The Centralized Performance System Medical Module

CPS Basics

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Medical Main

Summary Batch

Overview

Workbench Batch

Overview

Payment Home

Printed Reports Management

Summary Penalty Overview

Workbench To Do List Batch Payments Account

Administration

Summary Penalty Details

Workbench Penalty Details Payment Details TPA Assignment

HYPERLINKS On any page you within CPS one can

click on the blue hyperlink to see additional details.

In the summary or on the workbench you can view a specific penalty type (Rejected not Resubmitted (RNR), Timely Filing or Timely Payment) by clicking on any of the blue hyperlinks.

Centralized Performance System Overview

Performance information is detailed and summarized in CPS on a monthly basis.

A batch is the sum of all of an insurer’s medical bill data submitted and processed by the Division in a single calendar month.

Summary Batch Overview

Summary Penalty Overview

Summary Penalty Overview

Toggling Between Claims Handling Entities Use the drop down box on the right of the screen in the middle of the page

The View All Screen allows viewing of all Medical Bills submitted in a batch. At the bottom of this section you can select to download the information in Excel or CSV format.

MS Excel Output…

CSV Output…

Sending a Batch to the Workbench…Use the hyperlink to send the batch to your workbench

Selecting a BatchIn the box below there are two batches on this workbench.

The Workbench Overview To Do List

Timely Filing Penalty Detail Overview…

RNR Penalty Detail Overview…

Timely Payment Penalty Detail Overview…

Assigning Insurer Statuses to RNR, Filing and Payment Penalties :

Dispute: The Insurer/TPA has reviewed the medical bill data information and does not agree that a penalty should have been assessed.

Concur: The Insurer/TPA has reviewed the medical bill data information and agrees that the penalty is valid.

Data Correction Sent: The Insurer/TPA has reviewed the medical bill data and the information on the bill is incorrect and needs to be corrected.

Examples of Insurer Status Once you have reviewed the bill and reached a decision to concur, dispute or make a data correctionyou must select a box on each line. If the decision is the same for all bills you can “select all”.

Data Correction Sent There may be times when incorrect received or

paid date information is submitted to the Division. If an incorrect received or paid date is submitted

you should correct the data. Set the bill to Data Correction Sent. You will not

be able to submit the batch until the status changes to Data Correction Received.

The status will not change until the data is corrected by your submitter in MDS (Medical EDI).

Notes OverviewView Notes from the Workbench or

Summary Pages

Add Notes only from the Workbench

Notes may include attachments

All notes are PERMANENT!

Two Different Levels of Notes…

CPS Medical Note Types:

Batch Notes: Apply to the batch as a whole.

Detail (Penalty) Notes: Apply to a specific penalty, RNR, Filing or Payment.

Adding Penalty Notes

Each time a RNR, Filing or Payment penalty is disputed a note must be added to explain the reason for the dispute.

ALL Disputes must be accompanied by a note.

Batches cannot be submitted to the Division until each penalty that requires a note has one.

Allowed Attachments Include:When adding attachments the following file name extensions are acceptable

Htm Html Pdf Txt Doc Docx Xls Xlsx Tif Tiff Rtf

Viewing Batch Level Notes and Documents

This is how Batch Notes lookin the System…

To review a batch note click on the blue hyperlink under notes. To review a batch document click on the blue hyperlink Request To View. To add a note click on the blue hyperlink under notes.

Notes must be addedfrom the Workbench

Click the “Notes” hyperlink…

Add Note text and click “Add Notes.” You can also upload documents with the accepted file name extensions.

Batch Submission

Before submitting a batch all penalties must have an Insurer Status of Concur, Dispute, or Data Correction Received.

A note must be added to each penalty with an Insurer Status of Dispute.

Note attachments are optional.

Performing a Final Check…

Select the Perform Final Check tab to see if all bills have been reviewed and worked.

How to perform a final check…

All penalties that have not been worked will have a status of New.

The system WILL NOT automatically indicate which bills require notes. (HINT: Add Notes when you dispute the penalty to avoid confusion later.)

Use the Insurer Status and Notes column headers to quickly sort the data grids and locate the incomplete items on the penalty details pages.

Submit Clicking the Submit button will initiate the system’s review of the batch.

If any penalties have not been regarded OR if any disputed penalties do not have a Note the system will prompt the user.

Batches that pass the Final Check are submitted to the Division for evaluation.

The Confirmation Page…

After you have clicked the “submit” button…

If the batch is not complete…After you have clicked the “submit” button…

ERROR MESSAGE…..

