided as inputparameter.

Method Description

GetAdjustedRate Provide specific implementation for this protected abstractmethod.




Output Description


Method Description



None


Method Description



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None

Output Description


6.6.2.9GmcDentalReleaseInvoice

The GmcDentalReleaseInvoicewill be a class used by processes to generate invoices forGMC Detnal Release. It must be derived from SupplemetalInvoiceand IInvoiceManagement.However this invoice is different from all other supplemental invoices, the following methodsshould be overridden to provide the specific implementation.

Method Description

LoadApplicableBeneficiary Override implementation of this virtual method. Thisimplementation should provide GMC Dental Releaseeligibility information of a list of beneficiaries for a daterange.


StartServiceDate DateTime Start date of date range.


BeneficiaryIds List A list of beneficiary ids whosesupplemental eligibility isrequired.

Output Description

SupplementalInfoList A list that contains supplemental eligibility information ofall beneficiaries whose id was provided as inputparameter.




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Output Description


Method Description



None

Output Description


Method Description

LoadAdj Load Adjustment data specific to GMC Dental Release.


None

Output Description

none However populate the extracted data in Adjustmentdatamember.

Method Description

GetExpectedInvoices Override this virtual method to identify expected invoicesfor GMC Dental Release.




EligibilityInfo BeneEligibilityInfo Provides a beneficiaryseligibility information includingthe service month for which theexpected invoices will be


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expected invoices will be

identified.

HistoricalCapitationData InvoiceInfoList List of historical capitation data,it will be required forsupplemental invoices.

Output Description


Method Description

CalculateNewInvoices Override this virtual method to identify actual invoices forGMC Dental Release.




Output Description


Method Description



None

Output Description



Method Description



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Output Description


Method Description



None

Output Description


Method Description

LoadAdj Load Adjustment data specific to Savings SharingDisbursement.


None

Output Description



HistoricalInvoices InvoiceInfoList No historical invoices will beneeded to identify actualinvoices that need to be saved.


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Output Description


Method Description



None

Output Description


6.6.2.11 AdvancePaymentInvoice

The AdvancePaymentInvoicewill be a class used by processes to generate invoices forAdvance Payments. It must be derived from SupplemetalInvoiceand IInvoiceManagement.However this invoice is different from all other supplemental invoices, the following methodsshould be overridden to provide the specific implementation.

Method Description





Output Description





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None

Output Description


Method Description

LoadAdj Load Adjustment data specific to Advance Payments.


None

Output Description


Method Description

CalculateNewInvoices Override this virtual method to identify actual invoices forAdvance Payments.


HistoricalInvoices InvoiceInfoList No historical invoices areneeded to identify the actualinvoices that need to be saved.


Output Description


Method Description





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6.7 Capit at ionMgmtThe CapitationMgmtcomponent will handle import of MMCD data into the 820 database. It willcompute every eligible beneficiarys current as well prior months capitation. Also, it willgenerate data for capitation invoices.

6.7.1UseCase 1.2 Calculat e Capi t at ionRequirement SpecificationThe Calculate Capitation process begins with the receipt and processing of the BeneficiaryEnrollment files, where the Managed Care Health Care Plans (HCPs) and their enrolledbeneficiary data for the current month plus 12 prior months is supplied. The HCP andbeneficiary data is captured and used to calculate the capitation. This is where the Systemcalculates the current months enrollment data, and then compares the previous twelve monthsenrollment on the current file to the previous twelve months in history. The outcome is capturingand calculating the net eligibles per HCP for use in the next process of generating ManagedCare invoices.

Process Model

820Phase2System


6.7.2Class Diagram

CapitationProcessor


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+ExecuteProcess() : bool-LoadStagedRecords()-ValidateStagedRecord() : bool-IdentifyNewInvoices()-SaveData()

-historicalInvoices : InvoiceInfoList-ExpectedInvoices : InvoiceInfoList-InvoicesToBeSaved : InvoiceInfoList

+ClientIndexNumber : string+MedsRenewalDate : string+LastName : string+FirstName : string+HCP : string

+AidCode : string+Status : string+PaymentType : string

StagingBeneficiary

+FiscalYear : short+InvoiceTypeId : EnumInvoiceTypes+ContractPlanCode : int+Hcpid : short+AidCodeid : short+PaymentType : EnumPaymentType+Amount : decimal+Rate : decimal+ServiceDate : DateTime

struct

InvoiceInfo

InvoiceInfoList

*

1

datatypeEnumInvoiceTypes

datatypeEnumPaymentType

6.7.2.1CapitationProcessor

The CapitationProcessorclass will be a sealed class and it will be responsible for theexecution of the capitation process. Before executing the process, the caller should ensurethat only latest MMCD enrollment data is available in TB_STAGING_BENEFICIARY and

TB_STAGING_MONTHLY_INFO tables. The class would not contain any logic to ensurecompleteness or validity of the enrollment data.

