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ECM Pro™ Skilled Nursing Facility (SNF) Web Service User’s Guide

ECM Pro™ SNF Web Services User’s Guide

Published April 2, 2020 The format of this document is 8.5 x 11”

© 2020 Optum.

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© 2020, American Hospital Association (AHA), Chicago, Illinois. Reproduced with permission. No portion of this publication may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.

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EDC Analyzer™ - Patent No. 10,417,382

Optum11000 Optum Circle

Eden Prairie, MN 55344

[email protected]

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Table of ContentsChapter 1: Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

About Optum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Chapter 2: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Prior Knowledge Assumed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8The SNF Web Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8The Optimizer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Rate Manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Alternate Rate Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14User Paths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15National Provider Identifier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15EASYGroup™ Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Hardware/Software Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Chapter 3: Installation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18General Description of Program Files. . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Installing the Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Default Directory Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Testing the SNF Web Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 4: Integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Creating the SNF Rate Files. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Integrating the SNF Rate Files . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Configuring the FileReplace Web Service . . . . . . . . . . . . . . . . . . . . . . . . 30Preparing the Input Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Handling the Return Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Data Formatting Conventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Integrating the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Enabling Enhanced Web Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Chapter 5: Price Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46Price Only Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Price Only Pricer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Chapter 6: GroupPrice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50GroupPrice Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51GroupPrice Optimizer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52GroupPrice Grouper Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53GroupPrice Pricer Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Chapter 7: EditGroupPrice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56EditGroupPrice Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57EditGroupPrice Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Chapter 8: OCEEdit & OCEEditMessages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 OCEEdit & OCEMessages Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . 71OCEEdit Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72OCEEDITMessage Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Chapter 9: OCEErrorSummary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91OCEErrorSummary Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92OCEErrorSummary Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

tum | www.optum.com April 2, 2020

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Chapter 10: GetGroupPriceRules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99GetGroupPriceRules Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100GetGroupPriceRules Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Chapter 11: GetPayerList . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104GetPayerList Requests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105GetPayerList Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Chapter 12: GetTaxonomyList . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107GetTaxonomyList Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108GetTaxonomyList Responses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Chapter 13: Shared Input Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Patient_Claim_Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Edit_Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Diagnosis_Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Line_Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Paths [ezg_paths] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120Optimizer_Return_Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Chapter 14: FileReplace Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123ReplaceFiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Query . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Chapter 15: SNF Web Services Label Data File . . . . . . . . . . . . . . . . . . . . . . . 125File Layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Description of snfmsg Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131


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1 Overview

ECM Pro™ is an Enterprise Content Management (ECM) system for simplifying the complexities of Coding, Compliance, and Reimbursement Management (CCRM). With the multitude of regulatory content and its disparate and off-cycle release schedules, ECM Pro™ provides a valuable function by removing the heavy lifting associated with remaining current.

Through standard ECM practices, ECM Pro™:

• Aggregates content from multiple sources (CMS, AMA, Carriers, etc.)

• Syndicates content into reusable components such as technology components, online references, and publications

Deploys content in standards-based web services components, hyper linked references (APC Assistant™, www.optum.com, Coding Clinic, CDGs, and CPT Assistant™) and other online publications.

1.1 About OptumOptum is a health services business dedicated to making the health system work better for everyone. At Optum, we help modernize the health ecosystem, by bringing interoperable and connected technology, real-time information, streamlined administration and managed compliance, risk, and costs.

1.2 Contact Us

1.2.1 Corporate AddressOptum11000 Optum CircleEden Prairie, MN. 55344T 1 + (888) 445-8745www.optum.com

1.2.2 Need Assistance? Contact Optum Client ServicesWe welcome you as a valued client. Please contact Optum Client Services using one of the methods detailed below.

When opening a ticket with Optum Client Services you will be issued a ticket number. These ticket numbers correlate to individual issues. If you are experiencing multiple issues, it is recommended that you obtain individual ticket numbers.

When calling Optum Client Services regarding a previously opened ticket, have your ticket number available. If you misplaced or did not receive a ticket number, please ask the technician to provide it to you.


http://www.optuminsight.com

http://www.optum.com

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Optum Client Services Phone: 800-999-DRGS (3747)

1. Calls are answered in the order that they are received. If there is a high call volume, calls are held in a queue until a technician becomes available.

2. Calls classified as an industry expert category (i.e., case and reimbursement, logic encoder, etc.) will be escalated to Optum experts.

3. Technicians are available 24/7.

After selecting Option 6 for Technical Support you will hear the following choices:

Email: Optum Client.Services

1. Include name and number and detailed description of product issue.

2. Response time to email is generally within a few business hours.

3. Service technician has ability to do prior research before calling back.

1.2.3 Optum Client PortalFor access to announcements, user documentation, notices, release schedules, and much more please visit the Optum Client Portal.

1.2.4 Found an Error in This User’s Guide?Please feel free to contact our EASYGroup™ Documentation Team with any errors you may have found within this user’s guide:

EASYGroup_Documentation

We welcome feedback from our clients.

Table 1-1: Technical Support Options

Option # Description

Option 1 For password reset, login issues, or expiration error.

Option 2 For all other issues.


mailto:[email protected]

mailto:[email protected]

https://optum.secure.force.com/CustomerPortal

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2 Introduction

This manual provides the technical information needed to install and use the ECM Pro™ SNF Web Service. Using this web service, a developer writing an application on any web-accessible platform can request RUG (Resource Utilization Group) reading, and RUG-based pricing.

The ECM Pro™ SNF Web Service is comprised of a series of methods written in Microsoft® C# and distributed to run on the Microsoft® .NET platform and on Internet Information Server (IIS). Each method will accept the input data and reformat for submission to the EASYGroup™ Optimizer, which invokes the appropriate EASYGroup™ grouping and pricing components. Return data from the Optimizer is parsed and relevant fields are returned to the requesting operation.

This chapter includes the following sections:

• Prior Knowledge Assumed

• The SNF Web Service

• The Optimizer

• Rate Manager

• Alternate Rate Path

• User Paths

• National Provider Identifier

• EASYGroup™ Components

• Hardware/Software Requirements


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2.1 Prior Knowledge AssumedThis manual assumes that the reader has a functional understanding of the following:

• Web services architecture

• SOAP, XML, HTML

• EASYGroup™ components and component architecture

The user’s guide also assumes familiarity with standard medical coding and prospective payment terminology. For a more comprehensive review of specific inpatient functions, please refer to the EASYGroup™ User’s Guide.

2.2 The SNF Web ServiceThe operations (methods) that comprise the SNF Web Service are:

• GroupPrice Method (refer to Chapter 6)

• EditGroupPrice Method (refer to Chapter 7)

• GetGroupPriceRules Method (refer to Chapter 10)

• Price Method (refer to Chapter 5)

• OCE Editing (refer to Chapter 8)

• GetPayerList Method (refer to Chapter 11)

• GetTaxonomyList (refer to Chapter 12)

• FileReplace Web Service (refer to Chapter 14)

Input and output requirements for each operation are listed in the associated ASMX file (snf.asmx) (supplied with your distribution) using Web Service Definition Language (WSDL). These requirements are also defined in separate sections within this manual.

2.2.1 Overview of GroupPrice MethodThe GroupPrice method of the SNF Web Service implements the Optimizer combined group/price option for skilled nursing processing. This method integrates RUG reading and RUG-based pricing within a single request. Input data should include basic demographics, the reimbursement effective date, and variably occurring ICD-10-CM diagnosis codes, plus claim data (refer to the note below). Returned information includes RUG, total expected reimbursement, and additional grouping and pricing variables.

NoteThe RUG Reader searches the claim line for Revenue Code 0022 (Skilled Nursing Facility Prospective Payment System) and will extract the RUG from the HIPPS (Health Insurance Prospective Payment System) code on that line. Refer to Chapter 6 for more details.


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This operation invokes the Optimizer which reads the input patient or claim data, and identifies the facility, payer, and admit/discharge dates. Using this information, it reads the rate file data from Rate Manager (refer to the Rate Manager section below), identifies which Grouper or Reader type and version, and which Pricer to invoke. It then invokes the appropriate Grouper or Reader, passes the RUG into the Pricer, calculates reimbursement (again using the rate file data), and returns the combined results to the user. The GroupPrice request and return fields are described in Chapter 6.

2.2.2 Overview of EditGroupPrice MethodThe EditGroupPrice operation, available under the SNF Web Service, implements the Optimizer combined Edit/Group/Price option for SNF Part B coding and editing, based on Medicare’s integrated Outpatient Code Editor (I/ OCE). The SNF edits apply only to claims with a bill type of 022x or 023x. If licensed, the EASYGroup™ Ambulatory Code Editor™ (ACE) will apply the appropriate set of edits to SNF Part B claims according to Medicare guidelines. When called, ACE will audit SNF claims for coding errors, and will issue either line or claim-level Return Codes, depending on the severity of the edits contained on the claim.

Input data includes basic demographics, the reimbursement effective date, and claim data plus variably occurring ICD-9-CM diagnoses and claim line data, including HIPPS codes and modifiers, Revenue Codes, service dates, and units. Returned information includes claim-level editing and pricing results, variably occurring diagnosis edit results, variably occurring line-level edits, and pricing fields. For additional information on SNF editing, RUG assignment, and pricing functionality, please refer to the EASYGroup™ User’s Guide.

This operation utilizes the ACE to apply the OCE edits, the RUG Reader to return the appropriate grouping classification, and the SNF Pricer to calculate expected reimbursement. The EditGroupPrice request and return fields are described in Chapter 7.

2.2.3 Overview of GetGroupPriceRules MethodThe GetGroupPriceRules method of the SNF Web Service provides access to the grouping and pricing rules stored in the Rate Manager data files and referenced by the GroupPrice method during the reading of RUGs and the calculation of reimbursement. This operation invokes the EASYGroup™ Optimizer control programs to read the rate file data from the Rate Manager. Input data includes facility ID, payer ID, reimbursement effective date, admission date, and discharge date. Returned information includes the effective date of the most recent set of processing rules, along with the specified Grouper or Reader type and version, and Pricer type.

The GetGroupPriceRules request and return fields are described in Chapter 10.


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2.2.4 Overview of Price MethodThe Price method of the SNF Web Service implements the Optimizer PriceOnly option for skilled nursing processing. This method integrates RUG-based pricing within a single request. Input data should include basic demographic and variably occurring ICD-10-CM diagnosis codes, the reimbursement effective date, RUG(s), and claim data. Returned information includes total expected reimbursement and additional pricing variables.

This operation invokes the Optimizer which reads the input patient or claim data, and identifies the facility, payer, and admit/discharge dates. Using this information, it reads the rate file data from Rate Manager (refer to the Rate Manager section below), and identifies which Pricer to invoke. It then calculates reimbursement (again using the rate file data), and returns the results to the user.

The Price request and return fields are described in Chapter 5.

2.2.5 Overview of OCE EditingThese operations implement Outpatient Code Editor (OCE) edits. They are designed for SNF Part B cases only. Input data includes basic demographic data, the reimbursement effective date, ICD-10-CM diagnosis codes, and variably occurring sets of claim line-level information. Returned information includes claim-level (demographic) errors, diagnosis (ICD-10-CM diagnosis code) errors, and claim line-level errors. The returned results occur once for the demographic data and variably based on the size of the input diagnosis code and claim line arrays. Based on the method requested, an additional set of returned data (procedure code pairs) may also be returned.

The SNF Web Service offers three methods for invoking the outpatient edits:

1. OCEEdit: Implements OCE edits. Requires demographic data, the reimbursement effective date, ICD-9-CM diagnosis codes, and claim line data as input, and returns errors as coded fields. It is designed for higher volume processing, or if editing results will be stored in a database or as a data analysis package.

2. OCEEditMessages: This method works the same as OCEEdit except that the errors are returned as text messages rather than as coded fields. It is designed for individual claim editing where the results are preferred in explanatory text rather than coded output.

3. OCEErrorSummary: This method works the same as OCEEdit except that the error counts are returned for each edit in the OCEEdit method.

