CHS DATA MOVEMENT PROCESSES

Federal and Tribal Facilities Using the CHS FI

Creating Purchase Orders
Transmitting Data
Loading of EPO Data at the CHS FI
Creating EOBRs and Export Files for NPIRS
Updating CHS/MIS Purchase Orders with EOBR Data
Transmitting CHS Data to PCC (If CHS to PCC Link is On)

Tribal Facilities Using CHS/MIS but not the CHS FI

Creating Purchase Orders
Updating the CHS/MIS Purchase Orders with Final Payment Data
Transmitting CHS Data to NPIRS
Transmitting CHS Data to PCC (If CHS to PCC Link is On)

Tribal Facilities Not Using CHS/MIS or the CHS FI

Creating Purchase Orders
Updating the CHS/MIS Purchase Orders with Final Payment Data
Transmitting CHS Data to NPIRS

Area Consolidation Process

Data Movement Comparison

Keeping CHS Data Current

Updating CHS/MIS Application
Updating CHS FI Application
Updating PCC Application

Episode of Care

Data Sent with Two-year Dates

Getting Started

Facilities operated/managed by a specific tribe rather than by the Indian Health Service are generally referred to as "638" facilities, meaning the tribe operating the facility has either compacted or contracted using the Public Law 93-638 (PL 93-638) process. Such facilities may choose to use the Resource Patient Management System (RPMS) Contract Health Service/Management Information System (CHS/MIS) application for entering and maintaining their CHS data, or they may select a different application. In addition, the tribes can coordinate benefits and payments of the CHS visits by:

• using the FI to coordinate benefits and pay the providers,
• performing the work themselves, or
• contracting with a third party for these services.

Flowchart 1 in Appendix 2-A provides a complete overview of the CHS data movement process.

Appendix 2-A Chart 01 [DOC-327KB]

Federal and Tribal Facilities Using the CHS FI

All federally operated facilities and tribally operated facilities using the services of the CHS FI are required to use CHS/MIS (a component of RPMS) for entering and maintaining CHS data.

The first step in entering CHS data into the CHS/MIS application is to create a purchase order. The user will enter:

• the type of service (such as hospital, dental, or outpatient),
• the provider,
• information about the patient, (i.e. name, chart number),
• estimated date of service for a routine office visit or actual date of service for an emergency room visit,
• estimated charges,
• payment destination, and
• other data as indicated.

The user will enter the payment destination when creating a new purchase order; the choice for payment destination determines where the data will be exported. Federal and tribal sites using the CHS FI will normally select a payment destination of "F" and the data will be exported to the CHS FI so that the FI may make payment to the provider. An exception to this rule is if a site changes the payment destination to "I", which then exports the data to NPIRS (as opposed to the CHS FI) and is performed when there is a federal contract that has been paid for by the Area Office.¹ Tribal sites not using the CHS FI will select a payment destination of "I" and the data will be exported to NPIRS.

Federally operated sites may change the payment destination to "I", which creates a Type 7 record for NPIRS. The record is then sent to NPIRS in the CHS638 exports, and is commonly perceived as being sent by the tribal (638) site. Unfortunately, there is no information in the export file to distinguish 638 from non-638 data, so all data in this export is processed and referred to as CHS638 data.

A federal program will only send records that have allowable object class codes from CHS/MIS in the CHS638 exports and that have a payment destination of "I." These are, generally, federal contracts paid for by the Area Office. The only duplication would be with PCC if the link were set to "on." No duplication should exist between the CHS FI.

Transmitting Data

The initial purchase order information is electronically transmitted from the facility to the respective Area Office for consolidation² and transmission.

Refer to page 2-6 for additional information on the actions that occur during the Area consolidation process.

The types of records transmitted depend on whether the facility is federally operated (IHS) or tribally operated, and if the CHS FI has been contracted with to perform payment to the service provider/vendor (IHS administered sites-i.e. federal sites-are required to contract as a whole with whomever is awarded the FI contract. Tribal contract/compact tribes may contract with any FI or not contract with an FI at all). Federal facilities using the CHS FI transmit Records 2-5 to the Area Office. The Area Office then transmits Record 2 to the IHS finance system (CORE) and transmits Records 3-5 (i.e. the electronic purchase order [EPO]) to the CHS FI. Tribally operated facilities using the CHS FI transmit Records 3-5 to the Area Office, which then transmits Records 3-5 (i.e. the EPO) to the CHS FI.

