2.04 820 Design Specifications

820 Phase 2 Design Specifications
California Department of Health Care Services 820 Phase 2
Design Specifications
Document Id: Version: 1.3 Date: December 9, 2009
Project Identifier: 820 Phase 2 DHCS Project Manager: Curtis Milberger
California Department of Health Care Services, 820 Phase 2 System, 2009

For Internal Use Only
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Revision Record
Date 10-01-2009 Author Trinity Technology Development Team Grant Stewart Orri Rail Grant Stewart Revision 1.0 Change Reference Creation
10-20-2009 11-09-2009 12-09-2009
1.1 1.2 1.3
Revised Introduction Revised Business Objects Finalized Design documents and comments
Review Record
Name O. Rail P. Smith G. Stewart G. Stewart Position/Title Lead Developer Enterprise Architect Project Manager Project Manager Date 10-15-2009 10-15-2009 10-20-2009 12-09-2009
Approval Record
Name Position/Title Date

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Table of Contents
1 2 Introduction ...................................................................................................................................5 System Context Diagram..............................................................................................................8 2.1 Level 1 Context Diagram ........................................................................................................ 8 2.2 Level 2 Context Diagram ........................................................................................................ 9 820 System Activity Diagram......................................................................................................11 Component Architecture .............................................................................................................13 4.1 Component Diagram............................................................................................................. 13 4.2 Sequence Diagrams .............................................................................................................17 Orchestrations ............................................................................................................................20 5.1 ProcessAccounting ............................................................................................................... 20 5.2 ProcessPayment................................................................................................................... 22 5.3 ProcessCapition.................................................................................................................... 24 5.4 ProcessRemittanceAdvice .................................................................................................... 26 Business Objects ........................................................................................................................29 6.1 PaymentMgmt ....................................................................................................................... 29 6.2 ContractMgmt........................................................................................................................ 36 6.3 BeneficiaryMgmt ................................................................................................................... 41 6.4 ReportMgmt .......................................................................................................................... 46 6.5 RemittanceAdviceMgmt ........................................................................................................57 6.6 InvoiceMgmt.......................................................................................................................... 59 6.7 CapitationMgmt..................................................................................................................... 80 Data Objects ...............................................................................................................................86 7.1 Contract Data ........................................................................................................................ 87 7.2 Beneficiary Data.................................................................................................................... 88 7.3 Invoice Data .......................................................................................................................... 89 Database ....................................................................................................................................89 8.1 Entity Relationship Diagram.................................................................................................. 89 8.2 Table Descriptions ................................................................................................................ 91 User Interface .............................................................................................................................93 9.1 Site Map ................................................................................................................................ 93 9.2 Master Page.......................................................................................................................... 94 9.3 Master Page Layout.............................................................................................................. 94 9.4 Site Constraints..................................................................................................................... 96 9.5 Invoice Search ...................................................................................................................... 96 9.6 Invoice Summary .................................................................................................................. 99 9.7 Pre Payment ....................................................................................................................... 102 9.8 Beneficiary Search.............................................................................................................. 104 9.9 Beneficiary Summary..........................................................................................................107 9.10 Beneficiary Coverage..........................................................................................................112 9.11 Beneficiary Adjustment .......................................................................................................115 9.12 Beneficiary Payment History...............................................................................................118 9.13 Contract Search .................................................................................................................. 121 9.14 Contract Summary ..............................................................................................................123
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9.15 Contract Change................................................................................................................. 127 9.16 Contract HCP ...................................................................................................................... 130 9.17 Contract Disbursement Register......................................................................................... 133 9.18 Contract Plan-Based Payments..........................................................................................135 9.19 Vendor Search .................................................................................................................... 137 9.20 Vendor Summary ................................................................................................................139 9.21 Vendor Payment History .....................................................................................................142 9.22 Report Search ..................................................................................................................... 145 9.23 Reference Table Search .....................................................................................................147 10 Network Requirements .............................................................................................................150 10.1 Solution Platforms............................................................................................................... 150 10.2 Server Platforms ................................................................................................................. 155 10.3 Scalability, Load Balancing & Redundancy ........................................................................ 174 10.4 Security and Recovery........................................................................................................175 Appendix A Data Dictionary.........................................................................................................178 10.5 Table Details ....................................................................................................................... 178 10.6 User Permissions................................................................................................................ 236 Appendix B Process Model .........................................................................................................237