For additional information on the editing functionality, please refer to the EASYGroup™ User’s Guide. These operations utilize ACE to apply the OCE edits. Editing request and return fields are described in the following sections:

• OCE Edits (refer to Chapter E)

• OCE Edit Messages (refer to Chapter 8)


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• OCE Error Summary (refer to Chapter 9)

2.2.6 Overview of GetPayerList MethodThe GetPayerList method provides a list of payers set up for a specified facility in the Rate Manager files. Input is a facility identifier, and output is a list of payer identifiers and descriptions.

The GetPayerList request and return fields are described in Chapter 11.

2.2.7 Overview of GetTaxonomyListThe GetTaxonomyList operation provides a list of taxonomy codes for a specified facility. It also reads the Rate Manager rate file data. Input is a National Provider Identifier (NPI) and output is a list of taxonomy codes.

The GetTaxonomyList request and return fields are described in Chapter 12.

2.2.8 Overview of the FileReplace Web ServiceThe FileReplace Web Service, available within the SNF Web Service, allows users to replace rate files without having to reset the Internet Information Server (IIS). Unlike other ECM Pro™ Web Services the FileReplace Web Service possesses a User Interface (UI), for ease of use and to foster an enhanced user experience.

Figure 2-1. FileReplace User Interface


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For further information on the FileReplace UI and instructions on how to configure the FileReplace Web Service please refer to the Integration section.

The FileReplace Web Service is utilized by the following three methods:

• ReplaceFiles - Replaces the files found in the New directory. This is the primary method of the FileReplace Web Service and is the method that will relocate all rate files the user wishes to replace.

• Query - Retrieves the file information for the files currently being used by the Optimizer (i.e., the IOCONTROL control program). This method will indicate which files are currently open and in use by the Optimizer. Files set to zero (0) will alert the user that the file is currently active.

• Search - Retrieves the file information for the files located in the New directory. This method indicates which files will be replaced by the FileReplace Web Service. The user will be able to see what files are out on the Server without connecting to the Server.

NoteFor a for further details on the layouts of the FileReplace Web Service methods please refer to FileReplace Structures section.

The FileReplace Web Service Structure is illustrated below.


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2.3 The OptimizerThe SNF Web Service uses a control program, the Optimizer (optcntl) which allows the web service methods to communicate with the various Optum EASYGroup™ components. The Optimizer invokes appropriate grouping, pricing, and editing logic based on a set of user-defined rules. The Optimizer works with these rules and an integrated collection of EASYGroup™ components to provide customized grouping, pricing, and modeling functions. The Grouper/Reader and Pricer programs and associated data files are licensed individually and are provided on separate distributions. The Optimizer is described more fully in the EASYGroup™ User’s Guide.

The user-defined rules for editing and pricing are specific to a facility (i.e., hospital or provider) and period of time. These rules are stored in files which also contain data to drive the pricing functions.

2.4 Rate ManagerTo calculate expected reimbursement, the Optimizer and the EASYGroup™ Pricer(s) reference external data files that contain processing rules for various facilities, payers, and effective dates. For outpatient pricing using the SNF Web Service, pricing rules are stored in up to three data files, a Hospital Rate Calculator File (medsnf.dat), a Configuration File (config.dat), and when applicable, an outpatient rate data file (ratesnf.dat). These files are created using a data export feature in Rate Manager, which is installed separately, but included as part of the SNF Web Service distribution. Procedures for installing and using Rate Manager are detailed in the Rate Manager User’s Guide and the Rate Manager Installation Guide.

Rate Manager provides a user-friendly front-end to collect, edit, and maintain the facility and payer-specific processing rules and variables required by the SNF Web Service pricing methods. This pricing data is stored in the medsnf.dat, paysnf.dat, and config.dat files for outpatient processing. An additional file (ratesnf.dat), with specific rate data such as weights and payment rates may be required for pricing. These files are managed internally in SQL, but are exported as flat ASCII files for use with the SNF Web Service, which uses memory-mapped data files for faster access and retrieval.

2.5 Alternate Rate PathThe SNF Web Service allows the customer to reference an alternate set of rate data, which can reside in a directory other than the default rate data directory, which is generally C:\\inetpub\wwwroot\HSS\data. Each method requiring the use of rate data (that is, the data files that are maintained using Rate Manager, referenced above) is available in two formats: (1) a standard/historical method, which supports the use of the default rate data only, and (2) a new alternate path method, which is the same as the base/historical


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method, but includes a single additional input field, the fully qualified path to the desired alternate rate data.

NotePlease note that the length of the path environment variable must be within the limits of the operating system being used; this can vary from 1024 and 2048 characters (depending on the version and service pack).

2.6 User PathsWhen defined, the User Path overrides the System Path. This path should be set when EASYGroup™ component files (e.g., aceedit.dat, etc.) reside in a location that was not defined during the installation or within the System Path. The EASYGroup™ components will utilize the component files residing at this User Path location. The following methods support this input (in the user_path field):

2.7 National Provider IdentifierDuring the transition to National Provider Identifier (NPI), the SNF Web Service will support the user of hospital rate data identified by the old, legacy provider identifiers or the National Provider Identifier (NPI) and associated taxonomy code. If the incoming claim contains both old and new hospital identifiers, both can be submitted to the SNF Web Service. The underlying rate retrieval programs will attempt to locate rates first using the NPI and any taxonomy code, along with the first nine (9) bytes of the payer code. If this lookup fails, the second attempt will use the legacy hospital identifier along with the full payer code.

2.8 EASYGroup™ ComponentsThe SNF Web Service invokes the Optimizer, which in turn invokes the appropriate EASYGroup™ components. These are separately licensed modules that implement RUG reading (Grouper/Reader) and reimbursement calculations (Pricers), ICD-10-CM/PCS code translation (Mappers) and data editing (Editors). Each of the various EASYGroup™ components are managed by the Optimizer.

The relationship between the SNF Web Service methods and EASYGroup™ components are as follows:

• GroupPrice: This method utilizes the SNF Pricer, SNF RUG Reader, and the rate data files from Rate Manager.

Methods Supported

EditGroupPrice OCEEditMessages

OCEEdit OCEErrorSummary


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• EditGroupPrice: This method utilizes the SNF Pricer and ACE, with the Outpatient Code Editor (OCE)/Correct Coding Initiative (CCI) option. The CCI editing option is necessary due to the CCI structures that are utilized to return data for certain OCE edits.

• GetGroupPriceRules: This method utilizes the EASYGroup™ Optimizer control programs and the rate data files from Rate Manager.

• Price: This method utilizes the SNF Pricer, and the rate data files from Rate Manager.

• OCEEdit, OCEEditMessages, and OCEErrorSummary: These methods utilize the ACE with the OCE/CCI option.

• GetPayerList: This method utilizes the EASYGroup™ Optimizer control programs and the rate data files from Rate Manager.

• GetTaxonomyList: These methods utilize the EASYGroup™ Optimizer control programs and the rate data files from Rate Manager.

2.9 Hardware/Software RequirementsTo use the ECM Pro™ SNF Web Service, your operating environment must meet or exceed the following hardware and software requirements:

• Hardware

- Processor: 1GHz Pentium or equivalent (Minimum); 2.4GHz Dual Pentium (Recommended)

- RAM: 1GB (Minimum); 2GB or higher (Recommended)

- Hard Disk: 5 GB available space (Minimum); 10 GB available space (Recommended)

- Network Adapter: 100BASE-T (Minimum); 1000BASE-T (Recommended)

• Software

- Microsoft® Windows® Server 2008 (including R2) Service Pack 2 (SP2), 32-bit and 64-bit

- Microsoft® Windows® Server 2012 (including R2) Service Pack 2 (SP2), 64-bit

- Microsoft® Windows® Server 2016

- Microsoft® Windows® 7 Service Pack 1 (SP1), 64-bit

- Microsoft® .NET Framework V3.5 (Minimum); Microsoft® .NET Framework V4.6 Service Pack 1 (Recommended)

- Internet Information Services (IIS) V7.0, 7.5, 8.0, 8.5, and 10.0


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NoteFor further information on installation requirements please refer to the EASYGroup™ Installation Guide.


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3 Installation


• General Description of Program Files

• Installing the Program

• Default Directory Structure

• Testing the SNF Web Service


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3.1 General Description of Program FilesThe SNF Web Service is comprised of a series of methods written in Microsoft® C# and distributed to run on the Microsoft® .NET platform and on Internet Information Server (IIS). These methods are distributed on a single distribution and loaded locally using an automated installation program. The EASYGroup™ Optimizer is included in the SNF Web Service distribution.

The individually licensed EASYGroup™ components (Groupers/Readers, Pricers, Editors, etc.) are distributed on separate distributions. These components are also loaded (after installing the SNF Web Service) using automated installation programs.

3.2 Installing the ProgramInstalling the SNF Web Service consists of the following tasks:

1. Installing the SNF Web Service.

2. Installing all licensed EASYGroup™ Grouping, Pricing, and Editing components.

3. If you are using any pricing methods, installing Rate Manager.

Details on completing these tasks are provided below.

3.2.1 Installing SNF Web ServiceThe SNF Web Service installer (WS_SNF_Vnnnn.nn.exe) will take users through the installation process and will prompt users to select a destination directory/folder for the methods (.asmx), the web service description file (.wsdl), the Optimizer (optcntl), and associated components.

NoteFor new installations, the SNF Web Service may be installed on drives other than the C: drive. Updates to previous installations, will re-install the SNF Web Service to the formerly identified location.

The steps below detail this installation process:

1. Download the SNF Web Service from the Optum Update Wizard or the Optum Client Portal. Double-click on the WS_SNF_Vnnnn.nn.exe file to invoke the installation sequence.

2. Install Shield will begin to prepare the wizard for the web service installation.

3. When the Install Shield is ready, the following Welcome screen will appear.



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Figure 3-1. Welcome Screen

4. Terminate the setup at anytime during the installation process by clicking on the Cancel button. To continue, click on the Next button to view the License Agreement.


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Figure 3-2. License Agreement Screen

5. To return to a previous step, simply click on the Back button at any time. Read the License Agreement completely. To continue with the setup process, select the I accept the license agreement, required to continue this install radio button and then select Next to agree with the terms specified.

6. Next, the Choose Destination Location screen will appear. To select a location other than the C: drive select the Browse button. Select Next when finished.

NoteThe Choose Destination Location screen will be displayed during new installations only.


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Figure 3-3. Choose Destination Location Screen

7. The Setup Status screen will now appear indicating the progress of the web service installation.


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Figure 3-4. Setup Status Screen: Installing Web Service Files

8. After installing the web service files, the Install Shield will then load the Microsoft® .NET framework which is required to run .NET-based web applications or services.


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Figure 3-5. Setup Status Screen: Configuring Virtual Directories

9. When the .NET framework has finished loading, the following screen will appear. Click on the Finish button to complete the installation/ setup process.


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Figure 3-6. InstallShield Wizard Complete Screen

NoteRefer to the Default Directory Structure section for details on the locations of all web service files.

3.2.2 Installing the Associated EASYGroup™ Component(s)Associated EASYGroup™ components are stored on separate distributions. Follow the steps below for each EASYGroup™ component to be installed.

NoteAll associated EASYGroup™ component distributions MUST BE installed on the machine that has the SNF Web Service installation.

1. Download the necessary EASYGroup™ components from the Optum Update Wizard or the Optum Client Portal.

2. Follow the on-screen prompts to complete the EASYGroup™ Server installation. The setup program will install the appropriate executables (*.dll) and data files in the folder containing the SNF Web Service.


https://optum.secure.force.com/CustomerPortal/home/home.jsp

https://optum.secure.force.com/CustomerPortal/home/home.jsp

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3. When the installation process is complete, click Finish.

3.2.3 Installing Rate ManagerRate Manager is supplied on a separate distribution to provide a means of defining and creating the payment systems that are used by the SNF Web Service.

