NDIA Accountability Project

This project is in DRAFT

Request for Information, Analysis of Evidence, Case Finalisation

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DOCUMENT 2 DISCLOSURE LOG - FOI 24/25-1346 - DOCUMENTS Standard Operating Procedure

National Disability Insurance Scheme

Standard Operating Procedure

Payment Integrity Review Team:

• Request for Information

• Analysis of Evidence

• Case Finalisation

Version 1.0 Released 24/10/2024

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DISCLOSURE LOG - FOI 24/25-1346 - DOCUMENTS StandardStandard OperatingOperating ProcedureProcedure

Table of Contents

Purpose: ……………………………………………………………………………………………………………….. 3

To be used by ………………………………………………………………………………………………………… 3

Prerequisite checklist ………………………………………………………………………………………………. 3

Timeline for claim review process ……………………………………………………………………………… 3

Testing Tool …………………………………………………………………………………………………………… 4

Case Tracker Tab …………………………………………………………………………………………………… 4

Phase 1 – Claims allocation and Request for Information ………………………………………. 4

Creating a SharePoint Case Folder …………………………………………………………………………… 5

Day 1 ……………………………………………………………………………………………………………… 6

Plan Manager Courtesy Email ……………………………………………………………………………….. 6

Request For Information (RTP) Letter …………………………………………………………………….. 7

Phase 2 – Monitor Payment Integrity inbox for response ……………………………………….. 9

Phase 3 – Begin quality analysis process within the Testing tool …………………………… 10

Phase 4 – QA Tracker with relevant links to information ………………………………………. 11

Phase 5 – Send Invitation to Comment letter to the Legal Team and Provider for all

adverse decisions. ………………………………………………………………………………………….. 11

Phase 6 – Review of evidence …………………………………………………………………………. 13

Phase 7 – Send Outcome letter to the provider and move to completed …………………. 14

Version change control ………………………………………………………………………………………….. 17

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DISCLOSURE LOG - FOI 24/25-1346 - DOCUMENTS StandardStandard OperatingOperating ProcedureProcedure

Daily Testing of Provider Plan Manager Claims

selected for Review

Purpose:

The purpose of this Standard Operating Procedure (SOP) is to provide Case Officers with

guidance on the correct process to follow when a claim has been submitted by a Participant,

Provider/ Plan Manager who is subject to a manual payment review.

Case Officers will be responsible for: • Creating a testing tool to review claims that meet the criteria. • Reviewing the claim/s • Contacting a provider primary contact • Resolving the claim enquiry • Communicating the outcome to the provider primary contact • Documenting claim review

To be used by

• Payments Integrity Case Officers (CO’s)

Prerequisite checklist

• The authorised team member (APS6 or above) has applied a Manual Payment Review

to the claim based on the approved criteria. • The APS6 has added the requested claims to the Testing Tool tab of the Case Tracker

Timeline for claim review process Phase 1 Claims allocation and Request for Information

Phase 2 Monitor Payment Integrity inbox for response

Phase 3 Begin quality analysis process within the Testing tool

Phase 4 QA Tracker with relevant links to information

Phase 5 Send Outcome letter to the provider and move to completed

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DISCLOSURE LOG - FOi 24/25-1346 - DOCUMENTS Standard Operating Procedure

Testing Tool

The Testing Tool is where a Case Officer will complete the review of any claims allocated to them. They will answer questions relevant to the review and based upon the answers to these questions will determine the outcome of the review.

Case Tracker Tab

The Case Tracker tab will be used by Team Leaders to monitor the progression of their team’s cases and to record when correspondence and communication is made with the Participant, Provider or Plan manager. The case number column has a formula that aligns the case number allocated to the claimls in the testing tab and summarises that information into one case.

Phase 1 - Claims allocation and Request for Information

  1. The Team Leader (TL) is required to navigate to the Case Trackers in our Payment Integrity Folders in SharePoint.

Documents > Payments Integrity > Payment Lock Referral

D Name v 0. Case Trackers I

  1. RTP Cases

  2. Webform Referrals

  3. Select your TL Case Tracker and open (open in the desktop app).

  4. In the Claims Tab under the Case Status section, filter all ‘Not started -Assigned’.

Case Status a

  1. In the Case column, filter for the relevant RTP number.

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Creating a SharePoint Case Folder

  1. A SharePoint case folder is created using the Project Name to store any correspondence

sent or received relevant to the claim review.

  1. Navigate to the RTP Cases folder in SharePoint.

  2. Navigate to the In Progress folder

  3. Right click on the 02_RTP0000 – Draft Folder and select copy to; navigate to the relevant

Project name folder and copy here.

  1. Refer to your case tracker to obtain the Case Project Name.

  2. Right click on the folder, select Rename and overwrite the folder name with RTP

number assigned. 5

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  1. Any correspondence received or sent will be saved in the 1. Emails folder.

  2. All PDF versions of correspondence will be saved in the 2. Letters folder.

  3. Navigate to the 3. Claims Review folder, select Rename and overwrite the name with the

assigned RTP case number.

  1. Open the RTP – Testing Tool spreadsheet (open in desktop app).

  2. Copy and Paste the claims information from your individual case tracker across to the

Testing Tool tab of the RTP – Testing Tool spreadsheet starting at the Document Number

column. (paste as values).

  1. This will transfer to the RTP0000 – Claim Review tab within the Testing Tool.

  2. Rename both the RTP0000 – Claim Review and RTP0000 – Outcome tab with the

assigned RTP number.

Day 1

Plan Manager Courtesy Email

  1. After the initial checks have been completed in the Testing Tool, we then proceed to

sending out the first letter.

  1. Navigate to the Templates folder, then to the Request for Information Templates folder

and download a copy of the PMA – Notification of payments on hold.msg template. 6

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DISCLOSURE LOG - FOi 24/25-1346 - DOCUMENTS Standard Operating Procedure

  1. To locate the Plan Manager, navigate to Testing Tool tab, in column G you will find the plan manager information

G

Received from BP Name a 4. If the plan manager name if different to the Review Entity Name in column D, you will need to send the PMA notification email. 5. You will need to send a copy of the relevant claims to the plan manager via email. To do this navigate to the Testing tool tab, copy all relevant claims from the Posting Date and PRN fields and paste into the email template.

L Date Submitted Payment Reference Number Posting PRN Date a a 6. Complete the missing sections in the email template using the contact information located in SAP CRM/PACE. 7. Select the paymentsintegrityreview mailbox in the FROM section on the email if not already selected.

From …., 7E(d) - certain operations of agencies r–;-i I I

To I I ——— 8. Address the email to the contact listed above, proofread before hitting SEND. 9. Save a copy of the email in the 1. Emails folder and drag the email from your SENT box to the Provider folder in the group mailbox.

Request For Information (RTP} Letter

  1. Navigate to the 2. Letters folder of the RTP folder previously created and right click on the RTPOXXX Request for Information template and rename, saving using the assigned RTP number under naming convention RTP - Request for Information.

RTP0708 - Request for lnformation.docx

$ RTP0708 - Request for lnformation.pdf

  1. To locate the email address of the Review Entity, navigate to SAP CRM/PACE and search using the provider number found in column C of the Testing tool tab.

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