Worth noting is the practice of IHS paying vendors directly from an Area office. Some Area Offices have contracts between two federal agencies or unique contracts for that Area; there could also be a negotiated agreement between the Area Office and the vendor for a certain type of service, but only one entity would pay for that type of service. An example: a contract was negotiated for the taking of x-rays to be paid for by the Area Office and the reading of x-rays to be paid for by the FI, but no single part is paid for by both IHS and the FI. In such case, visit information may or may not be sent to NPIRS. If the facility is entering information into PCC, it may be received by NPIRS-otherwise the information is not sent to NPIRS.

Loading of EPO Data at the CHS FI

The normal manner in which claims records are created at the CHS FI, after the Area offices have exported the EPO data to the CHS FI, the data is automatically loaded into the FI's Indian Health Service Claims Processing System (IHSCPS) and claims records are created from the EPOs.

A less common method for creating records in the IHSCPS occurs when the CHS FI receives a hardcopy purchase order from a provider requesting payment prior to the FI receiving the EPO from the Area Office. When this happens, the CHS FI clerk must manually create a record in the IHSCPS using data from the claim and the purchase order.

The CHS FI receives additional obligation information (I313) from the CORE and claim information from the provider. The CHS FI then determines if payment should be made to the provider.

Creating EOBRs and Export Files for NPIRS

After the CHS FI pays the provider, two actions occur: (1) Electronic Explanation of Benefits Reports (EOBRs) are created and made available to the Area offices, and (2) export files are created containing CHS outpatient and inpatient data (sent in STATRECS files) and CHS dental data (sent in DENTSTAT files) that are electronically transmitted to NPIRS. NPIRS unduplicates and loads this data into its database.

EOBR data includes both medical and payment information about the claim, including:

• diagnosis and procedure codes,
• actual dates of service,
• actual paid amounts, and
• other relevant information.

Updating CHS/MIS Purchase Orders with EOBR Data

The Area Office obtains the EOBR data from the CHS FI, splits the EOBRs into separate files for each facility, and transmits them to the respective facilities. The facilities will then process the EOBRs in the CHS/MIS application. During this process, the purchase orders are updated with the information contained in the EOBRs.³

Occasionally, during the processing of the EOBRs, there may be a scenario where the EOBR does not find a match with the existing purchase order in CHS/MIS. This could result in the final payment not being posted to the existing purchase order, thereby preventing the information from being transmitted to PCC, which likewise prevents the PCC encounters from being created. When this happens, the CHS clerk should manually post the information from the hardcopy of the EOBR into CHS. Afterwards, the clerk should run the option in the CHS/MIS application that moves CHS data to PCC, transmitting the data for purchase order over to PCC.

For example, if the CHS FI made final payment to a provider, there will be a final pay EOBR. A final pay EOBR will update the existing purchase order in CHS/MIS with payment and medical information and the purchase order status will be changed to "closed." The EOBR update process will occur automatically for tribally operated facilities if the 638 program purchased the automatic update option. Tribally operated facilities that did not purchase the option must manually enter the EOBR data into the existing purchase orders. The update process occurs automatically for all federal facilities.

Transmitting CHS Data to PCC (if CHS to PCC link is On)

Once final payment has been posted to a purchase order in CHS/MIS, the information may be automatically transmitted electronically to RPMS' Patient Care Component (PCC), which is the central clinical repository at the facility. In order for the automatic transfer to occur, the link from CHS/MIS to PCC must be in the "on" position at the facility. If the link (which is set independently at each facility) is not on, then CHS data are not entered into PCC. For example, facility "A" in Billings Area may have an on link, while the link at facility "B" in Billings Area may be off. After the medical data have been transmitted to PCC, PCC encounter records are created and the records will be sent in the next export of the facility's PCC data to NPIRS via the Area office.

