Blue Cross Blue Shield

Of Illinois

Blue Cross Blue Shield

Of New Mexico

Blue Cross Blue Shield

Of Texas

Blue Chip System Documentation

BlueChip Blue Transfer Application

Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

Blue Cross Blue Shield

Of Illinois

Blue Cross Blue Shield

Of New Mexico

Blue Cross Blue Shield

Of Texas

Blue Chip Current System Documentation Effort

Blue Transfer AVI Adjudicate Vendor Input Version: 1.0 3rd Qtr. 2006

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

Document Contributors First Name Anthony Kathleen Montrice Shyae-Cheng Last Name Bilus Casey Noel Yang Area/Function Blue Chip Application Group Blue Chip Application Group Subscriber Services Division Blue Chip Application Group

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

TABLE OF CONTENTS
1. BLUE TRANSFER ADJUDICATE VENDOR INPUT .........................................................1-1

BUSINESS SYSTEM OVERVIEW ............................................................................................1-1 1.1 1.2 BUSINESS DESCRIPTION BLUE TRANSFER AVI.............................................................1-1 PROCESS DESCRIPTION .................................................................................................1-2
Diagram 1-1: Blue Transfer AVI System Overview ................................................................1-2

TECHNICAL SYSTEM OVERVIEW ..........................................................................................1-3 1.3 SYSTEM DEFINITION BLUE TRANSFER AVI ...................................................................1-3 1.3.1 System Tasks .........................................................................................................1-3 1.4 MODULES BLUE TRANSFER .........................................................................................1-4
Table 1-1: Blue Transfer AVI - Module List Table .....................................................................1-4

1.4.1 1.4.2 1.4.3 1.5

Module Descriptions ...............................................................................................1-4 Module Structure/Flow ...........................................................................................1-5 Module Development .............................................................................................1-6

Table 1-2: Blue Transfer AVI - Module Description Table.........................................................1-4 Diagram 1-2: Blue Transfer AVI Module Structure/Flow .......................................................1-5

AWARENESS ITEMS ........................................................................................................1-7

Table 1-3: Blue Transfer AVI - Job Table..................................................................................1-7 Table 1-4: Blue Transfer AVI - Report ID Table ........................................................................1-7 Table 1-5: Blue Transfer AVI - Transaction ID Table ................................................................1-7

1.6

FUNCTIONAL OVERVIEW DIAGRAM .................................................................................1-8

Diagram 1-8: Blue Transfer AVI Functional Overview ...........................................................1-8

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

1. BLUE TRANSFER ADJUDICATE VENDOR INPUT

BUSINESS SYSTEM OVERVIEW 1.1 BUSINESS DESCRIPTION BLUE TRANSFER AVI
Blue Transfer is an online process that provides the real time exchange of ACCUMS data between Blue Chip and outside pharmaceutical vendors. Currently, the vendors with whom data is exchanged are Caremark, Medco, and Prime Therapeutics (Prime). Based on the groups contract, the specific ACCUMS data that can be exchanged include overall lifetime maximum, standard deductibles and Out of Pocket Expenses (OPXs) utilized on a per claim basis. Individual and/or family ACCUMS can be exchanged based on the groups contract and the vendors capability. The pharmaceutical vendors receive eligibility files from either the Account or Blue Star, depending on the contractual agreement. They use this to ensure that they only send Blue Transfer transactions for patients with an active and good membership for the service date. An initial acknowledgement is sent to the vendors for each transaction received by HCSC. A second acknowledgement is sent once the transaction is successfully processed and posted to Blue Chip. This same scenario applies to transactions HCSC sends to the pharmaceutical vendors. In the event a transaction is received but is unable to be processed, it is stored on an internal error file for manual review and intervention. The Adjudicate Vendor Input (AVI) system is a component of the Blue Transfer process that retrieves, matches and uses the pharmaceutical vendors accumulator data to adjudicate medical claims.

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1.2

PROCESS DESCRIPTION

Diagram 1-1: Blue Transfer AVI System Overview

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

TECHNICAL SYSTEM OVERVIEW 1.3 SYSTEM DEFINITION BLUE TRANSFER AVI

The Blue Transfer system was developed by HCSC to meet the business requirements for sharing (exchanging) ACCUMS data with non-HCSC health services vendors, most notably prescription drug services providers. The system was developed to accept prescription claims from vendors and build vendor ACCUMS records. Once medical claims are processed, Blue Transfer updates the Blue Chip ACCUMS with amounts provided by the vendor and then returns the updated ACCUMS amounts to the vendor. The current process is limited to sharing the DE (deductible), OP (out of pocket expense) and MX (maximum) ACCUMS, but other ACCUMS such as CO (coinsurance) and CP (co-pay) can easily be incorporated. Since the Blue Transfer process takes place at various stages it is not a stream process and as such it consists of the following key components: PVI Process Vendor Input Receive, save, edit, and validate vendors data and build vendors accumulator file. AVI Adjudicate Vendor Input - Retrieve, match and use vendors accumulator data to adjudicate the medical claim within the Blue Chip process. GVO Generate Vendor Output Upon completion of the Blue Chip adjudication process at Claim Release, retrieve vendors accumulators, build vendor sharing records and transmit those records to the vendor. ERP Error Record Process Select for error correction or retransmission records that were rejected for any reason. This process handles PVI, GVO and acknowledgement rejected records. RIC Reports Inquiry Controls Inquiry of BT01 (vendor input and output) records and BT90 (vendor accumulator) records. ROR Reconciliation of Records Generates various reconciliation reports.