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1 Introduction
The purpose of this document is to provide software-level and hardware-level architecture specifications for the 820 Phase 2 project. This document identifies the new applications building blocks (software components) and their interdependencies. These are the detailed software specifications that will be used by application developers to build the 820 Phase 2 application. This document also serves as an 820 technical manual for architects and developers to extend and maintain the system. This document is divided into the following sections that define how the system will be built from a Software Engineering perspective. Software Architecture Orchestrations Business Objects Data Objects Database Model User Interface
The document also contains sections from a Network Architecture perspective, including: Solution and Server Platforms Scalability Security Backup and Disaster Recovery
A draft of the System Administration Guide (as specified as part of this deliverable, has been created separately in the 820 SharePoint site; filename: Draft System Admin Guide), includes: System Modifications and Maintenance Release Management Transition Management Software and Hardware Upgrades Customer Support

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Key artifacts gathered during the Analysis Phase were used to support the creation of the Design Specifications Document included the identification of Use Cases and the creation of the 820 Phase 2 Level One Process Model below.

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The below table represents a traceability matrix from the Use Cases in the Requirements Specification Document to the technical sections defined in this document. The Use Case analysis was fundamental in guiding the design of the technical components detailed in the following sections.
Use Case 1.1 Receive and Process Enrollment Data 1.2 Calculate Capitation 2.1 Generate Invoices 2.2 Review and Approve Invoices 2.3 HIPP BCCTP Invoice Management 3.1 Process Payment Files Use Case 4.1 Beneficiary Management 4.2 Contract Management 4.3 Generate Reports 4.4 Reference Data 4.5 HIPP BCCTP Beneficiary Management 4.6 HIPP BCCTP Vendor Management 5.1 Process and Send 820 Transactions
D esign Specification Section 2.1, 2.2, 3, 4.1, 4.2, 5.3 2.1, 2.2, 3, 4.1, 4.2, 5.3, 6.6, 6.7 2.1, 2.2, 3, 4.1, 4.2, 5.3, 6.6, 7.2, 7.3 2.1, 2.2, 4.1, 4.2, 6.6, 7.2, 7.3,9.1, 9.6 2.1, 2.2, 4.1, 5.3, 6.6, 7.2, 7.3, 9.6, 9.10 2.1, 2.2, 3, 4.1, 4.2, 5.1, 5.2, 6.1, 6.5 2.1, 2.2, 4.1, 6.3, 7.2, 9.8, 9.9 2.1, 2.2, 4.1, 6.2, 7.1, 9.13, 9.14 2.1, 2.2, 4.1, 6.4, 9.22 2.1, 2.2, 4.1, 9.23 2.1, 2.2, 4.1, 6.3, 7.2, 9.8, 9.9, 9.10 2.1, 2.2, 4.1, 9.19, 9.20 2.1, 2.2, 3, 4.1, 4.2, 5.4, 6.5, 7.3,

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2 System Context Diagram

The System Context Diagram represents all external entities that may interact with the system. The diagram is the highest level view of the system and is a good starting point to represent the system.
2.1 Level 1 Context Diagram

The Level 1 Context Diagram provides a high level view of the 820 Phase 2 system as a single entity and shows the flow of all external entities in and out of the system.
Level 1 Context Diagram
MEDS will send a file containing beneficiary eligibility information for the current months information and 12 historical months. Managed Care User will operate on the user interface and manages contracts, approves invoices and retrieves reports. Non-Managed Care User will operate on the user interface and manages beneficiaries, approves invoices and retrieves reports. Accounting will send a file (CMS64) which contains warrant information for invoice payments.

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SCO will send a file (CD102) summarizing all warrants (or payments) made out to a vendor. Vendor will receive an 820 Remittance Advice representing all invoice payments for a given month.
2.2 Level 2 Context Diagram

The Level 2 Context Diagram breaks the CapMan system down into smaller components, while the external entities stay the same. Data storage also becomes visible.
MEDS
Capitation File SCO
Capitation
CD102
Accounting CMS64 Payment Beneficiaries Contracts Invoices
Remittance Generation User Interface
820 Remittance Advice
Payment Recipient
Contract/Invoices Beneficiaries/Invoices Reports
Managed Care User
Non-Managed Care User
Level 2 Context Diagram In this diagram the CapMan system has been decomposed into five different processes. Capitation represents the process of consuming the capitation file from MEDS and processing the beneficiary eligibility data into data storage.

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Payment represents the process of consuming files from Accounting and SCO. Which includes verification and matching of payment information with invoices and finally calling the 820 Generation. Remittance Generation represents creating the Remittance Advice (based on invoices processed within Payment). This process also manages sending the 820 file to the appropriate location. User Interface represents any user interaction with managed and non-managed care users. Beneficiary, Contract and Invoice management falls under this process. Reports represent the process of creating reports from the Invoice data storage.