Additionally, there is a less common method to enter CHS data directly into PCC, independent of the CHS/MIS application. PCC data for CHS hospitalizations and visits are entered from CHS billing documents HRSA 43 and HRSA 64 and/or universal billing documents such as HCFA 1450 or HCFA 1500. These forms are completed by the CHS administrative staff and contract providers/vendors. Only documents with a final pay are entered into PCC using the options MIN or ENT from the PCC data entry menu, as described in Appendix 2-B.

Illustrations depicting the data movement process for federally and tribally operated facilities using the CHS FI are included in Appendix 2-A, Flowcharts 2 through 5.

Appendix 2-A Chart 02 [DOC-36KB]

Appendix 2-A Chart 03 [DOC-35KB]

Appendix 2-A Chart 04 [DOC-32KB]

Appendix 2-A Chart 05 [DOC-34KB]

Tribal Facilities Using CHS/MIS but Not the CHS FI

The process of entering and maintaining CHS data in the CHS/MIS application for tribally operated/managed facilities that are not using the CHS FI is similar to the process for sites that are using the CHS FI.

The first is to create a purchase order in the CHS/MIS. The user will enter:

• the type of service (such as hospital, dental, or outpatient),
• the provider,
• information about the patient, (i.e. name, chart number),
• estimated date of service for a routine office visit or actual date of service for an emergency room visit,
• estimated charges, and
• other data as indicated.

Unlike facilities that use the FI, the tribe coordinates the benefits of the patient, determines if payment should be made, and makes payment to the provider. Coordination of benefits means if the patient has other insurance (such as Medicare, Medicaid, or private insurance) the tribe will wait for the other insurance groups to pay the provider and then the tribe would pay the remaining balance.

Updating CHS/MIS Purchase Orders with Final Payment Data

Once the final payment to the provider has been made, a CHS clerk will manually post the final payment to the existing purchase order in CHS/MIS and enter any additional medical data from the provider's claim. Once complete, the purchase order status will be changed to closed. If the final payment is not posted, the purchase order will remain open and the information will not be transmitted to NPIRS and PCC, which could have a negative impact on CHS workload and/or user population counts.

Transmitting CHS Data to NPIRS

Once final payment has been posted to a purchase order in CHS/MIS, CHS data will be electronically transmitted from the facility to the respective Area office for consolidation and transmission. Tribally operated facilities not using the FI, but which transmit data to their respective Area Office, transmit Records 6 and 7 to the Area Office. The Type 6 Record remains at the Area Office for the Area's use/ information. The Type 7 Records (records specially reformatted during the consolidation process) are transmitted to NPIRS. Type 7 Records are sent in files prefixed with "chs638." NPIRS unduplicates and loads this data into its database.

Tribally operated facilities using the CHS/MIS application, but do not use the FI and do not send data to the Area Office, send the Type 7 to NPIRS not specially formatted for NPIRS. These records are sent in files prefixed with "ACHS." NPIRS then functions as the Area Office and processes the file through the MUMPS CHS consolidation application to reformat the Type 7 records, which are then output in files prefixed with "chs638." The consolidation must occur before NPIRS can load the records into the NPIRS database.

Transmitting CHS Data to PCC (If CHS to PCC Link is On)

Once final payment has been posted to a purchase order in CHS/MIS, the information may be automatically transmitted electronically to RPMS' Patient Care Component (PCC), which is the central clinical repository at the facility-however, the link from CHS/MIS to PCC must be in the "on" position at the facility. If the link is not on (set independently at each facility) then CHS data are not entered into PCC.

Illustrations depicting the data movement process for tribally operated facilities using CHS/MIS but not using the CHS FI are included in Appendix 2-A, Flowcharts 6 through 9.

