Here are some sample functional requirements for the Physician Mgmt RFP template:
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Patient Information
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| Maintain database of patient demographic, guarantor and insurance information for retrieval in registration functions (e.g. no re-entry of data). |
| Support pop-up windows to display valid codes or lookup functions in registration and medical record screens. |
| Provide ability to link multiple accounts for group or employer accounts (e.g. for employee physicals) for consolidated statements. |
| Support entry and tracking of referrals including name, contact, address, phone, type (e.g. pediatrician, hospital), and consulting doctor ID for insurance. |
| Support user-defined medical record templates consisting of at least 48 user-defined fields for clinical data. |
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Master Person Index
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| Support on-line enterprise-wide master person index (EMPI) consisting of patient demographic, insurance and visit history information for every patient identified to the health care enterprise. |
| Supply a single, universal identifying number for each patient seen at any provider facility (e.g. entity) of the healthcare enterprise. |
| Provide ability to add new patients to the master person index via registration and scheduling processes from interfaces patient information systems. |
| Support suspected duplicate EMPI record reporting with tools to merge and delete records, if appropriate. |
| Support HL7 interface standards for queries from patient information systems and sending back patient demographic, insurance and patient history information. |
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Eligibility
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| Maintain master file of health plans and payors including specific benefit options used in the adjudication and payment of provider claims. |
| Support EDI (Electronic Data Interchange) interface for inquiry into patient's pre-authorization status and eligibility from insurance provider's system or third-party network. |
| Provide on-line inquiry into member data including eligibility status, plan assignment, benefits and historical coverage records. |
| Support entry of free text comments to be associated with member eligibility records. |
| Provide ability to globally change eligibility data (e.g. change primary care physicians or health plan benefit options for a selected group of members) with minimal effort. |
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Authorizations
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| Support entry and tracking of detailed service authorizations at the procedure code level. |
| Provide ability to enter expiration dates and pricing in authorization records. |
| Automatically assign and maintain unique ID number for each authorization. |
| Automatically validate member eligibility and termination dates when processing authorizations. |
| Track member yearly and lifetime benefit limits by procedure and warn user when utilized benefits approach or exceed limits. |
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Scheduling
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| Support on-line scheduling of appointments for patient services. |
| Support appointment "templates" by individual doctor or resource to meet specific needs (e.g. intervals between appointments, start time in a.m.). |
| Provide ability to automatically find next available appointment slot for patient. |
| Track and manage schedule changes including bumps, cancellations and no-shows. |
| Print patient recall notices or letters including address, phone, reason, date, time, procedures, office address and provider. |
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Procedure Entry
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| Support entry and processing of multiple procedures per diagnosis. |
| Provide ability to look up doctor numbers, insurance companies, procedure codes and diagnosis codes while entering procedures (e.g. without having to exit entry screen). |
| Maintain ICD-9 diagnostic code master file including ICD-9 code, description and internal office abbreviation (e.g. mnemonic code). |
| Support alternative procedure codes in procedure code file for insurers that do not use CPT codes. |
| Provide ability to maintain a user-defined "standard" time by procedure for productivity reporting and use by the scheduling system. |
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Billing
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| Support editing and holding of bill generation pending completion of specific (e.g. user-defined) data elements. |
| Support family account (e.g. guarantor, group) billing of patients, producing single statement for related accounts. |
| Provide ability to print on-demand statements for patient at time of service. |
| Provide option to generate secondary bills for balance of charges to secondary insurance company. |
| Guarantee that ECS process complies with all HCFA regulations. |
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Accounts Receivable
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| Track accounts receivable by plan and by company. |
| Provide ability to automatically assign accounts to collection based on user specified criteria (e.g. number of days delinquent, minimum outstanding). |
| Provide on-line collection screens that display account status, billing dates, aging and payment history. |
| Automatically stop payment plan process if full payment is posted. |
| Provide ability to purge inactive patients with no visits past a user-specified cutoff date. |
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Payment Posting
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| Provide cash receipt batch controls including batch number, batch total, number of items, etc. |
| Provide ability to post payments to oldest charges first (FIFO). |
| Provide ability to automatically compare insurance payments to benefits. |
| Automatically calculate the approved amount, post payment and perform write-off for Medicare payments. |
| Automatically process write-offs, payment allocations and responsibility transfers when electronic remittances are processed. |
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Provider Claims
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| Automatically assign and maintain unique claim ID number for each claim. |
| Provide ability to look up ICD-9 and CPT codes from within claim entry screens. |
| Check for and prevent processing of duplicate claims (e.g. if services were provided with overlapping service dates). |
| Provide ability to receive electronic bills from physician offices and adjudicate them automatically. |
| Print check register sorted by check number listing date paid, vendor ID and name, amount and description. |
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Case Management
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| Automatically assign and maintain unique case record ID numbers for specific episodes of illness for individual patients. |
| Provide ability to link all claims for a specific episode of illness to a unique case number. |
| Display summary of authorized and actual costs on case inquiry screen. |
| Provide ability to mark events for HEDIS reporting and analysis purposes. |
| Provide ability to report similar cases (e.g. same type) for one or all providers to compare services rendered and results achieved. |
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Management Reports
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| Print revenue trend reports providing side-by-side comparisons of user-selected time periods. |
| Provide ability to print realization reports with summary totals by insurance company, HMO and PPO. |
| Provide ability to print realization reports with summary totals by provider. |
| Print referral trend summary reports listing source, number, revenue, MTD totals, YTD totals and practice-to-date. |
| Print referral reports summarized by: office. |
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HIPAA
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| Support an enterprise-wide single sign-on user authentication process that allows individual users to logon to different systems with one global user ID and password. |
| Support automatic log off of work stations connected to patient information systems after a site-defined time period of inactivity (e.g. 5 minutes). |
| Support data access controls that allows assignment of security at the data element level within files. |
| Provide mechanism for entity (e.g. unique individual) authentication such as: biometric (e.g. hand geometry, retinal/iris scan, fingerprint patterns, facial characteristics). |
| Provide contractual guarantee to deliver software releases and updgrades to ensure HIPAA compliance for current regulations within 12 months after go-live at no additional cost. |
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Technical & Support
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| Support graphical user interface GUI (e.g. Windows, buttons, toolbars, mouse, etc.) and menu-driven user control and initiation of system functions. |
| Support ability to use web browser (e.g. Netscape Communicator, Internet Explorer) to access system functions over Internet or internal intranet. |
| Provide keyboard shortcuts (e.g. Ctrl-C, Alt-F) or menu bypass functions for experienced users to quickly execute system functions. |
| Provide multi-level password security down to options within menus. |
| Provide commitment to support HL7 (Health Level 7) healthcare industry system integration standards. |
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