Coverage Gap Dispute Process

Overview

When a Coverage Gap Submission is validated, and the Coverage Gap data file line is assigned with a validation error, the process starts where the Validation Analyst can dispute the lines on the Data lines tab within the Coverage Gap Submission. Generate the dispute submission file and share it with TPA. The dispute process for Coverage Gap data files follows a specific process with statuses defined by the TPA. The Dispute Status follows this progression:

• Disputed: Disputes are identified by the manufacturer but not yet reported to the TPA.

• Submitted: Disputes are identified and have been submitted to the TPA, but no reply has been sent.

• Accepted: The TPA has accepted the dispute for consideration. The status is obtained from the dispute return report.

• Rejected: The TPA has rejected the dispute for consideration. The status is obtained from the dispute return report.

• Resubmit: Errors that caused rejection have been updated and the item can be resubmitted for dispute consideration.

• Upheld: The TPA has reviewed and upheld the dispute. The status is obtained from the dispute resolution report.

• Denied: The TPA has reviewed and denied the dispute. The status is obtained from the dispute resolution report.

Updating the Dispute Status for the Data Lines

The Analyst can either bulk edit and change the Dispute status for all the lines or individually perform the action by selecting desired lines on the Data line tab.

To update the Dispute Status:

1. On the Submissions list table, open the Coverage Gap Submission.

2. Navigate to the Data Lines tab.

3. Perform one of the following options:

   • To change the Dispute Status of all the rows listed on the Data lines list tab:

     1. Select the checkbox at the table header to select all the rows.

     2. A set of actions are displayed above the list table.

     3. Click the Dispute tab. Dispute options are displayed.

     4. By default, the Dispute Selected Lines toggle is set to No. Set it, Yes to dispute the line.

     5. Enter the dispute information details in the Dispute information text box.

     6. Click Apply.

   • To change the Dispute Status for a single row:

     1. On the list table, for the selected line row, set the Dispute toggle as Yes.
        A confirmation message is displayed showing the line count that has been disputed.

     2. The Dispute Text column will be highlighted for the row. Click on the highlighted text area and enter the Dispute information text.

4. When the lines are marked as disputed:

   • The Dispute Status column value is updated as Not Submitted.

   • The Dispute Reason Code column is updated with the dispute reasons associated with the data line. When a line is assigned with more than one dispute reason code, the Analyst can set a dispute reason as primary. For more details see Setting a Dispute Reason as Primary for a Data Line.

   • The Dispute Text column is updated with the dispute information added in the above step.

The rest of the Dispute Status updates will occur when reading the TPA dispute file for a Coverage Gap data file. When this happens, Validata looks for the lines with the Dispute Status that matches the incoming dispute file and updates the line appropriately.

Generate the Submission Dispute Report

Generate the Submission Dispute Report that will be shared with the TPA. The Dispute Submission Report includes Coverage Gap data lines with the Dispute Status you select to be included in the report.

To generate the report:

1. Within the Coverage Gap Submission, in the Submission header details section, click the ellipses icon.

2. Select the Export submission dispute report option.

3. The Export dispute submission report window is displayed. On the Export dispute submission report window:

   • The Dispute status field allows the Analyst to select the Dispute Status for which a report will be generated.

     Note: When there are lines with only one Status option the Dispute status field remains as a read-only option. The Analyst can not make any edits in this field. The count of rows from the data lines table that will be exported is displayed.

   • In the File name text box, a default report file name value is displayed. The default report file name is auto-created based on the Submission Name. The Analyst can either create the export file with the default name or else they can revise the file name as required.

4. Click the Export button.

5. The following confirmation message is displayed:

6. To view the generated report:

   • Within the Coverage Gap Submission, in the Submission header details section, click the ellipses icon.

   • Select the Download dispute report option.

   • In the Download Disputes window, download the generated PDF report.