If submission is successful:

The batch is no longer on the Insurer’s workbench.

The batch is viewable on the Insurer’s summary pages.

The batch has been moved to the workbench of a Specialist at the Division of Workers’ Compensation.

And then?

Each Insurer has a designated specialist at the Division.

The Specialist assigned to the submitted batch will process it in a timely manner.

The Specialist will review all disputed penalties and the notes/attachments associated with them.

The Specialist will determine if any of the disputes are acceptable according to current law, Administrative Rules and the policies of the Division of Workers’ Compensation.

Penalty Recalculation …

In general, a batch penalty amount can decrease according to the number of disputed penalties that are accepted by the Specialist assigned to the account.

Data corrections can change penalty amounts.

Penalty Recalculation cont…

If a Notice of Violation (NOV) has been sent and the batch has been processed by the Insurer/TPA and the Division Specialist, it is possible (but not necessary) to request a new Notice of Violation.

Payment for the batch can be made without a new NOV.

Finally… The Specialist will recalculate the batch if any

disputed penalties were accepted.

The batch will be returned to the Insurer’s workbench.

The Insurer can choose to pay in full or make a partial payment.

Special note: If an insurer has Timely Filing penalty in exceeds of $10,000, the penalty will be recalculated so that each untimely filed bill above $10,000 will be assessed a penalty of $5

For now:

Let us assume that the batch will be returned and the Insurer has decided to pay for the batch in full or make a partial payment.

All other scenarios will be addressed in the next session.

Viewing Batch Payment Information

Once a batch has been submitted to the Division it is no longer accessible on the Insurer Workbench.

The batch is accessible on the Summary pages. Payment Information can be accessed there or from the

Payments tab.

Batch Payment Information

Click on “Pending Payment”.

The Payment Screen

For Traditional Check Payments

To pay click the “New Payment” hyperlink

Batch Payment Options: There are two payment options

available at any time.

A Full Payment is simply the total batch payment amount.

A Partial Payment is the sum of all concurred penalties in a batch.

Let’s discuss when to use each method.

Partial Payment A partial payment can be made if the

Insurer receives the initial review of the batch penalties and feels that some or all of the disputed penalties that were denied by the Specialist should be reviewed again by the Division of Workers’ Compensation.

The CPS automatically calculates the partial payment amount as the sum of all concurred penalties in the batch.

Disputed penalties that were accepted by the Division are nullified and do not have an effect on the batch penalty amount.

Full Payment A Full Payment can be made whenever

the Insurer feels that all batch penalties have been sufficiently evaluated and reviewed and no further action is necessary.

Once the full payment amount is received by the Division the batch balance will be adjusted to zero and the batch will close.

At this point the batch is only viewable on the Summary Pages.

How do I make a Partial or Full Payment?

Enter Check Information

Payment Saved…Note: The insurer should print the “Payment Statement” to send with the payment to the Division.

Payment Listed…

The Centralized Performance System Medical ModuleAdministrative Functions

Administrative ActionsThe Insurer Administrator can:

Create New Sub-Accounts.

Edit the Permissions of Existing Sub-Accounts.

Lockout/Unlock Sub-Accounts.

Control TPA Access to Insurer batches.

Creating New Sub-Accounts

Insurer Administrators have the authority to create sub-accounts for their company and grant them permissions.

There is no limit to the number of sub-accounts that can be created.

To create a sub-account…

What happens next? Once the Add New link is clicked

the Account Administration Detail Page is displayed.

This page is essentially a blank user template.

Some information about a new user must be entered to create the account.

Click the “Add New” link…

Account Creation Part I…

What access rights shall the user have?• Account Access Rights (one of three

levels): View Items and Add Notes: This level of permission is

intended for use by managers, auditors, or any other agents the company wishes to empower to view ALL of the firm’s CPS data as well as add notes to CPS batches.

View Items and Update Status: This level of permission is intended to be used by personnel who will actively process CPS batches before they are submitted to the Division of Workers’ Compensation. Users with this level of permission can do everything listed above but can also assign penalties a status of Concur or Dispute.

Submit Batches: Users with this level of permission can view and add notes to batches, assign penalty statuses, and submit batches to the Division of Workers’ Compensation. By default this permission is given to each company’s Insurer Administrator. The Insurer Administrator can decide whether to retain this privilege or grant it to any number of sub-account users.

Account Creation Part II…The password will be sent via email to the addressee you will need to grant a level of access for this account. Once you have done this click “save record”.

