Validating a Non-Coverge Gap Submission

About  Non-Coverage Gap Submission

After importing the files into the Validata application, the lines in the file are ready to be validated against a validation set. The validation set tells Validata which validations, called Rule Sets, to perform on the data and how to handle any validation errors that are encountered. You can run any Rule Set validation on the lines in the Submission. Validata records the results and uses them to assign each line an overall status of either Included or Excluded. To learn more about validation, see the Validations documentation.

When creating a new Submission, if the analyst has opted to automate validation within the submission creation wizard, the Submission validation begins automatically without any manual actions. For more information about automatically initiating validation for Submission, see Validation Automation. The analyst can view the validation status within the Submission in the Process and results overview section. For more information about validation progress, see Validation Progress Status Details.

When the analyst has not opted for the automated validation within the submission creation wizard, the validation must be initiated manually for the Submission. 

Run Validation Manually

This section describes how to initiate the validation for a Submission manually.

1. In the Validata application, navigate to the Submission menu.

2. On the Submissions page, from the list table, click the Submission Name link to open the Submission.
   The Submission details page is displayed.

3. Click the Run Validations card.
   Note: The Run Validations button remains inactive when the file upload is in progress. When an error occurs during file upload, the Run Validations remains inactive.
   
   

4. The Run Validations is activated when at least one file upload to the Submission is completed.
   

5. Click Run Validations. The Validation Options window is displayed.
   The Analyst can also open the Validation Options window from the Submission header section.
   Click the ellipses (three dots icon) on the Submission header section. Select Validate & Options.
   

6. Specify the required validation options.

   • Type of validation: Whether to perform the validation using a Single Validation or a Chained Validation. The default is Single Validation.

   • The Run validation on lines with status indicates to the application’s validation execution which transactions, based on the Line Status, will be considered. The user input contains the following selectable options matching the Submissions workflow:

     • New: When the user input is selected as ‘New’, the lines with a Line Status value of New will be considered when validating the lines. The ‘New’ value was formerly known as Imported in the previous Transaction File workflow.

     • Included: When the user input is selected as ‘Included’, the lines with a Line Status value of Included will be considered when validating the lines. The ‘Included’ value matches the value of the same name in the previous Transaction File workflow.

     • Excluded: When the user input is selected as ‘Excluded’, the lines with a Line Status value of Excluded will be considered when validating the lines. The ‘Excluded’ value matches the value of the same name in the previous Transaction File workflow.

   • Validation set: Select the name of the Validation Set that will be used for validating the Submission. The list includes only Validation Sets or Chained Validation Sets based on the input for the Type of validation.

   • Duplicate check indicator: Specify the duplicate check status that will be considered while validating the Lines:

     • Processed: To validate the Submission Lines that were checked for duplicates previously.  

     • Not Processed: To validate the Submission Lines were not checked for duplicates previously.

     • All: To validate all the Submission Lines irrespective of whether they were checked duplicates previously. This is the default value.

   • Publish status: Specify the publish status of the lines that will be considered while validating the lines:

     • Published: To validate the Submission Lines with Published status.

     • Not Published: To validate the Submission Lines with Not Published status.

     • All: To validate all the Submission Lines irrespective of whether they were Published or not.

   • Include all dates of service: By default, the Include all dates of service is set to Yes; this means all the utilization lines, irrespective of their Date of Service, will be validated.
     When the Include all dates of service is set to No, you can specify the Date of Service period. That means all the utilization lines whose Date of Service falls under the specified start and end date will be validated. The utilization lines in the Submission whose Date of Service does not fall under the provided start date and end date period will be ignored during the validation of the Submission.
     Select the Start date and End date of the Date of service period using the calendar widget or enter manually in the MMDDYYYY format.

7. To start the validation, click Run Validations.

Validation Progress Status Details

Irrespective of automated or manual initiation of the validation process, the progress of the validation process is the same. You can verify the progress or validation status within the Submission in the Run Validations card. 

• :  This icon specifies that the file upload has been completed and validation can be initiated; user input is required to start the validation.

• :  This icon specifies that the system is running Submission validation.

• : This icon specifies that the Submission Validation has been completed. After the validation is completed, the Re-Validate and Mark Complete option is populated on the screen.
   

  • Using the Re-Validate option, the Analyst can revalidate a Submission. For more information about Submission revalidation, see Re-run the Validation Process. 

  • Using the Mark Complete option, the Analyst can notify the Validata application validation result review and analysis has been completed. For more information about marking a Submission as complete, see Mark Submission Validation Complete.

Re-Validate a Non-Coverage Gap Submission

The Validation Analyst can validate a Submission using different Validation Sets. Once a Submission is validated using a Validation Set, the Analyst can re-validate the Submission by choosing another Validation Set under the Validation Options section.

When the Validation Analyst makes some changes to the Submission once the first validation has been processed, the Analyst has to rerun the validation for the respective Submission. The Analyst has to re-validate a Submission when the following changes are made to the Submission after the first validation has been processed:

• Including additional files to the Submission.

• Changing the existing Mapping Set of any included files in the Submission.

• Change the Contract Details for the Submission at the header level or at the line level.

When the Analyst makes any one of the above changes and proceeds to save changes, the following confirmation message is displayed on the page:

Click Yes to proceed with saving the changes.

Mark Submission Analysis Complete 

When the Submission validation is completed, the Analyst can view the Submission Line Level details and make required overrides and status changes in the Line Level Details tab. Once the Submission validation result analysis and review are completed, the Analyst has to mark the Submission Analysis as complete to indicate to the application that the Submission validation analysis and review have been completed and the Submission is ready to be published. When Submission is marked as Analysis Completed, the Publish card action will be activated for user action.

Click the Mark Complete button. When the Analysis is marked as completed, the Mark Complete button becomes inactive, and the completed status is displayed for Analysis.

Note: When an error occurs during the validation process in the validation card, the status is displayed as Error, and the Run Validations button is displayed.

How the Run validation on line with status option works for different Submission types

This section is applicable to Spring 2024 RP3 HF1 and later releases.

When user validates Submissions with only Medical Benefit using no templates and with automatic validation, the New and Included line statuses are selected by default and disabled for the Run validation on line with status option. The Submissions move to the Review state, and error codes are stamped. For lines marked as Excluded, the users need to review the JCode conversion status and its corresponding errors, in addition to the Error Code column.

To revalidate the Submissions, click the ellipses (three dots icon) on the Submission header section, select Validate & Options,  select the required line statuses for the Run validation on line with status option, and click Run Validations.

When user validates Submissions with only Pharmacy Benefit using no templates and with automatic validation, only the New line status is selected by default and disabled for the Run validation on line with status option.

When the user validates Submissions with both the Medical and Pharmacy Benefit using no templates and with automatic validation, the New and Included line statuses are selected by default and disabled for the Run validation on line with status option.

The following table summarized the line statuses selected for the Run validation on line with status option for different Submission types: