Bills Overview
This Bill Processing encompasses the majority of functionality within the WCMBP System. The process begins with the submission of bills from multiple sources, such as paper forms (for example the 1500 or UB-04 forms), EDI transactions (837), or via Direct Data Entry (DDE) (using the WCMBP Provider Portal); continues through successful adjudication and pricing; and ultimately generates payments to the provider and/or the claimant.
At each step of the process, the system executes a series of business edits. These edits are composed and maintained in RuleIT™ Rules Engine and are control points dictating the ultimate disposition of a bill (paid, denied, or suspended). The bill data is validated at multiple points during the adjudication process, including validation at the EDI gateway, front-end processing (Mailroom), web portal validations, duplicate identification across claim types, and via procedural categories within the WCMBP System.
Bills that cannot be approved for payment are suspended or denied because they do not meet the policies as set forth and depicted in the defined disposition criteria of each edit and every audit. Suspended bills are routed to assigned work queues based on defined error allocation location for the edits and audits as per the requirement for each DOL program.