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3 820 System Activity Diagram

The 820 System Activity Diagram represents the workflow for the backend processing. The flow represents the entire high level process and does not show any errors condition processing. Error conditions will be addressed at a lower level in relation to the specific component that handles the error. This Activity Diagram is based of the Level 1 Process Model (see Appendix B) from the Requirement Specification.

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Shape Receive Capitation File
Description The system will receive the capitation file coming from MEDS. The capitation file will be parsed and loaded into a staging table. The parsed capitation data will be processed and calculations will be performed. Invoices will be generated based on the calculations. Invoices will be approved (from the UI). Since approved invoices will be mailed to accounting, the system will be an idle wait stage. The system will receive CMS64 files coming from accounting. The system will receive CD102 files coming from SCO. Payment information coming from Accounting and SCO will be matched against invoices. A payment remittance advice will created to send to the vendors.
Load into Staging Tables
Calculate Capitation
Generate Invoices
Approve Invoices Wait for Payments
Receive CMS64 File
Receive CD102 File
Match Invoices To Payment
Create Payment Remittance Advice

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4 Component Architecture
This section represents the components of the system. Components are high level pieces of code that can either be physical (i.e. DLL) or logical (interrelated groups of code).
4.1 Component Diagram

The component diagram's main purpose is to show the structural relationships between the components of a system. The component diagram provides a high-level, architectural view of the system, which helps developers begin formalizing a roadmap for the implementation, and make decisions about task assignments and/or design. System administrators will find the component diagram useful because they get a view of the logical software components that will be running on their systems.

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user interface NonManagedCareUI
user interface ManagedCareUI
orchestration ProcessCapitaion
orchestration ProcessPayment business layer ReportMgmt
business layer ContractMgmt
business layer InvoiceMgmt
business layer CapitationMgmt
business layer BeneficiaryMgmt
business layer PaymentMgmt
orchestration ProcessRemittanceAdvice
orchestration ProcessAccounting business layer RemittanceAdvice
Component Diagram Component InvoiceMgmt Type Business Description This component will be responsible for generating and approving invoices. The generation part will include performing retroactive adjustments and generating net-changes from previous invoices. It will provide calculations on a beneficiary level. Status management will also be part of this component (i.e. Approved, Paid).

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Component CapitationMgmt
Type Business
Description The Capitation component will be responsible to process the beneficiary data coming in from the monthly capitated file. It will handle the loading and pre-populating invoice data before performing the calculations. This orchestration will receive and process the capitation file coming from MEDS. The data will be processed into a staging table and then instantiate CapitionMgmt to process the data. This component will process the CMS64 file coming from Accounting. This will include parsing and mapping the file into a structure which will be used to call into PaymentMgmt. This component manages the CMS64 and CD102 data coming from Accounting and SCO. This component will process the CD102 file coming from SCO. Which includes parsing and mapping the file into a structure which will be used to call into PaymentMgmt. This component will start the process to create an 820 Remittance Advice when a payment file has been received. It will call into RemittanceAdviceMgmt. This component will receive information from ProcessRemittanceAdvice and create the 820 Remittance Advice. This component manages contracts within the system. This will include versioning of contracts and keeping invoices aligned with the correct version of a contract. This will be a user interface component containing all managed care user interfaces.
ProcessCapition
Orchestration
ProcessAccounting
Orchestration
PaymentMgmt
Business
ProcessPayment
Orchestration
ProcessRemittanceAdvice
Orchestration
RemittanceAdviceMgmt
Business
ContractMgmt
Business
ManagedCareUI
User Interface

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Component NonManagedCareUI
Type User Interface
Description This will be a user interface component containing all non managed care user interfaces. This component will manage the creation of reports. This component will be part of non managed care and will handle versioning of beneficiaries to invoices.
ReportMgmt
Business
BeneficiaryMgmt
Business

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4.2 Sequence Diagrams

Sequence Diagrams show how components of the 820 Phase 2 System interact with each other. They also represent lifeline and message calls between components.
4.2.1 Invoice Generation
ProcessCapitation
CapitationMgmt
InvoiceMgmt
Calculate Generate ErrorInformation
This sequence diagram represents how invoices will be created. The ProcessCapitation component will call Calculate in the CapitationMgmt component; CapitationMgmt will then call Generate in InvoiceMgmt. CapitationMgmt will return any error information to ProcessCapitation.