To edit an existing sub-account…

Click the “Edit” Link…

Editing Existing Sub-account permissions

The permissions of existing sub-accounts may be modified by the Insurer Administrator as needed at any time.

For details on how to edit existing user permissions please observe the following step-by-step example.

Sub-account fields to define include:

Contact person: This is the name of the sub-account user.

E-mail Address: This is the email address the sub-account user wishes to receive CPS messages at if they are given privileges to do so by their Administrator.

The Account Administration Detail Page…

Update all information and save or delete to remove the record completely

The User’s Account Opens…

The selected user’s profile opens.

Please make note of the usage of the buttons at the bottom of the screen as well. They are:

Buttons on the User Accounts Page are:

Save Record: Clicking this button will commit any changes made to a user’s record.

Cancel: This button will cancel any changes made to a user’s record since accessing their profile.

Delete: Clicking this button will delete the user’s account.

Optional Features…

Optional features of the User Accounts Page are discussed here. These features include:

– Lockout: Clicking inside the Lockout check box will lock or unlock a user’s account. Lockout can occur by the Insurer Administrator or by the Division of Workers’ Compensation. The lockout checkbox provides functionality to use this feature of the system.

– Receive Pre-NOV Email: If this checkbox is checked the user will receive any Pre-Notice of Violation e-mails sent by the system.

These User Profile Controls Look Like…A snapshot of the Lockout, Security and Receive Pre-N.O.V. controls:

These options are only listed on the Profile Page of the Insurer Administrator.

The Cc E-mail Control…

In the event that multiple parties wish to receive automated messages from the CPS their e-mail addresses can be added to the Cc Email text box under the “My Profile” tab.

Once their email address is input in the Cc Email box and the Save button is clicked all subsequent system generated email messages of the CPS will be sent to these persons.

A Close-Up of the Cc E-mail Control…

Lockout by the Division: The Division of Workers’ Compensation reserves the right to lock

any Insurer out of the CPS at any time. A system e-mail message shall be sent to the Insurer

Administrator of the affected Insurance Company notifying them of the lockout.

All sub-accounts of the affected Insurer are locked out by default. If the Insurer Administrator or a sub-account user attempts to

logon to the CPS a message is displayed informing them of the lockout and asks them to contact their Specialist at the Division of Workers’ Compensation for further information.

Once the Division unlocks the Insurance Administrator account, it is the duty of the Insurer Administrator to unlock each of their sub-accounts (performed by a single click of a check box) and notify them that their account is once again operational.

Lockout / Unlocking of Sub-accounts

The power to lock and unlock sub-accounts can be used in two ways.

Let’s discuss both lockout scenarios.

Account lockout at the Insurer’s discretion:

The Insurer Administrator reserves the right to lock any of their sub-accounts at any time.

Locking out a sub-account user is as easy as clicking inside a check box on the Administration Page of the CPS.

TPA Assignment

TPA name, contact, phone and email columns will be populated

You can change the security role of the TPA. You must put a check in the box under the “Select” column before the drop down menu will appear in the “Access” column.

Close Up…

By clicking on the View hyperlink above you can view the TPA address

TPA Address Pop-Up…

The Reports Tab…

Select a date range…

Click on the “Generate Report” button

VOILA!!!

Contact Outside of the System…

1. Refunds.

2. Preservation of Rights / Requesting a Hearing by DOAH or the JCC.

What About Refunds? The system shall automatically flag any

batch that has a negative balance with a status of “Refund Due”.

Specialists shall issue requests for any of their client’s batches with the “Refund Due” status.

An application for refund must be completed by the Insurer or TPA before the refund can be processed.

Preservation of Rights / Requesting a hearing by DOAH:

The final administrative privilege discussed is used only if a resolution to batch penalties cannot be found by working within the system.

In the event an Insurer wishes to preserve their rights and/or request a hearing by the Department of Administrative Hearings a written request must be filed with the Division within 21 days of the Insurer receiving the Notice of Violation.

The Notice of Rights and Notice of Violation are sent to Insurers by Certified Mail if batch penalties have not been resolved through the CPS during the Preliminary Notice of Violation Stage.

The 21-day clock begins when the Insurer signs the Certified Mail Receipt.

Questions?

Should you have further questions or concerns contact your Specialist. The name of your assigned specialist can be found at the bottom of your profile tab. You can call 1-850-413-1608 and request that person. If they are not available you can request to speak with the Medical Administrator.