1. Download Rate Manager from the Optum Update Wizard or from the Optum Client Portal.

2. Follow the on-screen prompts to complete the installation.

NoteIt is not necessary to load the Rate Manager program on the same machine that has the SNF Web Service installation. Typically, payment system files are copied to the SNF Web Service working directory after they have been created.

3. When the installation process is complete, click Finish.

4. Follow the instructions in the Rate Manager User’s Guide and Rate Manager Installation Guide to create the necessary payment systems, and then copy them to the working environment per the instructions detailed in Chapter 4.

NoteFor additional installation procedures for Rate Manager please refer to the Rate Manager Installation Guide.

3.3 Default Directory StructureThe SNF Web Service components will be installed in the following directories (by default):

NoteUsers can select other install locations during the installation process.

C:\Inetpub\wwwroot\HSS\...

\Data: This sub-directory contains all the data files required by the EASYGroup™ components including the data files built and exported by Rate Manager.

\Optimizer: This sub-directory contains the EASYGroup™ Optimizer and all the EASYGroup™ component executables.

\SNF: This sub-directory contains all of the SNF methods.

\FileReplace: This sub-directory contains the FileReplace Web Service.



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\FileReplaceHelper: This sub-directory contains the FileReplace Helper .dll files which can be useful if multiple application pools are being utilized.

\FileReplaceUI: This sub-directory contains the files needed for the FileReplace Web Service User Interface (UI).

C:\Ratemgr: Rate Manager is installed in this directory.

NoteThe three directories listed above for the FileReplace Web Service will be assigned to the same application pool where the user’s current ECM Pro™ SNF Web Service is configured.

3.4 Testing the SNF Web ServiceThe SNF Web Service distribution contains sample testing programs which accept patient data as input, and produces a basic listing of output fields. These programs can be used to validate your installation. The installation process will install all testing programs to the following directory path:

C:\Inetpub\wwwroot\HSS\Testers

Before any testing, make sure to install the appropriate EASYGroup™ components, and load any Rate Manager data files into the appropriate web services Data directory, as specified above.

For SNF testing, there is a single tester available.

//servername/HSS/Testers/SNFTest/Test.aspx

To test the GetGroupPriceRules or GetPayerList methods, invoke the method directly (without use of a Tester, //servername/hss/snf/snf.asmx). If the Rate Manager rate files are loaded correctly, and if the facility and paysource identifiers and a service date that matches the rules in the rate files are supplied, the GetGroupPriceRules method will return the processing rules for the applicable rate record. The GetPayerList method will return the payer numbers/names for the applicable facility. If input fields are incorrectly specified (that is, data that will not match the rate data), or if the Rate Manager data files are not loaded properly, one of the following messages will be generated indicating that the applicable rate record could not be retrieved:

return_code: 70 Configuration record error

return_code: 71 Cannot retrieve rate record in paysnf.dat

return_code: 72 Cannot retrieve rate record in medsnf.dat

return_code: 81 Cannot find paysnf.dat

return_code: 82 Cannot find medsnf.dat


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3.4.1 SNFTest ProgramTo run this sample tester, navigate to the following web address:

//servername/HSS/Testers/SNFTest/Test.aspx

Note“Servername” represents the name of the server on which the web service was installed.

To use this testing program to validate EditGroupPrice you must:

• Install the Ambulatory Code Editor™ (ACE)

• Install the SNF Pricer

• Install the SNF RUG Reader

• Create a set of SNF rate files (config.dat, paysnf.dat, medsnf.dat, and ratesnf.dat) which match your input test data

If no EASYGroup™ components have been installed, the web service installation can still be tested. Check for the errors from the Tester.

3.4.2 Using the Test Program(s)If the calling program has been integrated with the web service(s), you can use these interactive testing programs to assist with validating your integration:

1. Create test cases, enter the patient claim data into the calling program, and invoke the web service.

2. Open the appropriate *.aspx file for the method(s) to be tested. Input the same claim data into the fields provided, and invoke the tester to provide results.

3. Compare the results from the tester to the results from the calling programs integration. Results should match exactly.


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4 Integration

After installing the SNF Web Service and any associated EASYGroup™ components, the calling application will need to be modified to invoke this service. Typically, integration of the SNF Web Service with a host application involves the following steps:

1. Create grouping/pricing rate files (using Rate Manager).

2. Move rate files to working environment.

3. Assemble the required input data.

4. Determine how to handle the return data.

5. Create the appropriate calls to the web service.


• Creating the SNF Rate Files

• Integrating the SNF Rate Files

• Configuring the FileReplace Web Service

• Preparing the Input Data

• Handling the Return Data

• Data Formatting Conventions

• Integrating the Service

• Enabling Enhanced Web Security


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4.1 Creating the SNF Rate FilesUse Rate Manager to create the following rate files:

• paysnf.dat (Payer File)

• medsnf.dat (Hospital Rate Calculator File)

• ratesnf.dat (weights and means file)

• config.dat (Configuration File (including grouping, pricing, and editing rules))

Procedures for installing and using Rate Manager, and for exporting the rate files in the C/Windows® Optimizer format (medsnf.dat, paysnf.dat, config.dat, and ratesnf.dat) that is required for use with web services, are detailed in the Rate Manager User’s Guide and Rate Manager Installation Guide.

4.2 Integrating the SNF Rate FilesAfter creating the rate files, copy them to the SNF Web Service Data directory on the designated web server. When default directories are specified during the installation process, this directory will be:

C:\Inetpub\wwwroot\HSS\Data

4.3 Configuring the FileReplace Web ServiceThe FileReplace Web Service can be used to allow the SNF rate files to be replaced on the web server without performing an IIS reset. Use of the FileReplace Web Service is optional. To use this Web Service, complete the following steps:

1. Manually create two folders named: New and Old in the \\inetpub\wwwroot\hss\Data directory (or other user-selected location where rate files are stored).

NoteThe above step only needs to be completed the first time that the FileReplace Web Service is utilized.

2. Copy the updated rate files into the New folder.

3. Access the FileReplace Web Service User Interface (UI) available at this location: http://localhost/HSS/FileReplaceUI/FileReplaceUI.aspx.


http://localhost/HSS/FileReplaceUI/FileReplaceUI.aspx

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Figure 4-1. FileReplace User Interface (UI)

4. Enter or Select the directory that contains the currently in-use rate files

that you would like to replace, by selecting the Browse button next to the Rate Path field or by using the Search Tree on the right-hand side of the screen.


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Figure 4-2. Search Tree

Figure 4-3. Enter Rate Path

5. Once a directory is selected, enter any notes in the Notes section that you would like to be saved in the FileReplace.log file. Notes will appear as shown below in the FileReplace.log file.

Figure 4-4. Example of Notes Shown in FileReplace.log File

6. Next, select the File Replace button; which will invoke the FileReplace Web Service.

7. The updated rate files will then be moved from the New directory into the directory specified on page 27.

8. The replaced files will be moved into the Old directory to preserve rate history.

9. The logging information will be displayed in the File Replace Log section of the screen. An example is shown below.


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Figure 4-5. File Replace Log Screen

10. A FileReplace.log file will also be created in the root Data directory.


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Figure 4-6. Example of FileReplace.log File

11. Once the All files replaced! message is displayed, the updated rate files are now available for claims processing.


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Figure 4-7. All Files Replaced Message in UI

4.4 Preparing the Input DataSkilled nursing processing typically requires basic demographic and claim-related data including patient age or date of birth, patient sex, admission and discharge dates, discharge disposition, and total covered charges, and in some cases the reimbursement effective date. Users must also submit the HIPPS (Health Insurance Prospective Payment System) code containing the RUG on the service line. Refer to the EASYGroup™ User’s Guide for more details. Finally, all of the ICD-10-CM diagnosis codes available for the claim should be submitted to the service for accurate pricing.

Correct RUG-based processing requires that all skilled nursing services provided to the same patient during the hospital episode be included on a single claim. Split or interim bills, or multiple bills with overlapping claim spans, may not be priced correctly.

Typically, all the required data elements are present on a standard skilled nursing claim.

4.5 Handling the Return DataThe returned information from the SNF Web Service will depend on the method invoked. Typically, the results may include RUG and pricing information. This information must be stored in data files or presented to the user via screens or reports.


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4.6 Data Formatting ConventionsThe following conventions are used for input and returned parameters for all ECM Pro™ Web Services:

4.6.1 Input Fields

NoteFor all input fields, all leading and trailing spaces are removed prior to any other action.

• Text. Any leading or trailing spaces will be removed. Maximum length provided below.

• Fixed length text. Text string, leading spaces removed, required length provided below. If required length is not provided, spaces will be added on the right.

• Numeric text. Treat as fixed length text. Leading zeros required. Required length provided below. All case-mix indicators (DRG, MDC, APC, APG, CMG) should be treated as numeric text. If required length is not provided, zeros will be added on the left.

• Integers. Numeric fields without decimals. Leading zeros not required. Maximum size provided below.

• Dollars. Leading zeros not required. Decimal not required. If no decimal is supplied, input is assumed to be in whole dollars. If decimal is supplied, zeros will be added on the right if necessary (e.g. 1.00, 1.50). Maximum size for all dollar fields is 9(8).99.

• Decimals. Leading zeros not required. Exact number of digits after the decimal is specified below. Maximum number of digits before the decimal is specified below. Decimal not required. If no decimal is supplied, decimal will be assumed based on field specifications below. If decimal is supplied, zeros will be added on the right if necessary.

• ICD-9-CM codes. Left-justified. Decimals not required but may be submitted. Maximum length is six bytes.

• HCPCS or HIPPS codes. Five alphanumeric characters, no decimals.

• Dates. Eight digits, yyyymmdd format.

• Boolean. Numeric switch variable, 1=yes/true, 0=no/false.

4.6.2 Output Fields• Text. Any leading or trailing spaces will be removed. Maximum length

provided below. A blank result will be returned as an empty string.

• Fixed length text. Text string, leading spaces removed.


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• Numeric text. Treat as fixed length text. Leading zeros included. All case-mix indicators (DRG, MDC, APC, APG, CMG) will be treated as numeric text.

• Integers. Numeric fields without decimals. Leading zeros not included. Maximum size provided below. All error counts will be treated as integers.

• Dollars. The web service pricing operations will return dollar fields (marked here with a $$) without leading zeros, with explicit decimals, followed by two digits including any trailing zeros (e.g. “125.62” or “12.50” or “1250.00”), and zero dollars will be returned as “0.00”. Maximum size for all dollar fields is 9(8).99.

• Decimals. Leading zeros not required. Decimal will be included, plus the exact number of digits after the decimal, and up to the maximum number of digits before the decimal, as specified below.

• ICD-9-CM codes. Left justified. Decimals will be supplied. Maximum length is six bytes.

• HCPCS or HIPPS codes. Five alphanumeric characters, no decimals.

• Error codes. These will be returned as fixed length numeric fields. Required length is supplied below.

• Error messages. These will be returned as text fields. Format of error messages includes the error code, a space, plus a text description. Error codes will be numeric text fields, with a required length specified below. For the descriptions, no maximum length is specified, but error descriptions are supplied below.

• Repeating error codes. For error arrays (claim level, admit diagnosis, diagnosis, and procedure-related errors), only errors (non-zero entries) will be returned. The number of errors returned will equal the supplied error count. (For example, claim level errors can occur up to 15 times. If the claim level error count is 3, the returned data will include 3 non-zero entries but will not include 12 entries of zeros.

• Repeating error messages. For error message arrays (claim level, admit diagnosis, diagnosis, and procedure-related errors), only errors (non-blank entries) will be returned. The number of errors returned will equal the supplied error count. (For example, claim level errors can occur up to 15 times. If the claim level error count is 3, the returned data will include 3 messages only).

• Negative numeric or decimal fields. These will be returned with an explicit negative sign (e.g. -450.25).


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4.7 Integrating the ServiceIntegration of ECM Pro™ Web Services into a client application generally consists of the following steps. Note that this user’s guide assumes familiarity with the architecture and use of web services.