Appendix 2-A Chart 06 [DOC-31KB]

Appendix 2-A Chart 07 [DOC-29KB]

Appendix 2-A Chart 08 [DOC-31KB]

Appendix 2-A Chart 09 [DOC-29KB]

Tribal Facilities Not Using CHS/MIS or the CHS FI

The first step is to create a purchase order in the application that the tribe has selected for maintaining its CHS data. The user will enter:

• the type of service (such as hospital, dental, or outpatient),
• the provider,
• information about the patient, (i.e. name, chart number),
• estimated date of service for a routine office visit or actual date of service for an emergency room visit,
• estimated charges, and
• other data as indicated.

Unlike facilities that use the FI, the tribe or a third party with whom the tribe has contracted coordinates the benefits of the patient, determines if payment should be made, and makes payment to the provider.

Once final payment has been paid to the provider, a CHS clerk will manually post the final payment to the existing purchase order and enter any additional medical data from the provider's claim.

Transmitting CHS Data to NPIRS

At the time of this report, it is not known if all tribal facilities that send CHS data directly to NPIRS do so only after the final payment has been made to the provider and the purchase order closed. Tribal facilities may be sending data to NPIRS before final payment has been made. In addition, the format of the data files may vary from facility to facility; the files may be transmitted to NPIRS via FTP or some other method.

Once NPIRS receives the files, it reformats the records to what is called an "old format," which readies the records for loading. NPIRS then unduplicates and loads the records into the database.

An illustration depicting the data movement process for tribally operated facilities that do not use the CHS FI or CHS/MIS is included in Appendix 2-A, Flowchart 10.

Area Consolidation Process

The following occur during the consolidation process:

• The Area office receives export files from its respective federal and tribally operated operating units. These files are then consolidated into a single file using a MUMPS CHS application. Each record in the file is assigned a record type (i.e. records 2-7) to identify the type of data it contains.
• Based on the record types, the records are then split into separate files for the CORE, FI, and NPIRS exports.
• The CORE receives Type 2 records only, which contain obligation information.
• The FI receives Type 3 (patient), 4 (provider), and 5 (purchase order) records, which contain information such as the patient name, type of insurance, beginning date of service, and estimated obligation amount.
• Type 6 records remain at the Area office.
• NPIRS receives Type 7 records only, which are the statistical records, and are sent in files prefixed with "chs638." These records are sent only if the final payment has been made to the provider.
• The files for CORE and the FI are transmitted via file transfer protocol (FTP) automatically, whereas the file for NPIRS must be transmitted manually via FTP.

Data Movement Comparison

The following table delineates the differences between tribally operated (i.e. 638) facilities that use the CHS FI and those that do not use the CHS FI.

Tribally Operated Facilities using CHS/MIS and not the FI In the CHS/MIS application, the payment destination is set to "I" (IHS) in order to create the statistical (Type 7) record for NPIRS. The Area Office does not send a separate file to the FI. The Tribe coordinates the benefits and makes payment to the provider. There are no EOBRs sent from the CHS FI to the Area Office. There are no EOBRs sent from the Area Office to the respective facilities. The Tribe posts the final payment and medical data into CHS/MIS application. CHS data from the facility is sent to the Area Office for consolidation and export to NPIRS. NPIRS receives data in CHS638 export from the Area Office.

Tribally Operated Facilities using the FI In the CHS/MIS application, the payment destination is set to "F" (CHS FI) in order to create the electronic purchase order (Type 3, 4, and 5 records) for the CHS FI. The Area Office sends a separate file to the FI. The CHS FI coordinates the benefits and makes payment to the provider. The CHS FI posts the payment and medical data into its own application (IHSCPS). The CHS FI transmits EOBRs to the Area Office. The Area Office downloads the EOBRs and transmits them to the respective facilities. The facilities upload the EOBRs into CHS/MIS in order to update its existing purchase orders. NPIRS receives data in the STATRECS or DENTSTAT export from CHS FI.

Keeping CHS Data Current

The following scenarios describe in what manner existing records are updated in each application.

Updating CHS/MIS Application

Purchase orders in the CHS/MIS application are updated with EOBR or final payment data as described in Updating Purchase Orders with Final Payment Data.

