Claim/Remittance Testing Scenarios

Originator Name:

Test File Name:

	Coordination of Benefit Scenarios
#	Scenario	Description	Validation Elements	Included?
1	Other Insurance	Other Insurance COB (Primary)	Validating usage of claims filing indicators and COB amounts	Yes No N/A
2	Other Insurance	Other Insurance COB (Secondary)	Validating usage of claims filing indicators and COB amounts	Yes No N/A
3	Other Insurance	Other insurance COB (Tertiary)	Validating usage of claims filing indicators and COB amounts	Yes No N/A
4	Other Insurance	Other Insurance: Medicare Primary	Validating usage of claims filing indicators and COB amounts	Yes No N/A
5	Other Insurance	Other Insurance: Accident Related	Validating usage of claims filing indicators, accident indicators and COB amounts	Yes No N/A
6	Other Insurance	Other Insurance: Workers Compensation	Validating usage of claims filing indicators and COB amounts	Yes No N/A
7	Other Insurance	Other Insurance: Auto	Validating usage of claims filing indicators, accident indicators, state of accident and COB amounts	Yes No N/A

Institutional Scenarios
#	Scenario	Description	Validation Elements	Included?
8	Format	Service Provider Different Than Billing Or Pay -To	Primary And Secondary IDs	Yes No N/A
9	Service Types	Inpatient Hospital - Surgical	OR Procedure: ICD9, Admit Date, Admit Source, Patient Status, Revenue Codes , Admitting Provider, Operating Provider, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A
10	Service Types	Outpatient Hospital - Medical	Line Item Procedure Codes, Dates, Other Provider, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A
11	Service Types	Outpatient Hospital - Surgical	OR Procedure: HCPC Codes, Line Item Dates of Service, Procedure Codes, Other Provider, Operating Provider, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A
12	Service Types	Outpatient Hospital - Bill Type = 14X	Diagnosis Not Required, Modifer Codes	Yes No N/A
13	Service Types	Outpatient Hospital – Dialysis	Bill Type, Revenue Codes Condition Codes,HCPC Codes,Value Codes, Modifer Usage	Yes No N/A
14	Service Types	Ambulatory Surgical - Hospital Based	Bill Type, or Procedure: HCPC, Line Dates, Line Procedures, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A
15	Service Types	Line Item = Anesthesia - CRNA	Use Of Units = Minutes	Yes No N/A
16	Service Types	Line Item = Anesthesia-Epidural	Surgical Procedure Done By Anesthesiologist, Units	Yes No N/A
17	Service Types	Interim Billing	Bill Type, Revenue Codes	Yes No N/A
18	Service Types	Inpatient - Maternity Claim	Bill Type, Admit Type, Admit Source, Patient Status, Revenue Codes, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A
19	Service Types	Newborn	Bill Type, Admit Type, Admit Source, Patient Status, Revenue Codes, Occurrence Codes, Occurrence Span Codes, Value Codes, Condition Codes, Diagnosis Codes, Modifer Usage	Yes No N/A

Professional Scenarios
#	Scenario	Description	Validation Elements	Included?
20	Service Types	Professional Clinic Visit	Procedure Code And Modifier Usage	Yes No N/A
21	Service Types	Prof Charges Related To IP	Associated Dates of Service	Yes No N/A
22	Service Types	Chiroractic	Extra Segments	Yes No N/A
23	Service Types	Psychiatric-Counselor	Modifier Usage And Professional Degree/Specialty	Yes No N/A
24	Service Types	Psychiatric-Psychologist	Modifier Usage And Professional Degree/Specialty	Yes No N/A
25	Service Types	Psychiatric-Social Worker	Modifier Usage And Professional Degree/Specialty	Yes No N/A
26	Service Types	Occupational Therapy	Procedure/Modifier Usage	Yes No N/A
27	Service Types	Physical Therapy	Procedure/Modifier Usage	Yes No N/A
28	Service Types	Speech Therapy	Procedure/Modifier Usage	Yes No N/A
29	Service Types	Transportation: Ambulance and Helicopter	Procedure/Modifier Usage	Yes No N/A
30	Service Types	DME -Major Equipment Purchase	Procedure/Modifier Usage, Extra Dme Segment	Yes No N/A
31	Service Types	DME - Major Equipment Rental.	Procedure/Modifier Usage, Extra Dme Segment	Yes No N/A
32	Service Types	DME - Supplies - Minor Supply Items Can Be Billed Through Clinic Or Hospital.	Procedure/Modifier Usage, Extra Dme Segment	Yes No N/A
33	Service Types	Line Item Procedure = Unlisted Procedure	Narrative Usage	Yes No N/A
34	Service Types	Home Health Care	Procedure/Modifier Usage, Extra Segments	Yes No N/A
35	Service Types	Anesthesia Services	Units Qualifiers, Codes Used, Modifier Usage.	Yes No N/A
36	Service Types	Medicaid Product, Epsdt - Child And Teen Check Up	Procedure Modifiers, Epsdt Elements	Yes No N/A
37	Service Types	Purchased Services: Diagnostic Testing - Test Sent To Outside Lab, But Billed Through Clinic	Extra Segments	Yes No N/A

Dental Scenarios
#	Scenario	Description	Validation Elements	Included?
38	Format	Service Facility Submitted at Claim Level	Primary And Secondary IDs	Yes No N/A
39	Format	Billing and Rendering Providers are the Same, Pay-to Provider is Different	Primary And Secondary IDs	Yes No N/A
40	Format	Claim Level Rendering Provider Different than Line Level	Primary And Secondary IDs	Yes No N/A
41	Format	Claim Level Place of Service Different than Line Level	Place Of Service Elements	Yes No N/A
42	Format	Billing Provider = Rendering	Primary And Secondary IDs	Yes No N/A
43	Format	Billing , Pay-to and Rendering are all Different Entities.	Primary And Secondary IDs	Yes No N/A
44	Service Types	Oral Surgery-By Oral Surgeon	Billing Format	Yes No N/A
45	Service Types	Oral Surgery By Dentist	Billing Format	Yes No N/A
46	Service Types	Predetermination Of Benefits	Extra Elements	Yes No N/A
47	Service Types	Orthodontic Services Initial	Extra Elements	Yes No N/A
48	Service Types	Orthodontic Services Subsequent	Extra Elements	Yes No N/A

Other Provider Specific Scenarios
#	Scenario	Description	Validation Elements	Included?
49				Yes No N/A
50				Yes No N/A
51				Yes No N/A
52				Yes No N/A
53				Yes No N/A
54				Yes No N/A
55				Yes No N/A