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4.2.2 Approving Invoices
ManagedCareUI
InvoiceMgmt
ReportMgmt
Set Status
Get Invoice Report Invoice Report
This sequence diagram represents how invoices will be approved. The ManagedCareUI will call into InvoiceMgmt with an invoice status, in this case Approved. The ManagedCareUI retrieves the invoice by calling ReportMgmt.
4.2.3 Generate Remittance Advice
ProcessAccounting
ProcessPayement
PaymentMgmt
ProcessRemittanceAdvice
RemittanceAdviceMgmt
InvoiceMgmt
ProcessCMS64
ProcessCD102
Call ProcessRemittanceAdvice
CreateRemittanceAdvice
GetPaidInvoices PaidInvoices XMLPaidInvoices

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This sequence diagram represents how the 820 Remittance Advice will be generated. The ProcessAccounting component will call into PaymentMgmt to process the CMS64 file. The ProcessPayment component will also call into PaymentMgmt to process the CD102 file. Subsequently ProcessPayment will call ProcessRemittanceAdvice component to initiate the 820 Remittance Advice process. A call into RemittanceAdviceMgmt will then gather paid invoices from InvoiceMgmt and create an 820 Remittance Advice.

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5 Orchestrations
Orchestrations control the workflow for a business process. An example of an orchestration could be receiving and parsing a file and then calling logic to complete a business process. The following sections are design details for the orchestration types defined in the component diagram (section 4.1).
5.1 ProcessAccounting
The ProcessAccounting Orchestration will be responsible for receiving and logging the receipt of the CMS64 file from accounting and archiving the file. The orchestration will also parse the CMS64 file to match the invoice numbers within the file to the unpaid invoices within the 820 Phase 2 system.

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5.1.1 Activity Diagram
SFTP
Receive CMS64 File
Log CMS64 File Receipt
Map CMS64 File Contents against Unpaid Invoices
Update Unpaid Invoice Statuses with Claim Schedule Information
Archive
Archive CMS64 File
Activity Receive CMS64 File Log CMS64 File Receipt Map CMS64 to Unpaid Invoices Update Invoice Statuses and Information Archive CMS64
Description Receive CMS64 File from external interface, instantiating an instance of the orchestration. Log receipt of CMS64 File in 820 Phase 2 event log. BizTalk Map that extracts invoice information for only the 820 Phase 2 system from CMS64 and matches to invoice information. For all 820 Phase 2 invoices matched, the system will update the invoice status to CMS64 received. Archive the CMS64 physical file to the pre-determined archive location.

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5.2 ProcessPayment
The ProcessPayment Orchestration will be responsible for receiving and logging the receipt of the CD102 file from SCO and archiving the file. The orchestration will parse the CD102 file and match the claim schedule numbers to any unpaid invoices. The orchestration will enter an exception state given the following conditions: If any unpaid invoices have yet to receive claim schedule numbers If there are any unpaid invoices with claim schedule numbers that are not matched with the CD102 file If any invoice amounts are inconsistent
If all unpaid invoices are matched correctly, then the orchestration will start the Process820 orchestration.

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Activity Receive CD102 File Log CD102 File Receipt Get List of Unpaid Invoices Map CD102 against Unpaid Invoices
Description Receive CD102 File from external interface, instantiating an instance of the orchestration. Log receipt of CD102 File in 820 Phase 2 event log Poll the 820 Phase 2 system to get all unpaid invoices. A BizTalk Map that extracts claim schedule information for only the 820 Phase 2 system from the CD102 file and performs the matching.

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Activity
Exception: Invoices Do Not Match Update Invoice Statuses and Information Archive CD102 Begin Process820
Description System enters an exception state if invoice information is incomplete for unpaid invoices in the 820 Phase 2 system. The exception is reported to the system administrator and the orchestration instance is suspended awaiting further review. For all 820 Phase 2 invoices matched, update invoice with warrant information and status to CD102 received. Archive the CD102 physical file to the pre-determined archive location. Begin the Orchestration to process the 820 file for all unpaid invoices that have received the CMS64 and CD102 file.
5.3 ProcessCapition
The ProcessCapitation Orchestration will be responsible for receiving and logging the receipt of the MMCD Capitation files from MEDS and archiving the MMCD file. The orchestration will invoke the business layer to create invoices based upon the beneficiaries in the capitation file. This orchestration is a singleton, so only one instance of the ProcessCapitation orchestration will be run at the same time.