Existing purchase orders may also be completely canceled or partially cancelled. A user would completely cancel a purchase order if it was created in error. A purchase order would be partially cancelled if the original purchase order amount was over-estimated. For example, a purchase order for an office visit had an estimated cost of $75.00. Before final payment was made to the provider, it was discovered the patient had insurance and the CHS cost is only the co-pay of $15.00, necessitating a partial cancel of $60.00. When the partial cancel is complete, it restores funds from the Federal/local budget accounting system back to the CHS program, making it available for other uses.

Updating CHS FI Application

CHS FI claims records are created in the Indian Health Service Claims Processing System (IHSCPS) from the electronic purchase orders (EPOs) sent from the IHS Area offices or by CHS FI staff who create a record when a claim from a provider is received prior to the FI receiving the EPO from the Area Office. The IHSCPS records may be updated by the following methods:

• Updated automatically from EPOs received from the IHS Area offices, in the event a purchase order has changed from the last time the Area office transmitted it to the FI.
• Updated from new information received in a hardcopy purchase order or claim sent by a provider. These documents generally include more detailed information than the EPO, such as the diagnosis, actual dates of services, and other relevant information.
• Updated to indicate payment has been made to the provider, thereby closing out the purchase order.

Updating PCC Application

PCC encounter records may be created automatically by transmitting CHS data from CHS/MIS to PCC when the CHS to PCC link is set to the on position and final payment has been posted to a purchase order. The other method for creating CHS encounters is to directly enter them in PCC. Updating these encounters in PCC is as follows:

• CHS encounters in PCC created from medical data transmitted from the CHS/MIS application are updated automatically by a lookup on the original visit, deleting it, and restoring it with the updated information retransmitted from CHS/MIS, if any.⁴ Though data is only passed when the PO receives final payment and the PO is closed, occasionally a closed PO may be updated if additional medical data is obtained or if there is a refund that changed the PO amount.

  The Unique Visit ID of the original PCC encounter is also deleted and replaced with a new Unique Visit ID.

• CHS encounters created by entering the data directly into PCC (i.e. independent of the CHS/MIS application) may be updated by either modifying only the existing data using the Modify Data option in PCC or updated by modifying existing data and/or adding new data by using Append option in PCC. When selected, both options prompt for the patient name and visit date (see Appendix 2-C for instructions on modifying and appending existing CHS records in PCC).

Episode of Care

Defining what constitutes a CHS episode of care in the different applications (CHS FI's IHSCPS, CHS/MIS, and PCC) with the intent of developing a single definition across the applications proved problematic for the workgroup. Because of time constraints and higher priorities, the members unanimously agreed that determining a "one size fits all" definition was impractical at this time. See Appendix 2-D for a brief white paper relevant to defining an episode of care.

Data Sent with Two-Digit Year Dates

The tribally operated facilities listed below are still transmitting statistical CHS data to NPIRS with dates that are non-Y2K compliant, meaning they are sending dates, such as date of service and date of birth, in the two-digit year format (e.g. 99, 00, 97) rather than with the four-digit year format (e.g. 1999, 2000, 1997).

• 353901 (Norton Sound)
• 454810 (either Rocky Boy HC or Chippewa Cree Health Clinic)
• 661910 (Redding Rancheria)
• 757810 (Roger Saux H)

Since the NPIRS database stores dates in a four-digit-year format, these dates must be converted, or recoded, before they can be stored. The former Data Quality Action Team developed and approved the processing logic that NPIRS currently uses in its load programs. The logic is shown in the table below.

Original Date of Service Year	Recoded Date of Service Year	Original Date of Birth Year	Recoded Date of Birth Year
97	1997	00-97	19XX
97	1997	98-99	18XX
98	1998	00-98	19XX
98	1998	99	18XX
99	1999	00-99	19XX
00	2000	00	20XX
00	2000	01-99	19XX
01	2001	00-01	20XX
01	2001	02-99	19XX
02	2002	00-02	20XX
02	2002	03-99	19XX
03	2003	00-03	20XX
03	2003	04-99	19XX

For example, if a record is received with a date of service of 040197, the year value of 97 will be recoded to 1997. If the birth date for that same record had a date of birth of 051500, the birth year value will be recoded to 1900.