1. Discovering and Gathering Information about the Service. Browse to //servername/HSS/SNF/SNF.asmx. The HTML Description Page is displayed. This page provides the information required to request the web service and test the methods in the service. Select the Service Description on the page or go to //servername/HSS/SNF/SNF.asmx?WSDL (with the appropriate address) using a web browser. An XML formatted file is displayed which describes the mechanism for providing the service to any client using SOAP or HTTP.

2. Generating a Proxy Class of the Service and Using the Created Proxy Class to Invoke an Available Service. To serialize and de-serialize SOAP messages for various transport protocols, create proxy or “stub” objects, using web application development tools that are specific to the appropriate application development and run-time environment.

3. Writing an Interface for the Web Service. Creating an instance of the generated proxy class provides access to all the methods of the ECM Pro™ SNF Web Service. The appropriate arguments have to be provided for each chosen operation, and each desired operation must be invoked. The results of the requested operation are returned to the client application and become available for further processing.


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4.8 Enabling Enhanced Web SecurityIf you wish to enable Internet Information Services (IIS) Digest and Windows Authentication for the SNF Web Services and Web Services Tester you may do so by following the below instructions. Once these features are enabled, you will be prompted to log-in with a user name and password when launching the Web Services Tester. Once logged in, the same credentials will pass to the SNF Web Service. The Windows Authentication feature will allow you to be connected immediately to the Web Services Tester if you are already logged into Microsoft® Windows®.

NoteThese instructions are optional, but Optum strongly suggests that they are implemented to fully secure the Tester.

1. Navigate to Start>Control Panel> Program and Features.

2. Select Turn Windows features on or off from the menu on the left-hand side of the screen.

Figure 4-8. Program and Features Screen

3. You should now see the Windows Features screen. In this screen, select the check box next to Internet Information Services (IIS) and expand the options, as shown below.


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Figure 4-9. Windows Features Screen

4. Check the boxes next to Basic Authentication, Digest Authentication, and Windows Authentication (if desired).

5. Select OK when complete.

6. Open the IIS Manager: Start>Control Panel>Administrative Tools>Internet Information Services (IIS).

7. Once you have the IIS Manager screen open, select Authentication from the main window.


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Figure 4-10. Authentication Option

8. You should now see the Authentication window.

Figure 4-11. Enable Digest Authentication for the Web Services Tester


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9. In this window enable Digest Authentication for the Web Services Tester as shown above.

10. Do the same for the SNF Web Service, as shown below.

Figure 4-12. Enable Digest Authentication for the SNF Web Services

11. Once Digest Authentication has been enabled for both the Web Services Tester and the SNF Web Service, you will be prompted for a user name and password once the Web Services Tester is launched.


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Figure 4-13. Log-in Dialog Box

12. Next, navigate back to the Authentication window and enable Windows Authentication (if desired) for the SNF Web Service, as shown below.


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Figure 4-14. Enable Windows Authentication for the SNF Web Services

13. Do the same for the Web Services Tester, as shown below.


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Figure 4-15. Enable Windows Authentication for the Web Services Tester

14. Once the above steps are completed, you will immediately be connected once you launch the Web Services Tester if you are already logged into Microsoft® Windows®. Your credentials will automatically pass from the Web Service Tester to the SNF Web Service.

NoteOnce the above features have been enabled you will need to re-start Windows® for them to take affect.


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5 Price Only

NoteAlthough most fields are designated as string variables, select fields are considered arrays of string variables, and are identified by the [ ] symbol at the end of the variable name. Also note that the variable formats listed in this chapter are the COBOL-type definitions which identify the maximum field length or precision required by the EASYGroup™ components. For web service requests, please conform to standard web service parameter passing conventions, the field definitions in the ASMX and WSDL files, and the input and output parameter data formatting conventions described in Chapter 4.


• Price Only Request

• Price Only Pricer Responses


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5.1 Price Only RequestThe GroupPrice method has the following input structures:

• Patient_Claim_Data (refer to Table 13-1 on page 110)

• Diagnosis_Data (refer to Table 13-3 on page 118)

• Line_Data (refer to Table 13-4 on page 118)

Other input:

• Alternate Rate Path (rate_path)

Table 5-1: Alternate_Rate_Path

Field Description Format Variable Name Notes

Alternate Rate Path string rate_path Optional specification of directory containing alternate rate data. Supply the fully qualified rate path including drive letter.


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5.2 Price Only Pricer Responses

Table 5-2: PriceClaimResults


Pricer Return Code X(2) pricer_return_code 00 = No errors found01 = No hospital rate calculator record03 = Pricer type not licensed21 = Invalid bill type (not 18x, 21x, 22x, or 23x)23 = Service date invalid or out of range25 = Non payment claim 26 = Total units exceed patient’s length of

stay40 = Claim spans calendar year41 = Invalid billing of therapy services62 = Closed or inactive rate record72 = Medsnf record not found74 = No weights81 = Error reading Paysnf file82 = Error reading Medsnf file83 = Error reading Ratesnf file84 = Error reading fee schedule file87 = Program cannot be loaded88 = Initialization error89 = Error allocating memory94 = Invalid fromdate and/or thrudate95 = Parameter passing error

Pricer Type X(2) pricer_type 22 = Medicare SNF

Total Reimbursement 9(8)v9(2) total_reimbursement

Total patient reimbursement.

Total Part A Prospective Payment

9(8)v9(2) PPS_total Total Part A reimbursement.

AIDS Adjustment Factor

9(1)v9(4) aidsfactor Part A, if AIDS diagnosis code is present.

Markup/Discount Factor

9(1)v9(4) markup Optional markup factor.

Total Part B Third-Party Payment

9(8)v9(2) totpay Total reimbursement for this claim minus patient coinsurance.

Total Part BCo-Payment

9(8)v9(2) totcopay Total patient coinsurance for this claim.


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Table 5-3: PriceLineResults


Line Level Return Code

9(2) line_return_code 00 = No errors found01 = No RUG on this claim line02 = No rate available for RUG or HCPCS

code10 = Line item rejection from ACE (Part B

only)13 = Zip code missing or invalid (Part B

only)14 = Revenue Code not covered under

SNF Part B (22X only)28 = No available extended fee schedule

rate35 = Service for reporting purposes only

RUG X(5) payment_RUG Resource Utilization Group.

RUG Rate 9(8)v9(2) RUG_rate Per diem payment rate for RUG.

Adjusted RUG Rate or Fee Schedule Rate

9(8)v9(2) adjusted_RUG_rate

For Part A, adjusted per diem payment rate for RUG. For Part B, fee schedule rate

Part B Third-party Payment

9(8)v9(2) pay Payment for line minus patient coinsurance.

Part B Co-payment 9(8)v9(2) copay Total patient coinsurance for this line.

Total Line Payment 9(8)v9(2) total_line_pay Payment for this line.

Fee Schedule Type X(1) feetype A = Ambulance D = DMEPOSL = LaboratoryM = National RateR = PhysicianT = Therapy service subject to multiple

procedure payment reductionV = Vaccine paid at reasonable costX = Other fee schedule (user-defined)

Variable Per Diem Day Number

9(3) vpd_day_num Represents the first day of each HIPPS line. Used the determine the PT, OT and NTA variable per diem adjustment factors used to determine final payment.

HIPPS Rate 9(8)v9(2) hippsrate Per diem payment rate for each HIPPS code before wage adjustment, but after the VPD and HIV/AIDS adjustments.


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6 GroupPrice



• GroupPrice Request

• GroupPrice Optimizer Responses

• GroupPrice Grouper Responses

• GroupPrice Pricer Responses


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6.1 GroupPrice RequestThe GroupPrice method has the following input structures:




Other input:


Table 6-1: Alternate Rate Path


Alternate Rate Path X(255) rate_path


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6.2 GroupPrice Optimizer Responses

Table 6-2: GroupPrice Optimizer Responses


Optimizer Return Code

NoteThis field is no longer utilized and has been replaced by the Optimizer Return Code field (opt_rtn_code).

9(2) optimizer_return_code

00 = Reserved


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6.3 GroupPrice Grouper Responses

Table 6-3: GroupPrice, Grouper Claim Responses (GroupClaimResults)


Grouper Return Code

X(2) grouper_return_code

00 = No errors02 = No HIPPS code on claim87 = Program cannot be loaded

Grouper Type X(2) grouper_type 22 = Medicare RUG Reader

Grouper Version 9(2) grouper_version Grouper version.

Table 6-4: GroupPrice, Grouper Line Responses (GroupLineResults [ ])


HIPPS X(5) hipps Health Insurance Prospective Payment System code.

RUG X(5) rug Resource Utilization Group

Grouper Return Code

X(2) err RUG Reader line-level Return Code.

00 = No errors found01 = Invalid HIPPS code (Part A only)


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6.4 GroupPrice Pricer Responses

Table 6-5: GroupPrice, Pricer Claim Responses (PriceClaimResults)


Pricer Return Code X(2) pricer_return_code 00 = No errors found01 = No hospital rate calculator record03 = Pricer type not licensed21 = Invalid bill type (not 18x, 21x, 22x or

23x)23 = Service date invalid or out of range25 = Non payment claim26 = Total units exceed patient’s length of



Total Reimbursement 9(8)v9(2) total_reimbursement


Prospective Payment Total






Total Part B Third-party Payment


Total Part B Co-payment

9(8)v9(2) tocopay Total patient coinsurance for this claim.


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Table 6-6: GroupPrice, PriceLine Responses (PriceLineResults)






only) 14 = Revenue code not covered under

SNF Part B (22X only)28 = No available extended fee schedule






For Part A, adjusted per diem payment rate for RUG. For Part B, fee schedule rate.

Part B Third Party Payment


Part B Co-Payment 9(8)v9(2) copay Total patient coinsurance for this line.

Total Line Payment 9(8)v9(2) total_line_pay Payment for line.

Fee Schedule Type X(1) feetype A = AmbulanceD = DMEPOSL = LaboratoryM = National RateR = PhysicianT = Therapy service subject to multiple






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7 EditGroupPrice



• EditGroupPrice Requests

• EditGroupPrice Responses


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7.1 EditGroupPrice RequestsThe EditGroupPrice method has the following input:

Structures:


• Edit_Request (refer to Table 13-2 on page 117)



Other input:


• User Path (user_path)

Table 7-1: Rate Paths



User Path string user_path When defined, the User Path overrides the System Path. This path should be set when EASYGroup™ product files (e.g., apcrule.dat, etc.) resides in a location that was not defined during the installation or within the System Path. The EASYGroup™ programs will utilize the product files residing at this User Path location.


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7.2 EditGroupPrice Responses

Table 7-2: EditGroupPrice Responses (EditGroupPriceResult)


Web Method Return Code


string optimizer_return_code

00 = Reserved

Table 7-3: Editing Responses (EditMessages)





00 = Reserved

Editor Return Code string editor_return_code 00 = No parameter or I/O errors01 = Invalid Editor operation code02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error05 = Number of procedures < 106 = Claim spans > 365 days07 = OCE/CCI or CCI edit pairs have been

requested, but maxccierr < 108 = Unsupported bill type09 = Number of diagnoses < 110 = Final disposition exceeds maximum

acceptable level of error, or invalid override ID.

11 = MUE file open or I/O error87 = Program cannot be loaded88 = Initialization error89 = Memory allocation error95 = Parameter error


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OCE Version Number

string OCE_version_number

OCE version number applicable to this claim. This number is the last two digits of the calendar year, i.e. 05 is for calendar 2005.

Claim Error Count string claim_error_count The number of claim-level errors returned from ACE.

Diagnosis Error Count

string diagnosis_error_count

The number of diagnosis errors returned from ACE.

Claim Line Error Count

string procedure_error_count

The number of claim line-level errors returned from ACE.

OCE/CCI Code Pairs Count

string CCI_error_count The number of CCI edit pairs returned from ACE. Returned with an Edit Request (edit_request) of “CCI” or “OCE with edit pairs returned”.

Total Error Count string total_error_count Total number of errors identified for this patient visit.(claim_error_count + diagnosis_error_count + procedure_error_count)

Overall Claim Disposition

string overall_claim_disposition_message

Overall disposition of claim, incorporating claim, diagnosis, and procedure edits.00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspended04 = Claim returned to provider for

correction (RTP)05 = Claim rejected06 = Claim denied

OCE Error Disposition

string OCE_error_disposition

Claim disposition flag array: one flag for each disposition as listed under overall_claim_disposition_message.A “1” in any position indicates that one or more errors were identified on the claim with the matching disposition. For example, OCE _error_disposition of “010011” indicates that the claim contains errors that would result in line item denials, claim rejection, and claim denial.




Op

Claim Error Detail Message Array

array of string

claim_error_detail_message []

00000 = No errors found00010 = Condition code 2100023 = Invalid from-thru dates00024 = Date out of OCE range00025 = Invalid age00026 = Invalid sex00027 = Only incidental services reported00029 = Partial hospitalization services,

non-mental-health diagnosis00030 = Insufficient partial hospitalization

services (prior to January 1, 2009 only)

00031 = Partial hospitalization service with payment status “T” service

00032 = Partial hospitalization < 4 days with insufficient or inappropriate services

00033 = Partial hospitalization > 3 days with insufficient PHP services

00034 = Partial hospitalization > 3 days with inappropriate services

00035 = Only mental health education and training services are provided during one or more days

00036 = Extensive mental health services provided with payment status “T” service

00046 = Partial hospitalization condition code invalid for this bill type

00088 = FQHC payment code not reported for FQHC claim

Highest Admit Diagnosis Disposition

string highest_admit_diagnosis_disposition

00 = No errors found01 = Claim contains line item rejection02 = Claim contains line item denial03 = Claim suspended04 = Claim returned to provider for


Admit Diagnosis Error Count

string admit_diagnosis_error_count

00 = No errors01-03 Error count for this diagnosis

Admit Diagnosis Error Message Array

array of string

admit_diagnosis_error_message []

00000 = No errors found00001 = Invalid admit diagnosis00002 = Admit diagnosis/age conflict00003 = Admit diagnosis/sex conflict




Op

Table 7-4: ACE Diagnosis Message Response (acedxblkmsg)




00 = No errors01-05 Error count for this diagnosis00086 = Manifestation code not allowed as

principal diagnosis

Diagnosis Error Message

array of string

diagnosis_errors_message[]

A list of all diagnosis-level errors for this code.00000 = No errors detected00001 = Invalid diagnosis00002 = Diagnosis/age conflict00003 = Diagnosis/sex conflict00004 = Medicare as secondary payer

alert00005 = E-code as reason for visit00086 = Manifestation code not allowed as

principal diagnosis

Table 7-5: ACE Procedure Message Response (aceopblkmsg)


Highest Procedure Disposition

string highest_procedure_disposition

00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

Procedure Validity Indicator

string procedure_validity_indicator

0 = Procedure is valid for dates1 = Procedure not found in code table2 = Procedure not valid for service date

Procedure Error Count


00 = No errors found01 = Size of procedure_error array


Op

Procedure Error Message

array of string

procedure_errors_message[]

00000 = No error00006 = Invalid procedure code00007 = Procedure and age conflict00008 = Procedure and sex conflict00009 = Non-covered for reasons other

than statute00011 = Service submitted for FI/MAC

review (condition code 20)00012 = Questionable covered service00013 = Separate payment for services is

not provided by Medicare00014 = Code indicates a site of service

not included in OPPS00015 = Units exceed maximum (MUE)00016 = Multiple bilateral procedures

without modifier 5000017 = Inappropriate specification of

bilateral procedure00018 = Inpatient procedure00019 = Mutually exclusive procedure that

is not allowed by NCCI even if appropriate modifier is present




Op

Procedure Error Message (continued)

array of string


00020 = Code 2 of a code pair that is not allowed by NCCI even if appropriate modifier is present

00021 = Medical visit on same day as a type “T” or “S” procedure without modifier 25

00022 = Invalid modifier00023 = Invalid date00028 = Code not recognized by Medicare;

alternate code for same service may be available

00030 = Insufficient partial hospitalization services (valid January 1, 2009 and later)

00037 = Terminated bilateral procedure, or terminated procedure with units greater than one

00038 = Inconsistency between implanted device or administered substance and implantation or associated procedure

00039 = Mutually exclusive procedure that would be allowed by NCCI if appropriate modifier were present

00040 = Code 2 of a code pair that would be allowed by NCCI if appropriate modifier were present

00041 = Invalid revenue code00042 = Multiple medical visits on same

day with same revenue code without condition code G0

00043 = Transfusion or blood product exchange without specification of blood product

00044 = Observation revenue code on line item with non-observation HCPCS code

00045 = Inpatient separate procedures not paid

00047 = Service is not separately payable 00048 = Revenue center requires HCPCS

codecontinued below...




Op


array of string


00049 = Service on same day as inpatient procedure

00050 = Non-covered based on statutory exclusion

00051 = Multiple observations overlap in time

00052 = Observation does not meet minimum hours, qualifying diagnoses, and/or type “T” procedure conditions

00053 = Codes G0378 and G0379 only allowed with bill type 13x

00054 = Multiple codes for the same service

00055 = Non-reportable for site of service00056 = E/M condition not met and line

item date for observation code G0244 is not 12/31 or 1/1

00057 = Composite E/M condition not met for observation and line item date for code G0378 is 1/1

continued below...




Op


array of string


00058 = G0379 only allowed with G037800059 = Clinical trial requires diagnosis

code V707 as other than primary diagnosis

00060 = Use of modifier CA with more than one procedure not allowed

00061 = Service can only be billed to the DMERC

00062 = Code not recognized by OPPS; alternate code for same service may be available

00063 = OT (occupational therapy) code only billed on partial hospitalization claims

00064 = AT (activity therapy) service not payable outside the partial hospitalization program

00065 = Revenue code not recognized by Medicare

00066 = Code requires manual pricing00067 = Service provided prior to FDA

approval00068 = Service provided prior to date of

National Coverage Determination (NCD) approval

00069 = Service provided outside approval period

00070 = CA modifier requires patient status code 20

00071 = Claim lacks required device code00072 = Service not billable to the FI/MAC00073 = Incorrect billing of blood and blood

products00074 = Units greater than one for bilateral

procedure billed with modifier 5000075 = Incorrect billing of modifier FB or

FC00076 = Trauma response critical care

code without revenue code 068x and CPT® 99291

00077 = Claim lacks allowed procedure code

00078 = Claim lacks required radiolabeled product

00079 = Incorrect billing of revenue code with HCPCS code

00080 = Mental health code not approved for partial hospitalization program

00081 = Mental health service not payable outside the partial hospitalization program

00082 = Charge exceeds token charge ($1.01)

continued below...




Op


array of string


00083 = Service provided on or after effective date of NCD non-coverage

00084 = Claim lacks required primary code00085 = Claim lacks required device code

or requiredprocedure code00087 = Skin substitute application

procedure withoutappropriate skin substitute product code00089 = FQHC claim lacks required

qualifying visit code00090 = Incorrect revenue code reported

for FQHC payment code00091 = Item or service not covered under

FQHC PPS00092 = Device-dependent procedure

code billed without device code99999 = Line item denial from external

Editor

Maximum Units string maximum_units Maximum allowable units for this procedure. If no maximum allowable units have been defined, this field defaults to zero.

MUE AdjudicationIndicator

string mai Indicates the type of Medically Unlikely Edit (MUE) that was applied to this claim line.

0 = No MUE Edit1 = Line Level Edit2 = Day Level Edit (policy)3 = Day Level Edit (clinical)

Table 7-6: ACE-CCI Message Response (acecciblkmsg)


Procedure Code #1 string procedure_code1 First HCPCS procedure code plus one optional modifier

Claim Line Pointer for Procedure Code #1

string claim_line1 Line number of line containing first procedure code.

Procedure Code #2 string procedure_code2 Second HCPCS procedure code plus one optional modifier.


string claim_line2 Line number of line containing second procedure code.




Op

Error Code Message string error_code_message

OCE/CCI Edits:114 = Mutually exclusive procedures115 = Column 1/Column 2 CCI edits

Full CCI Edits:101 = Do not code services essential to

procedure102 = Code is a CPT® separate procedure 103 = Code only the more extensive

procedure for the same site104 = With and without codes should not

be used together105 = Anesthesia should not be reported

separately when administered by the operating physician

106 = Do not code lab services separately; code lab panel

107 = Report code for completed service only

108 = Do not code services integral to procedure

109 = These codes should not be reported together per CPT® coding guidelines

110 = These codes should not be used together per code definition

111 = These services are not typically performed together

112 = Codes indicate mutually exclusive services

113 = Codes indicate sex conflict

Modifier Flag Message

string modifier_flag_message

0 = Modifier will not affect edit1 = An OCE edit has been generated but

an appropriate modifier on code 1 or code 2 may affect this edit

2 = Code pair is accompanied by a modifier that is acceptable to the OCE but would not override the OCE/CCI edit according to standard coding practice.

Table 7-7: Reader/Grouper Claim Responses (GroupClaimResults)


Grouper Return Code

X(2) grouper_return_code

00 = No errors02 = No HIPPS code on claim87 = Program cannot be loaded

Grouper Type X(2) grouper_type 22 = Medicare RUG Reader

Grouper Version 9(2) grouper_version Grouper version.

Table 7-6: ACE-CCI Message Response (acecciblkmsg)



Op

Table 7-8: Reader/Grouper Line Responses (GroupLineResults [ ])


HIPPS X(5) hipps Health Insurance Prospective Payment System code.

RUG X(5) rug Resource Utilization Group

Grouper Return Code

X(2) err RUG Reader line-level Return Code.

00 = No errors found01 = Invalid HIPPS code (Part A only)

Table 7-9: SNF Price Claim Results (PriceClaimResults)


Pricer Return Code X(2) pricer_return_code 00 = No errors found01 = No hospital rate calculator record03 = Pricer type not licensed21 = Invalid bill type (not 18x, 21x, 22x or

23x)23 = Service date invalid or out of range25 = Non payment claim26 = Total units exceed patient’s length of



Total Reimbursement

9(8)v9(2) total_reimbursement


Prospective Payment Total






Total Part B Third-party Payment


Total Part B Co-payment

9(8)v9(2) tocopay Total patient coinsurance for this claim.


Op

Table 7-10: SNF Price Line Results (PriceLineResults)






Only) 14 = Revenue code not covered under SNF

Part B (22X only)28 = No available extended fee schedule






For Part A, adjusted per diem payment rate for RUG. For Part B, fee schedule rate.

Part B Third Party Payment


Part B Co-Payment 9(8)v9(2) copay Total patient coinsurance for this line.

Total Line Payment 9(8)v9(2) total_line_pay Payment for line.

Fee Schedule Type X(1) feetype A = AmbulanceD = DMEPOSL = LaboratoryM = National RateR = PhysicianT = Therapy service subject to multiple






Op

8 OCEEdit & OCEEditMessages



• OCEEdit & OCEMessages Requests

• OCEEdit Response

• OCEEDITMessage Responses


Op

8.1 OCEEdit & OCEMessages RequestsThe OCEEdit method has the following input.

Structures:





Other input:








Op

8.2 OCEEdit Response

Table 8-2: OCEEdit Result





00 = Reserved

Editor Return Code string editor_return_code

00 = No parameter or I/O errors01 = Invalid Editor operation code02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error05 = Number of procedures < 106 = Claim spans > 365 days07 = OCE/CCI or CCI edit pairs have been




OCE Version Number



Claim Error Count string claim_error_count

The number of claim-level errors returned from ACE.






The number of procedure errors returned from ACE.

OCE/CCI Code Pairs Count

string CCI_error_count The number of CCI edit pairs returned from ACE. Returned with an Edit Request (edit_request) of “CCI” or “OCE with edit pairs returned”.