1.3.1 System Tasks 1. Adjudicate Vendor Input Driver 1 HGABTD20 (See Diagram 1-2 Blue Transfer AVI Module Structure/Flow) This module is called by the Accum System Accum Update Driver program HGAACDR1. This module is called for every service line of the claim being processed by HGAACDR1. After receiving control from HGAACDR1, this program performs parameter and interface flow control logic.

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI Control is then passed to the Adjudicate Vendor Input Program 1 HGABTA01.

Upon return from HGABTA01, control returns to HGAACDR1. 2. Adjudicate Vendor Input Program 1 HGABTA01 (See Diagram 1-2 Blue Transfer AVI Module Structure/Flow) This module is called by the Adjudicate Vendor Input Driver program HGABTD20. Based on accum type (Ded, Max or OPX), the following fields are verified for each occurrence of ATBL: ATBL Benefit Period = BT90 Benefit Period ATBL Value qualifier = BT90 value qualifier ATBL Benefit Period = INTB Benefit Period ATBL Table Slot = INTB Slot Pointer BT90 Beginning date = INTB beginning date BT90 end date = INTB end date If all of the above criteria are met, fields from the ATBL Accum Work File are compared to fields from the GCPS Contract File. If all fields match: Move BT90 ACCUM amount into ATBL vendor amount. Add BT90 ACCUM amount onto ATBL current utility. Subtract BT90 ACCUM amount from ATBL allowable difference. Control then returns to HGABTD20.

1.4

MODULES BLUE TRANSFER

Module List HGABTA01 HGABTD20 Table 1-1: Blue Transfer AVI - Module List Table

1.4.1 Module Descriptions

Module ID HGABTA01 HGABTD20 Type COBOL/CICS COBOL/CICS Description Adjudicate Vendor Input Program 1 Adjudicate Vendor Input Driver 1

Table 1-2: Blue Transfer AVI - Module Description Table

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI 1.4.2 Module Structure/Flow

Diagram 1-2: Blue Transfer AVI Module Structure/Flow

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI 1.4.3 Module Development
Module ID: HGABTA01 Adjudicate Vendor Input Program 1 Processing Overview: Updates account level ATBLs. Input Files: The Blue Chip Adjudication system modules reference common data areas for all of its input and output record processing through the use of record pointers that are passed in the following copybooks: HGCDCIA - Common Interface Area for Eligibility, Membership, Claim Level, ACCUMS, and other relevant item information HG2DGCIA Common Interface Area for Contract and Benefit Information. HGCDATBL ATBL ACCUM work file data. HGCPCLM Claim PWIP file data. HGA90050 BT90 Vendor Accum File. Output Files: HGCDATBL ATBL ACCUM work file data. Processing Functions: 1. Receive control from HGABTD20. 2. Based on accum type (Ded, Max or OPX), for each occurrence of ATBL verify that the values of various data fields are correct. 3. If all of the data fields are correct, compare ATBL Work File fields to corresponding GCPS Contract File fields. 4. If all fields match, update selected ATBL amounts. 5. After all ATBL occurrences are checked, return control to HGABTD20. Frequency/Volumes: IL TX Triggers: Called by HGABTD20 Adjudicate Vendor Input Driver 1 Reports: N/A Dependencies: N/A Additional Information: N/A Module ID: HGABTD20 Adjudicate Vendor Input Driver 1 Processing Overview: Performs call to Adjudicate Vendor Input Program 1 (HGABTA01). Input Files: The Blue Chip Adjudication system modules reference common data areas for all of its input and output record processing through the use of record pointers that are passed in the following copybooks: HGCDCIA - Common Interface Area for Eligibility, Membership, Claim Level, ACCUMS, and other relevant item information HG2DGCIA - Common Interface Area for Contract and Benefit Information

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Blue Chip Evergreen - Current System Documentation Blue Transfer AVI

Module ID: HGABTD20 Adjudicate Vendor Input Driver 1 Output Files: See comments in Input Files. Processing Functions: 1. Receive control from HGAACDR1. 2. Perform Parameter and Interface flow control logic. 3. Call HGABTA01 to update Account Level ATBLs. 4. Return control to HGAACDR1. Frequency/Volumes: IL TX Triggers: Called by HGAACDR1 ACCUM Driver 1. Reports: N/A Dependencies: N/A Additional Information: Calls HGABTA01.

1.5
JOB N/A

AWARENESS ITEMS
DESCRIPTION N/A SCHEDULED RUN TIME N/A Table 1-3: Blue Transfer AVI - Job Table DEPENDENCIES N/A

REPORT ID N/A

DESCRIPTION N/A

CUSTOMER N/A

REPORT FREQUENCY N/A

Table 1-4: Blue Transfer AVI - Report ID Table

TRANSACTION ID N/A

DESCRIPTION N/A

CUSTOMER N/A

TRANSACTION FREQUENCY N/A

Table 1-5: Blue Transfer AVI - Transaction ID Table

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1.6

FUNCTIONAL OVERVIEW DIAGRAM

Diagram 1-8: Blue Transfer AVI Functional Overview

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