Status of the process will be logged-in an XML file for reporting purposes.


ExecuteProcess This method will execute the entire capitation processthat includes saving of MMCD enrollment data inCAPMAN database, calculation of capitation amount andsaving of invoice data.


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Since the caller of this method does not have anyinformation about the capitation date for which theprocess is being executed, the class will assumeMedsRenewalDate of the very first enrollment record asthe capitation date. Using the capitation date, start andend service date will be identified (13 month period).

Once capitation and service dates are identified, theprocess will read MMCD enrollment data. Using theenrollment data, expected invoices will be identified bycalling GetExpectedInvoicesmethod of CapitationInvoiceclass. The returned expected invoices will be stored inexpectedInvoices data member. The expected invoiceswill be compared against the historical invoices to find theinvoices that should be saved in the database.


None

Output Description

Bool True if the process completes successfully otherwisefalse.

Method Description

LoadStagedRecords This private method will get MMCD enrollment data fromstaging database tables. Paging should be used to readthe staged data.


LastReadCin String Last read client identificationnumber. This will help to

implement paginated reading ofthe staged data.

Output Description

List A list of staged enrollment data.


ValidateStagedRecord This private method will perform validation of individualstaged record. The method will be called for each recordextracted by LoadStagedRecordsmethod.


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A few of the critical validations that the method willperform:

1. MedsRenewalDate of the record should be same asthe capitation date identified at the start of theprocess.

2. Client Index Number should not be null or empty andit must be exactly 9 characters long.

3. First Name and Last Name should not be null.

4. Hcp code and aid code must exist in CAPMANdatabase.


stagedRec StagingBeneficiary The staged record that shouldbe validated.

Output Description

bool True if valid otherwise false.

Method Description

IdentifyNewInvoices This private method will load historical invoices inhistoricalInvoices data member. It will passhistoricalInvoices and expectedInvoices as parameters toCalculateNewInvoicesmethod of CapitationInvoiceclassto identify the actual invoices. The returned values will be

saved in invoiceToBeSaved.


None

Output Description

none

Method Description

SaveData This private method should call saveInvoices method ofC it ti I i bj t It ill i i i


none

Output Description


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p p

None However an exception will be thrown if any error occursduring save and ExecuteProcesswill catch it.


6.7.3Sequence Diagram Process Capitat ion


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ProcessCapitation CapitationProcessor

Receive MMCD File

Log MMCD File Receipt

Persisit MMCD to Staging

ExecuteProcess

SQLProcedures

LoadStagedRecords

InvoiceManager

List

LoadInvoiceDataByBene

LoadInvoiceInfoList

IList

InvoiceInfoList

CalculateNewInvoices

SaveData

UpdateInvoiceStatus

LogInformation

Log Invoice Processing Results

CapitationReporter


3. ProcessCapitation objectpersists the MMCD file into staging tables in Persist MMCDto Staging

4. ProcessCapitationcalls CapitationProcessorwith function ExecuteProcess to startthe calculation process


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5. CapitationProcessorcalls SQLProcedureswith function LoadStageRecords to loadthe Beneficiary records from the staging tables

6. SQLProceduresreturns a list of StagingBeneficiaryobjects loaded from the stagingtables

7. CapitationProcessorcalls InvoiceManagerwith function LoadInvoiceDataByBene toget the historical beneficiary records

8. InvoiceManagercalls SQLProcedureswith function LoadInvoiceInfoList to loadhistorical beneficiary records

9. SQLProceduresreturns a list of historical beneficiary records

10. InvoiceManagerreturns a list of historical beneficiary records

11. CapitationProcessorcalls InvoiceManagerwith function CalculateNewInvoices tostart the calculation using historical and current beneficiary records

12. CapitationProcessorsaves the calculated beneficiary records with function SaveData

13. CapitationProcessorupdates the invoice status to Pending with functionUpdateInvoiceStatus

14. CapitationProcessorlogs the processing information with function c

Documents

2.04 820 Design Specifications