Op



string overall_claim_disposition




string OCE_error_disposition





Op

Claim Error Detail string claim_error_detail []



















Admit Diagnosis ErrorMessage

string admit_diagnosis_errors[]





Op

Table 8-3: ACE Diagnosis Responses (acedxblkmsg)


Highest Diagnosis Disposition

string highest_diagnosis_disposition





Diagnosis Errors array of string

diagnosis_errors []

00 = No errors found01 = Invalid diagnosis02 = Diagnosis/age conflict03 = Diagnosis/sex conflict04 = Medicare as Secondary Payer alert05 = E-code as reason for visit

Table 8-4: ACE Procedure Responses (aceopblkmsg)












Op


array of string

procedure_errors []




not provided by Medicare00014 = Code indicates a site of service not

included in OPPS00015 = Units exceed maximum (MUE)00016 = Multiple bilateral procedures
















Op

Procedure Error Message(continued)

array of string

procedure_errors []







code00049 = Service on same day as inpatient

procedure00050 = Non-covered based on statutory

exclusion00051 = Multiple observations overlap in

time00052 = Observation does not meet

minimum hours, qualifying diagnoses, and/or type “T” procedure conditions










continued below...




Op


array of string

procedure_errors []












Op


array of string

procedure_errors []


00071 = Claim lacks required device code00072 = Service not billable to the Fiscal

Intermediary/MAC00073 = Incorrect billing of blood and blood













or requiredprocedure code00087 = Skin substitute application

procedure withoutappropriate skin substitute product code00089 = FQHC claim lacks required

qualifying visit code00090 = Incorrect revenue code reported

for FQHC payment code00091 = Item or service not covered under

FQHC PPS00092 = Device-dependent procedure code

billed without device code99999 = Line item denial from external

Editor





Op




Table 8-5: ACE-CCI Responses (acecciblkmsg)


Procedure Code #1 string procedure_code1 First HCPCS procedure code plus one optional modifier.



Procedure Code #2 string procedure_code2 Second HCPCS procedure code plus one optional modifier.






Op

Error Code string error_code OCE/CCI Edits:114 = Mutually exclusive procedures115 = Column 1/Column 2 correct coding

edits



procedure for the same site104 = With and without codes should not be

used together105 = Anesthesia should not be reported










Modifier Flag string modifier_flag 0 = Modifier will not affect edit1 = An OCE edit has been generated but an

appropriate modifier on code 1 or code 2 may affect this edit


OCE Indicator string oce_indicator 0 = Edit is used in the CCI but is not used in the OCE

1 = Edit is used in the CCI and is also used in the OCE in mutually exclusive context

2 = Edit is used in the CCI and is also used in the OCE in comprehensive/component context

Table 8-5: ACE-CCI Responses (acecciblkmsg)



Op

8.3 OCEEDITMessage Responses

Table 8-6: OCEMessages Result (OCEEditMessages)





00 = Reserved

Editor Return Code string editor_return_code

00 = No parameter or I/O errors01 = Invalid Editor operation code02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error05 = Number of procedures < 106 = Claim spans > 365 days07 = OCE/CCI or CCI edit pairs have been




OCE Version Number



Claim Error Count string claim_error_count

The number of claim-level errors returned from ACE.






The number of procedure errors returned from ACE.

CCI Error Count string CCI_error_count The number of CCI edit pairs returned from ACE. Returned with an Edit Request (edit_request) of ‘CCI’ or ‘OCE with edit pairs returned’.


Op


Overall Claim Disposition Message

string overall_claim_disposition_message




array of string

OCE_error_disposition





Op

Claim Error Detail Message Array

array of string

claim_error_detail_message []


















00 = No errors01 - 03 Error count for this diagnosis


array of string

admit_diagnosis_error_message []


Table 8-7: ACE Diagnosis Message Responses (acedxblkmsg)




00 = No errors01 - 05 = Error count for this diagnosis




Op

Diagnosis Error Message

array of string

diagnosis_errors_message[]

00000 = No errors found00001 = Invalid diagnosis00002 = Diagnosis/age conflict00003 = Diagnosis/sex conflict00004 = Medicare as Secondary Payer

alert00005 = E-code as reason for visit

Table 8-8: ACE Procedure Message Responses (aceopblkmsg)











Table 8-7: ACE Diagnosis Message Responses (acedxblkmsg)



Op


array of string






included in OPPS00015 = Units exceed maximum (MUE)00016 = Multiple bilateral procedures
















Op


array of string








code00049 = Service on same day as inpatient

procedure00050 = Non-covered based on statutory

exclusion00051 = Multiple observations overlap in

time00052 = Observation does not meet

minimum hours, qualifying diagnoses, and/or type “T” procedure conditions










continued below...




Op


array of string











00071 = Claim lacks required device code00072 = Service not billable to the Fiscal

Intermediary/MAC00073 = Incorrect billing of blood and blood













or required procedure code00087 = Skin substitute application

procedure without appropriate skin substitute product code

continued below...




Op


array of string


00089 = FQHC claim lacks required qualifying visit code

00090 = Incorrect revenue code reported for FQHC payment code

00091 = Item or service not covered under FQHC PPS

00092 = Device-dependent procedure code billed without device code

99999 = Line item denial from external Editor





Table 8-9: ACE-CCI Message Responses (acecciblkmsg)


Procedure Code #1 string procedure_code1 First HCPCS procedure code plus one optional modifier



Procedure Code #2 string procedure_code2 Second HCPCS procedure code plus one optional modifier






Op

Error Code Message string error_code_message

OCE/CCI Edits:114 = Mutually exclusive procedures115 = Column 1/Column 2 correct coding

edits



procedure for the same site104 = With and without codes should not be

used together105 = Anesthesia should not be reported










Modifier Flag Message

string modifier_flag_message

0 = Modifier will not affect edit1 = An OCE edit has been generated but an

appropriate modifier on code 1 or code 2 may affect this edit


Table 8-9: ACE-CCI Message Responses (acecciblkmsg)



Op

9 OCEErrorSummary



• OCEErrorSummary Requests

• OCEErrorSummary Responses


Op

9.1 OCEErrorSummary RequestsStructures:





Other input:








Op

9.2 OCEErrorSummary Responses

Table 9-2: OCEErrorSummary Responses (OCEErrorSummaryResult)




string ErrorsSummary_return_code

00 = Reserved

Editor Return Code string editor_return_code 00 = No parameter or I/O errors01 = Invalid Editor operation code02 = Code file open or I/O error03 = CCI edit file open or I/O error04 = OCE/CCI edit file open or I/O error05 = Number of procedures < 106 = Claim spans > 365 days07 = OCE/CCI or CCI edit pairs have been




OCE Editor Version string editor_version OCE version number applicable to this claim. This number is the last two digits of the calendar year, i.e. 05 is for calendar 2005.


string overall_claim_disposition



Total Error Count integer total_error_count Total number of errors identified for this patient visit.(claim_error_count + diagnosis_error_count + procedure_error_count)


Op

OCE Errors Array array of string

OCEErrors[]

CCI Errors Array array of string

CCIErrors[]

Error Number int error_number OCEErrors:00000 = No errors detected00001 = Invalid diagnosis00002 = Diagnosis/age conflict00003 = Diagnosis/sex conflict00004 = Medicare as secondary payer alert00005 = E-code as reason for visit 00006 = Invalid HCPCS code00007 = Procedure and age conflict00008 = Procedure and sex conflict00009 = Non-covered for reasons other




included in OPPS00015 = Service unit out of range for

procedure00016 = Multiple bilateral procedures






00022 = Invalid modifier00023 = Invalid date00024 = Date out of OCE range00025 = Invalid age00026 = Invalid sex00027 = Only incidental service reportedcontinued below...




Op

Error Number(continued)

int error_number 00028 = Code not recognized by Medicare; alternate code for same service may be available

00029 = Partial hospitalization service for non-mental health diagnosis

00030 = Insufficient services on day of partial hospitalization

00031 = Partial hospitalization on same day as significant procedure (type “T”)

00032 = Partial hospitalization spans > 3 days with insufficient services of electro-convulsive therapy (ECT) or significant procedure (type “T”) in at least one of the days


00034 = Partial hospitalization claim spans 3+ days with insufficient number of days meeting partial hospitalization criteria

00035 = Only activity and/or occupational therapy services provided

00036 = Extensive mental health services on day of significant procedure










00047 = Service is not separately payable continued below...




Op


int error_number 00048 = Revenue center requires HCPCS code

00049 = Service on same day as inpatient procedure

00050 = Non-covered based on statutory exclusion

00051 = Multiple observations overlap in time

00052 = Observation does not meet minimum hours, qualifying diagnoses, and/or type “T” procedure conditions








00060 = Use of modifier CA with more than one procedure is not allowed

00061 = Service must be billed to the DMERC

00062 = Code not recognized by OPPS, alternate may be available

00063 = Occupational therapy can only be billed on PHP or CMHC claims

00064 = Activity therapy can only be billed on PHP or CMHC claims



approval 00068 = Service provided prior to NCD

approval00069 = Service provided outside approval

period00070 = CA modifier requires patient status

code 20continued below...




Op


int error_number 00071 = Claim lacks required device or procedure code

00072 = Service not billable to the fiscal intermediary/MAC

00073 = Incorrect billing of blood and blood products

00074 = Units greater than one for bilateral procedure billed with modifier 50

00075 = Incorrect billing of modifier FB00076 = Trauma response critical care








CCI Errors:00101 = Do not code services essential to

procedure00102 = Code is a CPT® separate

procedure 00103 = Code only the more extensive

procedure for the same site00104 = With and without codes should not

be used together00105 = Anesthesia should not be reported









continued below...




Op


int error_number 00113 = Codes indicate sex conflict00999 = Multiple CCI errors, same codeOCE/CCI Errors:00114 = Mutually exclusive procedures00115 = Column 1/Column 2 correct coding

edits

Error Description string error_description Refer to Error Number above for the list of Error descriptions.

Error Count int error_count The number of occurrences of the indicated edit.




Op

10 GetGroupPriceRules



• GetGroupPriceRules Requests

• GetGroupPriceRules Responses


Op

10.1 GetGroupPriceRules Requests

Table 10-1: GetGroupPriceRules Requests


Provider Identifier X(16) facility_id Facility or provider identifier (i.e. Medicare Provider ID, TIN or other identifier). Submit NPI in NPI field.

Payer ID or Contract Code

X(13) payer_id Payer identifier or contract code.

From or Admission Date

9(8) from_date YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Thru or Discharge Date

9(8) thru_date YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

If still a patient set equal to today’s date.

National Provider ID X(10) national_provider_id

National Provider ID, including check digit.

Taxonomy Code X(10) taxonomy_code 282N00000X = Short term general hospital282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital-based or free

standing renal dialysis unit283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct part

unit282NC2000X = Children's hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part unit275N00000X = Swing bed in short term

hospital (others per 837 definitions)


If no alternate rate path is supplied, the default location is: C:\\inetpub\wwwroot\HSS\Data.


Op

Alternate Rate Look-up

X(1) pyr_altlook_sw Flag used to indicate that additional searches of the rate files should be performed if the initial search fails.

0 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

1 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided or not found, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

2 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

3 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

Table 10-1: GetGroupPriceRules Requests



Op

10.2 GetGroupPriceRules Responses

Table 10-2: GetGroupPriceRules Responses


Return Code 9(2) return_code 00 = No error01 = Error accessing Paysnf file02 = Error accessing hospital rate file03 = Missing rate calculator record15 = Invalid from or thru date70 = Configuration record error71 = Paysnf record not found72 = Medsnf record not found81 = Paysnf file error82 = Medsnf file error

Effective Date 9(8) effective_date YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Grouper Type Text grouper_type 22 = Medicare SNF RUG Reader

Grouper Version 9(2) grouper_version Grouper version


ICD-9 Mapping Flag 9(1) mapping_flag Not applicable to Medicare SNF.

Rate Ownership X(1) rate_ownership Y = Facility and payer ID has its own set of rates/weights

N = Facility and payer ID has no rates/weights

L = Facility and payer ID has been linked to another facility identifier, payer identifier and/or effective date rate/weight information

Linked Facility ID X(16) linked_facility_id The facility identifier under which applicable rate information has been stored in the rate file.

Linked Payer ID X(13) linked_payer_id The payer identifier under which applicable rate information has been stored in the rate file.

Linked Effective Date 9(8) linked_effective_date

YYYYMMDD. The effective date under which applicable rate information has been stored in the rate file.

Classification Type X(3) classification_type

RUG = Resource Utilization Groups for Skilled Nursing

Linked NPI X(10) linked_npi The National Provider Identifier under which applicable rate information has been stored in the rate file.

Linked Taxonomy X(10) linked_taxonomy The taxonomy code associated with the linked National Provider ID, if applicable.


Op

Key Type X(1) key_type Output field.

1 = National Provider ID plus taxonomy code used for rate lookup

0 or blank = Legacy Provider ID used for rate lookup

Editor Requests 9(10) edit_request Position: 1: 1 = DSC edits requested2: 0 = Reserved for EASYEdit request3: 1 = NCCI edits requested4: 1 = OCE edits requested5: 1 = OCE with CCI pairs edits requested6: 1 = LCD/NCD edits requested7: 1 = Non-OPPS OCE edits requested8: 1 = POA editing request9: 1 = HAC editing request10: 0 = Reserved for future expansion

Note: More than one edit type can be requested.

Short Grouper Type 9(2) short_grouper_type

22 = Medicare SNF

Facility Retrieved string pyr_facility Unique facility identifier.

Effective Date Retrieved

string pyr_edate The date on or after which the rate variables contained on this record should be used for calculating reimbursement. This field will be equal to either the beginning of the federal fiscal year or the beginning of the hospital's fiscal year (e.g. 20001001).

Table 10-2: GetGroupPriceRules Responses



Op

11 GetPayerList



• GetPayerList Requests

• GetPayerList Responses


Op

11.1 GetPayerList Requests

Table 11-1: GetPayerList Requests





Taxonomy Code X(10) taxonomy_code 282N00000X = Short term general hospital282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital-based or free-

standing renal dialysis unit283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct part

unit282NC2000X = Children's hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part unit275N00000X = Swing bed in short term



If no alternate rate path is supplied, the default location is: C:\\inetpub\wwwroot\HSS\Data.


Op

11.2 GetPayerList Responses

Table 11-2: GetPayerList Responses (PayerListResults)


Return Message 9(2) return_message


List of Payers PayerList [] Array of payer data

PayerID or Contract Code

X(13) payer_number Payer identifier or contract code.

Payer Name X(25) payer_name Description of the payer identifier or contract code.

National Provider Identifier

X(10) national_provider_id

National Provider Identifier including check digit

Taxonomy Code X(10) taxonomy_code Taxonomy code associated with this NPI, if applicable

Key Type string key_type Identifies the type of provider ID under which these payer records are stored.1 = National Provider ID plus Taxonomy

Code used for rate lookup0 or blank = Legacy Provider ID used for

rate lookup


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12 GetTaxonomyList



• GetTaxonomyList Requests

• GetTaxonomyList Responses


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12.1 GetTaxonomyList RequestsThe GetTaxonomyList method has the following input:

12.2 GetTaxonomyList Responses

Table 12-1: GetTaxonomyList Requests




Rate Path string rate_path Optional specification of directory containing rate data. Supply the fully qualified rate path include drive letter.

Table 12-2: GetTaxonomyList Responses


Return Message 9(2) return_message INT plus description00 = No error 71 = No taxonomy found for this NPI81 = Payor/Payout file error


X(10) national_provider_id

National Provider Identifier including check digit

Taxonomy Code X(10) taxonomy_code [] Taxonomy code associated with this NPI, if applicable

Note: Method will return an option at an empty string for NPI records that have a blank taxonomy


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13 Shared Input Structures

NoteAlthough most fields are designated as string variables, select fields are considered arrays of string variables, and are identified by the [] symbol at the end of the variable name. Also note that the variable formats listed in this chapter are the COBOL-type definitions which identify the maximum field length or precision required by the EASYGroup™ components. For web service requests, please conform to standard web service parameter passing conventions, the field definitions in the ASMX and WSDL files, and the input and output parameter data formatting conventions described in Chapter 4.


• Patient_Claim_Data

• Edit_Request

• Diagnosis_Data

• Line_Data

• Paths [ezg_paths]

• Optimizer_Return_Data


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13.1 Patient_Claim_Data

Table 13-1: Patient_Claim_Data Structure


Provider Identifier string facility_id Facility or provider identifier (i.e. Medicare Provider ID, TIN or other identifier). Submit NPI in NPI field.

Payer Identifier or Contract Code

string payer_id Payer identifier or contract code. Required.

From or Admission Date

string from_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

Thru or Discharge Date

string thru_date UB-04 FL06. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31

If still a patient, set equal to today’s date.

Date of Birth string birthdate UB-04 FL10. YYYYMMDD, where:YYYY = year including century MM = month; 01-12DD = day; 01-31.

Age in Years string age Patient age in years. Required for all inpatient and outpatient processing. Valid values are 000-124.

Sex string sex UB-04 FL11. Required for all inpatient and outpatient processing.0 or U = Unknown1 or M = Male2 or F = Female

Medical Record Number

string medical_record_number

UB-04 FL03B. Optional field to uniquely identify patient.

Patient Control Number

string control_number UB-04 FL03A. Optional field to uniquely identify a patient account.

Reason for Visit Diagnosis

array reason_for_visit_diagnosis []

UB-04 FL70a. Reason for visit diagnoses, up to three ICD-9-CM codes, for outpatient processing.


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Discharge Disposition

string discharge_disposition

UB-04 FL17. Patient Discharge Status.01 =Discharged to home or self care02 =Discharged/transferred to short-

term general hospital03 =Discharged/transferred to skilled

nursing facility, Medicare-certified04 =Discharged/transferred to a facility

that provides custodial or supportive care

05 =Discharged/transferred to designated cancer center or children's hospital (valid beginning October 1, 2007)

06 =Discharged/transferred to home health service organization

07 =Left against medical advice09 =Admitted as an inpatient (valid only

for Medicare outpatient claims)20 =Expired/died21 =Discharged/transferred to court/

law enforcement (valid beginning October 1, 2009)

30 =Still a patient43 =Discharged/transferred to federal

health care facility (valid beginning October 1, 2003)

50 =Hospice, home51 =Hospice, certified medical facility61 =Discharged/transferred to swing

bed, hospital-based and Medicare-approved (valid beginning with October 1, 2001)

62 =Discharged/transferred to inpatient rehabilitation facility or unit (valid beginning January 1, 2002)

63 =Discharged/transferred to long term care hospital, Medicare-certified (valid beginning January 1, 2002)

64 =Discharged/transferred to nursing facility, certified under Medicaid but not Medicare (valid beginning October 1, 2002)

65 =Discharged/transferred to psychiatric hospital or distinct part unit (valid beginning April 1, 2004)

continued below...




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Discharge Disposition(continued)

string discharge_disposition

66 =Discharged/transferred to critical access hospital (valid beginning January 1, 2006)

70 =Discharged/transferred to another type of health care institution not defined elsewhere in this code list (valid beginning April 1, 2008)

71 =Outpatient services, another facility (valid October 1, 2001 through September 30, 2003)

72 =Outpatient services, this facility (valid October 1, 2001 through September 30, 2003)

Total Covered Charges

string total_charges UB-04 FL47-48. Subtract Non-covered charges (FL 48) from Total Charges (FL 47).

UB-04 Condition Codes

array of stringoccurs 24 times

condition_codes [] UB-04 FL18-28. Condition codes.

Bill Type string billtype UB-04 FL4. UB-04 bill type consists of 3-character category plus frequency.

UB-04 Value Code array of stringoccurs 24 times

value_code [] UB-04 FL39-41. Value codes.

UB-04 Value Amount

array of stringoccurs 24 times

value_amount [] UB-04 FL39-41. Leading digit should always be zero. Supply according to UB-04 conventions for the remaining 9 digits of this field.

Deductible string deductible Remaining Medicare outpatient deductible for this patient at the time of this visit.

Provider ZIP Code string provider_zip_code UB-04 FL01. Required for professional claims only.


string national_provider_id UB-04 FL56. National Provider ID, including check digit.




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Taxonomy Code string taxonomy_code 282N00000X = Short term general hospital

282NC0060X = Critical access hospital282E00000X = Long term care hospital261QE0700X = Hospital-based or

freestanding renal dialysis unit283X00000X = Rehabilitation hospital273Y00000X = Rehabilitation distinct

part unit282NC2000X = Children’s hospital283Q00000X = Psychiatric hospital273R00000X = Psychiatric distinct part

unit275N00000X = Swing bed in short term


UB-04 Occurrence Codes

string, occurs up to 24 times

occurrence_codes [] UB-04 FL31-34. Occurrence codes.

UB-04 Occurrence Dates

date, occurs up to 24 times

occurrence_dates [] UB-04 FL31-34. Occurrence dates. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31

UB-04 Occurrence Span Codes

string, occurs up to 24 times

occurrence_span_codes []

UB-04 FL35-36. Occurrence span codes.

UB-04 Occurrence Span Date #1


occurrence_span_dates1 []

UB-04 FL35-36. Occurrence span date 1. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31

UB-04 Occurrence Span Date #2


occurrence_span_dates2 []

UB-04 FL35-36. Occurrence span date 2. YYYYMMDD, where: YYYY = year including century MM = month; 01-12 DD = day; 01-31

Effective Date 9(8) eff_date Format is: YYYYMMDDWhere: YYYY = year including centuryMM = month (01-12) DD = day (01-31)

Extended Structure Switch

X(1) ext_blk_sw Enable new 5010 output structures and new 5010 block formats once all updated programs that reference these structures have been installed.1 = Enable




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Paper Claim Flag 9(1) paper_flag 1 = Claim being processed is a paper claim

0 = Claim being processed is an electronic claim

Retrieve Payer X(1) pyr_lookup_sw Allows Edit Only call to perform Retrieve Payer function.

ICD-9 or ICD-10 Coding Classification

X(2) code_class 00 = ICD-9 coded claim01 = ICD-10 coded claim

Health Plan Identifier (HPID)

9(10) hplan_id UB-04 FL51. Health Plan Identifier (HPID).

UB-04 Admission/Start of Care Date

9(8) admit_date UB-04 FL12. YYYYMMDD, where:YYYY = year; including centuryMM = month; 01 - 12DD = day; 01 - 31




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Alternate Rate Look-up

X(1) pyr_altlook_sw Flag used to indicate that additional searches of the rate files should be performed if the initial search fails.

0 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

1 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided or not found, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided or not found, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

2 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using NPI without taxonomy. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform third search of the rate files using Medicare ID (OSCAR)/Medicaid ID.

3 = Perform search of the rate files using NPI and taxonomy if provided. If NPI/taxonomy not provided, not found, or closed/inactive rate record encountered, perform second search of the rate files using Medicare ID (OSCAR)/Medicaid ID.




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Log Request X(1) log_req 0 = Log file (ezglog_yyyymmdd_seconds.txt) not requested

1 = Log file (ezglog_yyyymmdd_seconds.txt) requested

Instructions for setting this field:Step 1: Set this switch to 1.Step 2: Process the claim you wish to

log.Step 3: Set this switch to 0.

NoteThis option is designed for use with a single claim, or a small set of claims. It should not be set to 1 for all claims processing, as the log file will grow rapidly in size and processing speed may be affected.

Traditional Medicare Switch

9(1) tradmed_sw 0 = Apply Medicare Advantage Requirements

1 = Apply Medicare Fee-for-Service (FFS) Requirements

NoteThe Traditional Medicare Switch does not affect processing or reimbursement for claims with service dates on or after January 01, 2019.”