     The downloaded Submission Dispute Report can be shared with the TPA for further action. This file supports signed overpunch, as required by the TPA. For more information, see Special Considerations for Coverage Gap Files. The appropriate headers and trailers are added to the file, as required by the TPA. Note that the Detail Record Count, Total Reported Gap Discount Previous Amount, Total Reported Gap Discount Current Amount, and Total Gap Discount Amount This Period are not included in the Submission Dispute Report. The TPA Administrator sends back the TPA Dispute Return File. For more details see Uploading and Reading a TPA Dispute Return File.

When the Dispute Submission report generation process is completed, the Dispute Status for the submitted lines is set to ‘Submitted’.

Uploading and Reading a TPA Dispute Return File

The Coverage Gap data files have a “pay and chase” approach for disputing. This means that the client has to pay upfront and then dispute the data. If the Third Party Administrator (TPA) upholds the dispute, the client does not reverse the payment; the TPA simply submits a correction. The TPA Dispute Return File is the first file sent by the TPA in the disputing process, used to display the inbound dispute information from the TPA process. The TPA dispute return file either results in the stamping of the line as accepted or rejected for review.

If they accept something for review, it does not mean that the dispute will be upheld, just that it is under consideration. This file also includes dispute edit codes indicating the reason why something was rejected, which would primarily be if the file is missing the required information.

To upload a TPA Dispute Return File:

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

2. Open the Coverage Gap Submission to which you want to add the TPA dispute files.

3. Navigate to the File tab.

4. In the Select additional file section, using the Browse Local Files option, search and select the Dispute Return file.

5. In the Uploaded files section, choose the File Type column value as ‘Dispute Return'.
   Note:

   • The application locks the initial selection for the File Type option. The Analyst can not alter the previous selection.

   • Mapping set selection is not required for a dispute resolution file.

6. Click the Save button to save the changes done on the File tab. When the processing of the file is completed and the Dispute Return is uploaded successfully to the Coverage Gap Submission, the Validation Analyst can view the result on the Data lines tab as below:

   • When a matching line is found, but the Dispute Status of the line is something other than Submitted, no updates are made when reading the TPA Dispute Return file.

   • When the system finds a match where the Dispute Status is Submitted, the line is updated based on the record type of that item in the TPA Dispute Return file, as follows:

     • Accepted: The TPA has accepted the dispute for consideration. The status is obtained from the dispute return file.

     • Rejected: The TPA has rejected the dispute for consideration. The status is obtained from the dispute return file.

   • For a rejected line, the edit codes in the TPA file (fields 24-33) are assigned to the line in the TPA Dispute Edit Codes field on the Data lines list table.

     Note: When a line is stamped with Dispute Status as ‘Rejected’ the Validation Analyst can again dispute. For more details see Disputing Lines with Rejected Status.

Note: When a line is updated with a dispute status of “Accepted” there are no dispute actions needed to be made on that line. Therefore, the user should not be able to edit the dispute information or change the primary dispute reason code.

Disputing Lines with Rejected Status

When the TPA Administrator rejects a data line, after loading the TPA Dispute Return File to the Validata application, on the Data line tab the Dispute Status of the line is updated to Rejected. When a line is stamped with Dispute Status as ‘Rejected’ the Validation Analyst can again dispute.

1. On the Submissions list table, open the Coverage Gap Submission.

2. Navigate to the Data Lines tab.

3. Follow one of the below options:

   1. Option 1:

      1. Select the checkbox at the table header to select all the rows. A set of actions are displayed above the list table.

      2. Click the Dispute tab. Dispute options are displayed.

      3. The Dispute Selected Lines toggle is set to Yes and the toggle is read-only state. The Analyst can not make any change to this toggle.

      4. Enter the dispute information details in the Dispute information text box.

      5. Click Apply.

   2. Option 2:

      1. On the Data line list table scroll to the Dispute Text column. For a data line with a Dispute Status value 'Denied the column value can be edited.

      2. Specify the dispute text information. Press the enter key or move outside of the text area.

When the rejected lines are marked as disputed:

• The Dispute Status column value is updated as ‘Ready to re-submit’.

• The Dispute Text column is updated with the dispute information added in the above step.

• The TPA Dispute Edit Code column error codes are no longer displayed for the data line.

