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).
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Support pop-up windows to display valid codes or lookup functions in registration and medical record screens.
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Provide ability to link multiple accounts for group or employer accounts (e.g. for employee physicals) for consolidated statements.
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Support entry and tracking of referrals including name, contact, address, phone, type (e.g. pediatrician, hospital), and consulting doctor ID for insurance.
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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.
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Supply a single, universal identifying number for each patient seen at any provider facility (e.g. entity) of the healthcare enterprise.
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Provide ability to add new patients to the master person index via registration and scheduling processes from interfaces patient information systems.
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Support suspected duplicate EMPI record reporting with tools to merge and delete records, if appropriate.
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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.
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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.
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Provide on-line inquiry into member data including eligibility status, plan assignment, benefits and historical coverage records.
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Support entry of free text comments to be associated with member eligibility records.
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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.
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Provide ability to enter expiration dates and pricing in authorization records.
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Automatically assign and maintain unique ID number for each authorization.
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Automatically validate member eligibility and termination dates when processing authorizations.
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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.
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Support appointment "templates" by individual doctor or resource to meet specific needs (e.g. intervals between appointments, start time in a.m.).
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Provide ability to automatically find next available appointment slot for patient.
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Track and manage schedule changes including bumps, cancellations and no-shows.
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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.
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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).
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Maintain ICD-9 diagnostic code master file including ICD-9 code, description and internal office abbreviation (e.g. mnemonic code).
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Support alternative procedure codes in procedure code file for insurers that do not use CPT codes.
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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.
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Support family account (e.g. guarantor, group) billing of patients, producing single statement for related accounts.
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Provide ability to print on-demand statements for patient at time of service.
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Provide option to generate secondary bills for balance of charges to secondary insurance company.
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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.
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Provide ability to automatically assign accounts to collection based on user specified criteria (e.g. number of days delinquent, minimum outstanding).
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Provide on-line collection screens that display account status, billing dates, aging and payment history.
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Automatically stop payment plan process if full payment is posted.
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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.
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Provide ability to post payments to oldest charges first (FIFO).
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Provide ability to automatically compare insurance payments to benefits.
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Automatically calculate the approved amount, post payment and perform write-off for Medicare payments.
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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.
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Provide ability to look up ICD-9 and CPT codes from within claim entry screens.
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Check for and prevent processing of duplicate claims (e.g. if services were provided with overlapping service dates).
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Provide ability to receive electronic bills from physician offices and adjudicate them automatically.
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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.
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Provide ability to link all claims for a specific episode of illness to a unique case number.
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Display summary of authorized and actual costs on case inquiry screen.
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Provide ability to mark events for HEDIS reporting and analysis purposes.
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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.
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Provide ability to print realization reports with summary totals by insurance company, HMO and PPO.
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Provide ability to print realization reports with summary totals by provider.
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Print referral trend summary reports listing source, number, revenue, MTD totals, YTD totals and practice-to-date.
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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.
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Support automatic log off of work stations connected to patient information systems after a site-defined time period of inactivity (e.g. 5 minutes).
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Support data access controls that allows assignment of security at the data element level within files.
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Provide mechanism for entity (e.g. unique individual) authentication such as: biometric (e.g. hand geometry, retinal/iris scan, fingerprint patterns, facial characteristics).
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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.
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Support ability to use web browser (e.g. Netscape Communicator, Internet Explorer) to access system functions over Internet or internal intranet.
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Provide keyboard shortcuts (e.g. Ctrl-C, Alt-F) or menu bypass functions for experienced users to quickly execute system functions.
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Provide multi-level password security down to options within menus.
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Provide commitment to support HL7 (Health Level 7) healthcare industry system integration standards.
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