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13.2 Edit_Request

Table 13-2: Edit_Request Structure


Acceptable Level of Error

string acceptable_level_of_error

Level of error that will be acceptable to continue with grouping and pricing. If a claim has a final disposition that is less than or equal to the value supplied here, the claim will be grouped and priced. Otherwise, the claim will not be grouped or priced.00 = No errors found01 = Claim contains line item rejections02 = Claim contains line item denial03 = Claim suspension04 = Claim RTP05 = Claim rejection06 = Claim denial

ACE Override ID string ace_override_id Used to request ACE override functionality. Refer to the EASYGroup™ User’s Guide for more details.

CCI Code Pairs Request

boolean OCECCIpairs Used to request code pairs associated with OCE CCI edits related to mutually exclusive or comprehensive/component code pairs. Not recommended if EnhancedReporting is requested.

Enhanced Reporting Request

boolean EnhancedReporting

Used to request enhanced ACE reporting. Under this option, the returned edit messages will be longer and more informative. Not suitable for high volume processing, but useful for individual claim investigations and data correction.

OCE Request boolean OCE 1 = Request OCE edits

CCI Request boolean CCI 1 = Request NCCI edits

Non-OCE Request boolean Non_Oce 1 = Request non-OPPS OCE edits


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13.3 Diagnosis_Data

13.4 Line_Data

Table 13-3: Diagnosis_Data Repeating Structure


Diagnosis string diagnosis ICD-9-CM or ICD-10-CM diagnosis codes. Input field. Left-justified, blank-filled with no decimal points. Codes should be contiguous, i.e., no gaps or blanks between codes. Principal diagnosis should be in the first position.

Diagnosis Code Type (input)

X(3) type Input field. Reserved for ICD-10 implementation.BK = Principal ICD-9 diagnosisBF = Other ICD-9 diagnosisABK = Principal ICD-10 diagnosisABF = Other ICD-10 diagnosis

Table 13-4: Line_Data Repeating Structure


HCPCS Code string HCPCS_code UB-04 FL44. Level I or II HCPCS or HIPPS code where applicable. Left-justified.

Modifiers array of strings

modifiers [] UB-04 FL44. Optional modifiers.

Note: Modifiers must be entered in UPPERCASE format.

Units string units UB-04 FL46. Separate APC or APG payments may be received for each unit of service.

Charges string charges UB-04 FL47 and 48. Total covered charges for this procedure (individual covered charges times units).

Date date date UB-04 FL45. Service date for this procedure (YYYYMMDD). Required for all service lines effective January 1, 2005.

Revenue Code string revenue_code UB-04 FL42. Revenue code.

Line Override string override 1 = Reserved2 = External line item rejection/denial

(ignore)3 = Reserved4 = Reserved5 = External line item rejection/denial

(consider)


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Decimal Units 9(3) dec_units Allows submission of decimal units for Medicare SNF.

Table 13-4: Line_Data Repeating Structure



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13.5 Paths [ezg_paths]

Table 13-5: PATHS [ezg_paths] Repeating Structure

Field Description

Variable Name Format Notes

System Path system_path string Submit only if data files reside in a location other than the location defined on install. If Alternate Rate or User Path is not defined, the program will look in this location for all data files. Supply the fully qualified path including the drive letter.

Alternate Rate Path

rate_path string Optional specification of directory containing alternate rate data. Supply the fully qualified rate path including drive letter.

User Path user_path string When defined, the User Path overrides the System Path. This path should be set when EASYGroup™ product files (e.g., apcrule.dat, etc.) resides in a location that was not defined during the installation or within the System Path. The EASYGroup™ programs will utilize the product files residing at this User Path location.


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13.6 Optimizer_Return_Data

Table 13-6: Optimizer_Return_Data output



X(2) opt_rtn_code 00 = No errors found05 = Error calling Mapper Control

Program (mapcntl)06 = Error calling Editor Control Program

(edtcntl)07 = Error calling Grouper Control

Program (grpcntl)08 = Error calling Pricer Control Program

(prccntl)09 = Error calling Retrieve Payer Control

Program (rtvpyr)10 = Error calling Model Control Program

(mdlcntl)11 = Non-zero return code from Mapper12 = Non-zero return code from DSC

Editor13 = Non-zero return code from

EASYEdit™14 = Non-zero return code from ACE, or

accept if less than ACE DISP15 = Non-zero return code from Grouper16 = Non-zero return code from Pricer17 = Non-zero return code from LCD

Editor18 = Non-zero return code from Retrieve

Payer Control Program (rtvpyr)19 = Non-zero return code from Model

Control Program20 = Memory Allocation Control Program

(ezgmem) cannot be loaded21 = Non-zero return code from the

TRICARE APC Editor22 = Non-zero return code from

Physician Editor88 = Initialization error89 = Memory error90 = Invalid request (invalid opcode1)95 = Parameter error96 = Reserved97 = Reserved98 = Reserved99 = Reserved


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Function Return Code

9(2) func_rtn_code 01 = Error accessing rate files07 = GRPCNTL cannot be loaded08 = PRCCNTL cannot be loaded15 = Non-zero return code from the

Grouper16 = Non-zero return code from the

Pricer17 = Invalid patient type70 = Configuration record error87 = Program cannot be loaded88 = Initialization error94 = Invalid dates95 = Parameter error

Rate File Version X(7) rf_vers Output field. Version of the rate file that was used to process a specific claim.

Table 13-6: Optimizer_Return_Data output



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14 FileReplace Structures

This chapter contains the following sections:

• ReplaceFiles

• Query

• Search


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14.1 ReplaceFiles

14.2 Query

14.3 Search

Table 14-1: ReplaceFiles Layout


Path The directory name of where the file is located.

Force Direction (true/false) to the Optimizer (IOCNTRL) to not wait for all files to not be in use/open (Active = 0).

Table 14-2: Query Layout


Path The name of the directory where the file is located.

Name The file name.

Active Number of clients currently using the given file name.

Table 14-3: Search Layout


Path The directory where the file is located.

Name The file name.

Current Equals true if the file currently exists on the system.

New Equals true if the file currently exists in the New directory.


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15 SNF Web Services Label Data File


• File Layout

• Description of snfmsg Values

tumInsight | www.optum.com April 2, 2020

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15.1 File LayoutThe SNF Web Service uses an external data file (snfmsg.dat) to retrieve the labels for values that are output in the SNF Web Service. The layout is as follows:

NoteFor further information please refer to Table 15-2.

15.2 Description of snfmsg ValuesBelow is the mapping of code type values to the fields that return them. In the snfmsg.dat file these items will be sorted alphabetically. The Code Values in field 2 range from 1 digit to 5, and only these values should be returned for their respective Code Type values.

Table 15-1: Snfmsg.dat File Layout

Field Position Format Description

1 1 - 4 X(4) Code Type

2 5 - 9 X(5) Code Value

3 10 - 209 X(200) Description

4 210 - 250 Filler

Table 15-2: Code Type Values, Descriptions, and Web Service Infrastructure

Code Type Values

Description Corresponding SNF Web Service Field(s)

Corresponding SNF Web Service Structure(s)

E01 Editor Return Code editor_return_code, 9(2)

UB04_EditGroupPriceUB04_OCEErrorSummaryUB04_OCEEditUB04_OCEEditMessages

E02 OCE Error Disposition

overall_claim_disposition_message, 9(2)


E03 Claim Error Detail Message Array


Editor Procedure Results


claim_error_detail_message, 9(5)

admit_diagnosis_error_message, 9(5)

diagnosis_error_message, 9(5)

procedure_errors_message, 9(5)



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E04 Error Code Message

error_code_message, 9(3)


E05 Modifier Flag Message

modifier_flag_message, 9(1)


E06 MUE Adjudication Indicator

mai, 9(1) UB04_EditGroupPriceUB04_OCEErrorSummaryUB04_OCEEditUB04_OCEEditMessages

G01 Claim-Level Grouper Return Code

grouper_return_code, 9(2)

UB04_EditGroupPriceUB04_GroupPrice

G02 Line-Level Grouper Return Code

err, X(2) UB04_EditGroupPriceUB04_GroupPrice

G03 Claim-Level Grouper Type Label

grpr_type, X(2) UB04_EditGroupPriceUB04_GetGroupPriceRulesUB04_GroupPrice

O01 Optimizer Return Code

opt_rtn_code, 9(2) UB04_EditGroupPriceUB04_GroupPriceUB04_PriceUB04_OCEErrorSummaryUB04_OCEEditUB04_OCEEditMessages

O02 Optimizer Return Code

optimizer_rtn_code, 9(2)

UB04_EditGroupPriceUB04_GroupPriceUB04_PriceUB04_OCEErrorSummaryUB04_OCEEditUB04_OCEEditMessages

O03 Taxonomy Lookup Return Code

return_message, 9(2) UB04_GetTaxonomyList

P01 Claim Level Pricer Return Code

pricer_return_code UB04_EditGroupPriceUB04_GroupPriceUB04_Price

P02 Line Level Pricer Return Code

line_return_code, 9(2) UB04_EditGroupPriceUB04_GroupPriceUB04_Price

P03 Fee Schedule Type feetype, X(1) UB04_EditGroupPriceUB04_GroupPriceUB04_Price

Table 15-2: Code Type Values, Descriptions, and Web Service Infrastructure

Code Type Values

Description Corresponding SNF Web Service Field(s)

Corresponding SNF Web Service Structure(s)


List of TablesTechnical Support Options 6

Alternate_Rate_Path 47

PriceClaimResults 48

PriceLineResults 49

Alternate Rate Path 51

GroupPrice Optimizer Responses 52

GroupPrice, Grouper Claim Responses (GroupClaimResults) 53

GroupPrice, Grouper Line Responses (GroupLineResults [ ]) 53

GroupPrice, Pricer Claim Responses (PriceClaimResults) 54

GroupPrice, PriceLine Responses (PriceLineResults) 55

Rate Paths 57

EditGroupPrice Responses (EditGroupPriceResult) 58

Editing Responses (EditMessages) 58

ACE Diagnosis Message Response (acedxblkmsg) 61

ACE Procedure Message Response (aceopblkmsg) 61

ACE-CCI Message Response (acecciblkmsg) 66

Reader/Grouper Claim Responses (GroupClaimResults) 67

Reader/Grouper Line Responses (GroupLineResults [ ]) 68

SNF Price Claim Results (PriceClaimResults) 68

SNF Price Line Results (PriceLineResults) 69

Rate Paths 71

OCEEdit Result 72

ACE Diagnosis Responses (acedxblkmsg) 75

Optum | www.optum.com April 2, 2020

ACE Procedure Responses (aceopblkmsg) 75

ACE-CCI Responses (acecciblkmsg) 80

OCEMessages Result (OCEEditMessages) 82

ACE Diagnosis Message Responses (acedxblkmsg) 84

ACE Procedure Message Responses (aceopblkmsg) 85

ACE-CCI Message Responses (acecciblkmsg) 89

Rate Paths 92

OCEErrorSummary Responses (OCEErrorSummaryResult) 93

GetGroupPriceRules Requests 100

GetGroupPriceRules Responses 102

GetPayerList Requests 105

GetPayerList Responses (PayerListResults) 106

GetTaxonomyList Requests 108

GetTaxonomyList Responses 108

Patient_Claim_Data Structure 110

Edit_Request Structure 117

Diagnosis_Data Repeating Structure 118

Line_Data Repeating Structure 118

PATHS [ezg_paths] Repeating Structure 120

Optimizer_Return_Data output 121

ReplaceFiles Layout 124

Query Layout 124

Search Layout 124

Snfmsg.dat File Layout 126


Code Type Values, Descriptions, and Web Service Infrastructure 126



IndexCContact Optum 5Contact Us 5

Client Services 5Corporate Address 5

FFileReplace Structures 123GGuide Overview 5, 7, 18, 29, 125OOverview 5SSNF Web Services Label Data File 125

Description of snfmsg Values 126File Layout 126

snf web service · 2020-05-29 · application on any web-accessible platform can request rug...

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