21st Century CLAIMS RECONCILIATION AUTOMATED MANAGEMENT SYSTEM |
FREQUENTLY ASKED QUESTIONS (FAQ) |
3. Will I need any special equipment or software to use CRAM 21? |
10. If I want my own in-house CRAM 21 system, what is the hardware and software requirements? |
14. Does CRAM 21 capable of handling COB (Coordination Of Benefits) Transactions? |
1. What is CRAM 21 - CRAM 21 is a claims reconciliation system for pharmacy drug claims. Pharmacy claims are transmitted, real-time, by providers (pharmacy POS) to insurers in HIPAA NCPDP V5.1 Telecommunications Standard. An immediate response is transmitted by the insurer’s processor to the pharmacy POS in the same HIPAA standard. The pharmacy POS system stores the claims/response data (transferred to CRAM21) for subsequent reconciliation with the insurer’s payment and confirming payment datafile (HIPAA 835) as the payment advice transaction. Upon payment receipt, CRAM21 initiates the process of reconciling the pharmacy claims transaction with the HIPAA 835 payment advice datafile. CRAM 21 then produces a number of exception reports that enables a complete accounting system with controls enabling balanced Accounts Receivable reporting for the pharmacy drug chain claims/payment process. |
2. How will my business benefit from CRAM 21? - Dynamic generation of Accounts Receivable data and controls are now available on demand by the User company. Access by the Internet enables synchronized and consistent information regarding A/R status for the User and any authorized parties to hasten problem resolution. Statement of Accounts are generated on a per-payer, per-month, per-store basis. Summary Statement of Accounts displays all Payers in Unpaid Claims balance sequence to assist collection efforts by the A/R department. The collection effort is also assisted by automatic or demand issuance of Payer Statement of Account by Email to designated parties. It will benefit the drug chain as it will manage better, faster and more accurate claims and payments transaction files. Improved management of claims and payments files will result in a faster collection with less A/R labor and administrative printing and paper expense. |
3. Will I need any special equipment or software to use CRAM 21? - Computer hardware and software is required for those users who choose to maintain their own in-house system. DPRx also offers an ASP service over the Internet whereby all the user needs is a PC with Internet Browser such as Internet Explorer, Mozilla, Firefox or Opera. (We recommend Firefox as this is the closest competitor of IE without the security issues.) By signing up for the ASP service, the Chain is relieved of any database, network or system administration responsibility. DPRx will perform all those jobs including backing up your data. |
4. Can I submit claims right on the internet? - Yes. You can send a claim directly from your PC browser. |
5. Can I submit payment files right on the internet? - Yes. You can send a payment transaction file from your browser. |
6. What types of claims are supported? - Pharmacy Claims in NCPDP V5.1 Telecommunications Standard. This standard is the one adopted by HIPAA law for prescription drug claims processing. DPRx offers customization services if required for data files that are format non-compliant. |
7. What types of payments are supported? - HIPAA 835 Payment Advice format. |
8. Are there any online reports for my claims? or payments? - There are various online reports (html and PDF format) for the claims and payments. There are reports for those claims that have aged for days or months. There is a report for payments that have no available claims. For a complete list of reports, go to the DPRx demo site shown under “Sample Reports”. PDF reports can be downloaded and forwarded to your insurers/payers for faster payment processing by eliminating hard copy paper transmission by mail, FAX or FEDEX. |
9. Will I know the status of a claim? - Yes. Claims are categorized as Open Claims (unpaid) or Closed Claims (Paid Claims). There are also claims which remain conditionally open: such as claims are not yet 100% paid. Other Claim’s status such as Write-Off Claims, Manual Payment Claims, Denied Claims, Reversed Claims and Other Claims is provided as Exception reports. Open Claims are the ones with most importance because these are the claims that are not yet paid by the insurers or payers. All such data is viewable over the Internet on demand with no delay. |
10. If I want my own in-house CRAM 21 system, what is the hardware and software requirements? - For hardware requirements, an Intel based server is required. Dell, HP or IBM sell Intel-based servers. A Quad-CPU, 2.0 Ghz-up, 2-4Gb of memory with SCSI or SATA drives configured in RAID system (the highest HD capacity is advisable). If you expect very large transaction volumes, DPRx can plan and configure a system that Load-Balances the transaction processing. For a system with a Load-Balancer, the minimum number of servers is four and two desktop PC's that will be configured as the load balancer. For software requirements, we require Debian Linux, Apache, Mysql, PHP, PHPLIB, FPDF, CRAM 21 system and other support software that are freely available or GPL licensed that can be downloaded from the Internet. By using Open Source software, your cost of running the CRAM 21 system will minimized. The CRAM21 system is designed to take advantage of the Open Source software and thereby limit the User’s investment in software and mandatory upgrades. |
11. Where do I get claims transaction files? - You obtain your claims transaction files from your in-store Pharmacy POS (Point Of Sale) system or from a pharmacy claims clearing house such as NDC. |
12. Where do I get the payments files? - Payment files are generated by the insurers/payers adjudication system and sent to the pharmacy chain administrator or manager in an electronic format. These are usually stored CD-ROM, DVD, Tapes or transferred electronically via a web based system, FTP (File Transfer Protocol) or any other form of delivery that is agreed to by both the pharmacy chain and the insurer/Payer. Of course the payment in monetary form should also be included. Please note that for electronic transfer of payments data, an electronic transfer of funds may also exist as a separate transaction in a form of EFT or Electronic Fund Transfer. |
13. Does CRAM 21 capable of handling reversal transactions? - Yes. CRAM 21 is capable of processing reversal transactions. A reversal claim transaction is similar to the other claim transactions except that as it is detected during the uploading of data, CRAM 21 searches first for the existing claim and updates the record status as reversed. Of course, the data to be uploaded will be checked first if the reversal was really accepted by the insurer/payer. |
14. Does CRAM 21 capable of handling COB (Coordination Of Benefits) Transactions? - Yes. CRAM 21 is capable of handling Coordination of Benefits records (COB). These are the same as regular transactions except that there is another field of information that identifies it either as a Primary, Secondary, Tertiary payer. |
15. Does CRAM 21 capable of handling Rebilling? - Yes. CRAM 21 is capable of handling Rebilling Transactions. For rebilling transactions, it is a two step process. First, the original claim is reversed. Second, the new transaction is uploaded just like all the other regular transactions. |
16. Is there another way of uploading a large amount of data (claims or payments) in excess of a few megabytes? Yes. Another way of transferring/uploading large amount of data file is using the SSh protocol (SSh – Secured Shell). We are currently using Openssh to implement this. Openssh is a command like interface of uploading data. It is also secured as the login, and copy of data is encrypted. This is also using a Public-Private Key mechanism to handshake between client and server. If you are using a windows machine to upload a data file, putty.exe and pscp.exe can be used as a SSH client program to login and transfer files. The use of putty and pscp is documented in www.dprx.com/cram/ |