Generate the Submission Dispute Report for the Re-Submitted Lines

Generate the Submission Dispute Report for the re-submitted lines that will be shared with the TPA. The Dispute Submission Report includes Coverage Gap data lines with the Dispute Status you select to be included in the report.

To generate the report:

1. Within the Coverage Gap Submission, in the Submission header details section, click the ellipses icon.

2. Select the Export submission dispute report option.

3. The Export dispute submission report window is displayed. On the Export dispute submission report window:

   1. The Dispute status field allows the Analyst to select the Dispute Status for which a report will be generated.
      By default both the Ready to re-submit and Submitted options are selected. You can proceed with the default selection to export the submission dispute report for all the lines or change the selection based on your requirements.

   2. In the File name text box, a default report file name value is displayed. The default report file name is auto-created based on the Submission Name. The Analyst can either create the export file with the default name or else they can revise the file name as required.

4. Click the Export button.

When the dispute submission report generation process is completed, the Dispute Status for the submitted lines is set to ‘Submitted’. The generated dispute submission report is shared with the TPA for further action on the lines that were previously rejected. The TPA Administrator sends back the dispute resolution file. For more details see Uploading and Reading a Dispute Resolution File.

Uploading and Reading a Dispute Resolution File

The dispute resolution file is the second file sent by the TPA in the disputing process indicates if the dispute is upheld or denied for the lines. This file also includes a text field for dispute resolution text for any additional information on why the dispute was upheld or denied.

To upload a TPA Dispute Resolution File:

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

2. Open the Coverage Gap Submission to which you want to add the TPA dispute files.

3. Navigate to the File tab.

4. In the Select additional file section, using the Browse Local Files option, search and select the Dispute Resolution file.

5. In the Uploaded files section, choose the File Type column value as ‘Dispute Resolution'.
   Note:

   • The application locks the initial selection for the File Type option. The Analyst can not alter the previous selection.

   • A dispute return file will always come before a dispute resolution file. The Analyst can not select ‘Dispute resolution’ as a file type until a previous file is uploaded and selected as ‘Dispute return’.

   • Mapping set selection is not required for a dispute resolution file.

6. Click the Save button to save the changes done on the File tab. When the processing of the file is completed and the Dispute Resolution file is uploaded successfully to the Coverage Gap Submission, the Validation Analyst can view the result on the Data lines tab as below:

   • When a matching line is found, but the Dispute Status is something other than Accepted, no updates are made when importing the TPA file.

   • When the system finds a match where the Dispute Status is Accepted, the line is updated based on the Dispute Disposition field in the TPA file, as follows:

     • Upheld: The TPA has reviewed and upheld the dispute. The status is obtained from the dispute resolution report.

     • Denied: The TPA has reviewed and denied the dispute. The status is obtained from the dispute resolution report.

   • For a denied line, the dispute resolution text in the TPA file (fields 932-1011) is added to the respective line and populated on the Dispute Resolution Text column.

Note:

• When a line is updated with a dispute status of “Upheld” there are no dispute actions needed to be made on that line. The Analyst can not edit the dispute Information or change the primary dispute reason code.

• When a line with a Dispute Status of Accepted > Submitted is updated to ‘Denied’ from the dispute resolution file, the Analyst can proceed with updating the primary dispute reason code and editing the dispute information to allow the Analyst to re-dispute as desired. In this scenario, the dispute process flow is as below:

• For a denied data line the text displayed on the Dispute Resolution Text column can not be updated unless the following dispute resolution file is uploaded and the line is denied again in the dispute process. In that scenario on the Dispute Resolution Text column, the revised text retrieved from the latest dispute resolution file will be displayed. When the latest dispute resolution file contains a blank value, in the Data lines list table a blank value will be displayed on the Dispute Resolution Text column.

The Analyst can follow the above dispute process for the data line if there is still time allotted in the Days to Dispute header information or the current date has not surpassed the Dispute due date. Lines can be disputed and multiple dispute return/dispute resolution files can be uploaded.

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