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Activity
Receive MMCD File Log MMCD File Receipt Persist MMCD File into Staging Table Call Invoice Processing Business Object Log Invoice Processing Results
Description Receive MMCD File from external interface, starting the orchestration. The orchestration receipt also validates the format of the MMCD File. Log receipt of MMCD File in 820 Phase 2 Event Log. Contents of the MMCD File are persisted into staging tables in the 820 Phase 2 database. This will call into the OHC820.BO.InvoiceMgmt business layer to process the capitation calculations. The calculation log from the OHC820.BO.InvoiceMgmt component is persisted. Upon processing all MMCD files (by plan), invoices are created allowing the calculated values and the invoices themselves to be visible on the UI.
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Finalize Invoices

5.4 ProcessRemittanceAdvice
The ProcessRemittanceAdvice Orchestration will be responsible for creating the 820 Remittance Advice file upon receiving a list of paid warrants from the Process Payments Orchestration. This will generate XML-Formatted 820 files which are then processed by the XEngine interface to validate and transform the XML files to X12 5010 820 EDI files. The X12 5010 820 EDI Files are then processed and sent to the external SFTP Interface to be delivered to clients.

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Activity Receive List of Paid Invoices Map Paid Invoices to 820 Format Translate 820 Paid Invoices to EDI Format Log XEngine Errors Archive 820 EDI File Send 820 Files to Clients
Description A list of paid invoices is received from the ProcessPayments orchestration. The List of Paid Invoices is mapped to multiple 820 files in XML Format. The 820 XML Files are sent to the XEngine interface to be validated and transformed to a 5010 820 Remittance Advice EDI File. Any XEngine errors (SNIP) that occur during translation are returned and persisted the 820 Phase 2 Event Log. The 820 EDI File is archived to the file system. All 820 Files are sent to the SFTP Interface where they are then forwarded to the corresponding recipients.

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6 Business Objects
The Business Objects will define business logic and rules. The objects are designed following Object Oriented Design methodologies (OOD. Both the user interface layer and orchestration layer call into the business layer. The following sections are design details for the business types defined in the component diagram (section 4.1).
6.1 PaymentMgmt
The PaymentMgmt component will handle the processing of the two distinct payment files for 820 Payment Processing, CMS64 and CD102. CMS64 processing entails matching approved invoices with an incoming CMS64 file. For a matching invoice, a Claim Schedule Number will be persisted with a new status of CMS64Processed. CD102 processing entails matching CMS64 processed invoices with the incoming CD102 file. For a matching invoice, a warrant numbers will be persisted with a new status of Paid. All errors will be logged in an XML error document.
6.1.1 Use Case 3.1 Receive and Process Payment Files

Requirement Specification The Process Payments process focuses on the receipt and reconciliation of the CMS64 and CD102 payment files received from the Accounting Office. The System matches the invoices to the Claim Schedule Numbers on the CMS64 on a weekly basis, and then reconciles the Claim Schedule Numbers to the Warrant Numbers on the CD102 file, which is received on a monthly basis. Once the invoices have been reconciled to the payment data (CD102 File), the invoices are ready to for the next process of going on an 820 transaction. Process Model

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6.1.1.1 Use Case Exceptions

o o If the format or structure is incorrect then system logs an error and halts processing of file (CMS64). If the vendor number from the CMS64 file does not match with the CAPMAN vendor number, System updates Invoice status to CMS64 Payment Error. System generates the following payment error notification:CMS64 Payment Error Vendor Number [##] in system Does Not Match Vendor Number [##] on CMS64 file for Invoice Number [##]. Accounting must re-submit a corrected Claim Schedule. Else, if warrant has already been issued for original Claim Schedule, user must enter a payment error adjustment. If the invoice amount from the CMS64 file does not match with the CAPMAN invoice amount, System updates Invoice status to CMS64 Payment Error. System generates the following payment error notification:CMS64 Payment Error Invoice Amount [$$] Does Not Match Amount [$$] on CMS64 file for Invoice Number [##]. Accounting must re-submit a corrected Claim Schedule. Else, if warrant has already been issued for original Claim Schedule, user must enter a payment error adjustment. If file format or structure is incorrect, system logs an error and halts processing of file (CD102) If Invoice Status = CMS64 Payment Error, the invoice is not retrieved and the CD102 Payment information for that invoice is not processed. Invoice Status remains CMS64 Payment Error, and is flagged to
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o o

resume further processing once the invoice status becomes CMS64 Received. If the total dollar amount of the invoices within a Claim Schedule does not match the Warrant Amount on the CD102, system updates the status of all invoices on that Claim Schedule to CD102 Payment Error. System generates the following payment error notification for each invoice with status of CD102 Payment Error:CD102 Payment Error Sum of Invoice Amounts [$$] for Claim Schedule [##] is not equal to the Warrant Amount [$$] on CD102 File. User must enter a payment error adjustment. If the number of warrants associated with the Claim Schedule Number does not equal the number of unique vendor codes for the all invoices within the Claim Schedule, then system updates the status of all invoices to CD102 Payment Error. System generates the following payment error notification for each invoice with status of CD102 Payment Error:CD102 Payment Error Number of Warrants [##] on CD102 for Claim Schedule Number [##] is not equal to Number of Vendors [##] for the Claim Schedule in System. User must enter a payment error adjustment.

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6.1.2 Class Diagram
6.1.2.1 PaymentService
The PaymentService class will be used to retrieve invoices that will either be a) Approved or b) CMS64Processed. The class will also provide services to retrieve the vendor number for an invoice. The ProcessCD102 and ProcessCMS64 classes will use this class. Method GetInvoices Description Retrieve a list invoices. The ProcessCMS64 class will use this list to create the CMS64 files and ProcessCD102 class will use to create the CD102 files.

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Parameters invoiceStatus
Type enumStatus
Description Either enum64 or enumCD102 status
Output IList<Invoice>
Description List of Invoice objects
Method GetVendorNumber Parameters invoiced
Description Retrieve the Vendor number for an invoice. Type int Description The invoice id
Output String
Description The invoice number
6.1.2.2 ProcessCMS64
The ProcessCMS64 class will be used to process a CMS64 file. After retrieving a list of invoices with the status of CMS64Processed (using PaymentService), matching of each invoice will occur against the CMS64 file. Any matching errors will be generated in an XML error log. Method Process Output bool Description This method will start the process of matching invoices against the CMS64 file Description Success or Failure.
Method GettErrorXml Output XmlDocument
Description Retrieve the list of errors if Process fails. Description An XML representation of the any errors during invoice matching.

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6.1.2.3 InvioceMatch
The InvoiceMatch class will be a helper class to keep track of any issues matching the incoming CMS64 file invoices with the existing invoices in the database. Any issues will be logged. Property Invoice Output OHC820.Data.Invoice Property CMS64 Output CMS64Record Property Log Output XmlDocument Description The invoice matched from the CMS64 file. . Description The Invoice object coming from the Data objects. Description A single CMS64 record coming from the CMS64 file Description An object representing the CMS64 record. Description A log entry when a failure happens. Description An xml representation of a a failure
6.1.2.4 ProcessCD102
The ProcessCD102 class will be used to process a CD102 file. After retrieving a list of invoices with the status of Paid (using PaymentService), matching of each invoice will occur against the CD102 file. Any matching errors will be generated in an XML error log. Method Process Output bool Description This method will start the process of matching invoices against the CD102 file Description Success or Failure.
Method GettErrorXml Output XmlDocument
Description Retrieve the list of errors if Process fails. Description An XML representation of the any errors during invoice matching.

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6.1.2.5 PaymentMatch
The InvoiceMatch class will be a helper class to keep track of any issues matching the incoming CMS64 file invoices with the existing invoices in the database. Any issues will be logged. Property Invoice Output OHC820.Data.Invoice Property CD102 Output CD102Record Property Log Description The invoice matched from the CMS64 file. . Description The Invoice object coming from the Data objects. Description A single CD102 record coming from the CMS64 file Description An object representing the CD102 record. Description A log entry when a failure happens.
6.1.2.6 CMS64Record
This class will represent a single record in the CMS64 file. Property SequenceNumberField ScheduleNumberField PaymentAmountField InvoiceAmountField AdjustAmountField AdjReasonCodeField ServiceNameField PayDateField CovdPeriodFromField CovdPeriodToField VendorCodeField VendorNameField VendorEinField VendorcityField VendorstateField Type String String String String String String String String String String String String String String String Description The sequence number The schedule number The payment amount The invoice amount The adjustment amount The adjustment reason code The service name The pay date The coverage period from The coverage period to The vendor code The vendor name The vendor ein The vendor city The vendor state

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ForeigncntryField VendorzipField VendorTypeField InvoiceNumberField ServiceCodeField
String String String String String
The foreign country The vendor zip code The vendor type The invoice number Sthe service code
6.1.2.7 CDI02Record
Property SqheduleNumberField BeginWarrantNumberField EndWarrantNumberField WarrantDateField FederalFiscalYearField AmountField Type String String String String String String Description The schedule number The start warrant number The end warrant number The warrant date The federal fiscal year The amount field
6.2 ContractMgmt
The ContractMgmt component will be used with contract data. Contracts will be versioned for every change made. There will be no deletion or updates. This component will also handle HCPs, Aid Code Group and Aid Codes. Both ManagedCareUI and InvoiceMgmt components will interact with it.
6.2.1 Use Case 4.2 Contract Management

Requirement Specification This Use Case describes the process for Users to view, add and update Contracts, Amendments, Change Orders and Disbursement Register for Managed Care Plans. .
6.2.2 Use Case - 2.1 Generate Managed Care Invoices

Requirement Specification The Process Invoices process begins with the generation of all Managed Care invoices for the current enrollment month based on the completion of processing the Beneficiary Enrollment file. The invoices are then made available for review and approval by the Managed Care Department. They are then manually printed by the user and provided to the DHCS Accounting department. Additionally, HIPP/BCCTP Department staff manually creates invoices and print them out for the DHCS Accounting Department. Contract and Beneficiary Adjustments are also available for the user in this process, which will ultimately be shown on the appropriate

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invoice(s). The invoices are now ready for payment reconciliation, which is described in the next section: Process Payments.
Process Model

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6.2.3 Class Diagram

interface IContractService +GetContracts() +UpdateContract() +GetContractById() +GetRelatedContracts() ManagedCareUI
ContractService
Data.Contract
ContractMgr -HcpToContractMap -HcpToSupplementalMap +IdentifyEffectiveCurrentContracts() +LoadContractSupplementalData() +GetApplicableContract()
CapitationMgmt InvoiceMgmt
6.2.3.1 IContractService
The IContractService interface will define methods to retrieve and save contract information. This interface will be used by the ManagedCareUI component. Method GetContracts Parameters IncludeDetails Bool Description Get all contract related data. This includes HCP, Aid Code groups and Aid codes. Type Description Flag indicated if all contract relationships should be loaded The vendor type id
vendorTypeId
Int

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contractNumber
String
The contract number
healthCarePlanTypeId
Int
The health care plan type
countyCodeTypeId
Int
The country code type id
contractTypeId
Int
The contract type id
effectiveFrom
DateTime
Effective from date
effectiveTo
DateTime
Effective to date
Output Contract[]
Description An array of Data.Contract objects
Method UpdateContract Parameters Contract
Description Update conctract information. This will create a new version of all contract data. Type Data.Contract Description The contract values to update.
Method GetContractById Parameters IncludeDetails
Description Get all contract related data. This includes HCP, Aid Code groups and Aid codes. Type Bool Description Flag indicated if all contract relationships should be loaded The contract id
contractId
Int
Output Contract
Description A Data.Contract object

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Method GetRelatedContracts Parameters IncludeDetails
Description Get all contact version tied to a specific contract Type Bool Description Flag indicated if all contract relationships should be loaded The contract id
contractId
Int
Output Contract[]
Description An array of Data.Contract objects
6.2.3.2 ContractMgr
The ContractMgr class will be used by the InvoiceMgmt component to retrieve the applicable contract information to perform invoice calculations on beneficiaries. Method LoadContractData Method IdentifyEffectiveCurrentContracts Parameters Beneficiary Description Loads all contracts from the database Description Itentifies the contracts matched for beneficiary information Type Data.Beneficiary Description The beneficiary to match with a contract
Output Contract
Description The matching contract
Method LoadContractSupplementalData Parameters supplementalAidCodeType
Description Load the supplemental contract information Type Data.AidCodeType Description The supplemental aid code
Method GetApplicableContract
Description Get applicable supplemental contract

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Parameters hcpId Short
Type
Description The id of the health care plan The applicable service month The applicable payment type
serviceMonth
DateTime
payType
Short
Output List<Data.SupplementalInfo>
Description A list of Data.Supplemental objects
Property HcpToContractMap Output Dictionary<int, List<Data.Contract>>
Description Dictionary mapping an HCP to contracts Description A dictionary keyed on hcp id with a list of applicable contracts
Property HcpToSupplementalMap Output Dictionary<int, List<SupplementalData>>
Description Dictionary mapping an HCP to supplemental data Description A dictionary keyed on hcp id with a list of supplemental data
6.3 BeneficiaryMgmt
The BeneficiaryMgmt component will be used to manage beneficiaries and their associated entities. This will include retrieval for both non-managed and managed care beneficiaries. For managed care only, adding risk factor and supplemental information, and for non-managed care only, creating new beneficiaries with associated coverage. This component will be referenced by ManagedCareUI and NonManagedCareUI, and will be reference the Data component.
6.3.1 Use Case 4.1 Beneficiary Management

Requirement Specification This use case describes the process for users to view Beneficiary Eligibility Data and Payment History, and update Supplemental Eligibility information via the user interface. California Department of Health Care Services, 820 Phase 2 System, 2009
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6.3.2 Use Case 4.5 HIPP and BCCTP Beneficiary Management

Requirement Specification This Use Case describes the steps for adding, updating and viewing HIPP, BCCTP, and GHPP Beneficiary information in the 820 Phase 2 System via the user interface.
6.3.3 Class Diagram

interface IMCBeneficiaryService +GetBeneficiaries() +InsertRiskFactor() +UpdateSupplementalInformation() +InsertSupplementalEligibility()
ManagedCareUI
interface INonMCBeneficiaryService +GetBeneficiaries() +SaveBeneficiary() +InsertAdjustment() +InsertCoverage() BeneficiaryService
NonManagedCareUI
Data.Beneficiary
6.3.3.1 IMCBeneficiaryService
The IMCBeneficiaryService interface will define methods to retrieve beneficiaries and add supplemental information. This interface will be used by the ManagedCareUI component.

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Method GetBeneficiaries Parameters CIN
Description Retrieve beneficiaries Type String Description The CIN number of a beneficiary to retrieve First Name
firstName
String
lastName
String
Last Name
dateOfBirth
DateTime
The date of birth
alienStatus
String
The alien status
healthCarePlanId
Int
The health care plan id
primaryEligibilityId
Int
The primary eligibility id
supplementalEligibilityId
Int
The supplemental eligibility id
supplementalEligibilityFromDate
DateTime
The from date of the supplemental eligibility information The to date of the supplemental eligibility information
supplementalEligibilityToDate
DateTime
Output Beneficiary[]
Description An array of Data.Beneficiary objects
Method UpdateContract Parameters
Description Update conctract information. This will create a new version of all contract data. Type Description

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Contract
Data.Contract
The contract values to update.
Method InsertRiskFactor Parameters beneficiaryId
Description Insert Risk factor for a beneficiary. Type Long Description The beneficiary id
riskFactor
Decimal
The risk factor
Method InsertSupplementalEligibility Parameters beneficiaryId
Description Insert supplemental information for a beneficiary Type Long Description The beneficiary id
supplementailAidId
Long
The supplemental id code id
diagnosis
String
The diagnosis code
6.3.3.2 INonMCBeneficiaryService
The INonMCBeneficiaryService interface will define methods to retrieve and save beneficiary information. This interface will be used by the NonManagedCareUI component.

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Method GetBeneficiaries Parameters CIN
Description Retrieve beneficiaries Type String Description The CIN number of a beneficiary to retrieve First Name
firstName
String
lastName
String
Last Name
dateOfBirth
DateTime
The date of birth
alienStatus
String
The alien status
healthCarePlanId
Int
The health care plan id
primaryEligibilityId
Int
The primary eligibility id
supplementalEligibilityId
Int
The supplemental eligibility id
supplementalEligibilityFromDate
DateTime
The from date of the supplemental eligibility information The to date of the supplemental eligibility information
supplementalEligibilityToDate
DateTime
Output Beneficiary[]
Description An array of Data.Beneficiary objects
Method SaveBeneficiary Parameters Beneficiary
Description Save a single beneficiary Type Data.Beneficiary Description The beneficiary to save

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6.4 ReportMgmt
The ReportMgmt component will be used manage and create reports. Reports will be initiated from the user interface and will either be formatted for Excel or Adobe Reader. The ManagedCareUI and NonManagedCareUI components will use it. This component will reference the Data component.
6.4.1 Use Case 4.3 Generate Reports

Requirement Specification This use case describes the process for users to generate, view, print and export reports via the user interface. .
6.4.2 Class Diagram

ReportManager +GetAvailableReports() * 1 Reports IList 1 Report PACEClaimScheduleReport * +Generate() +SetFormat() +SetDateFilter() HealthPlanPaidInvoiceReport
RateSheetReport ExpendituresByFundingSourceReport
CapitationReport
ContractEncumbranceAndExpenditureReport
EnrollmentReport
PlanPaymentHistoryReport PermReport
ExpendeturesByWaiverAuthorityReport
OMCAndPHPClaimScheduleReport

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6.4.2.1 ReportManager
The ReportManager class will be the managing class within this component. It will used to access all available reports. Method GetAvailableReports Output Reports Description Get a list of available reports Description A list of Report objects
6.4.2.2 Reports
The Reports class will implement System.Collections.Generic.IList and will contain a list of Report objects. The list will be strongly typed and each object can be accessed by index.
6.4.2.3 Report
The Report class will be an abstract class containing methods that are common across report objects within the system. Method Generate Output Reports Description Generate the report based on a date filter. Description A list of Report objects
Method SetFormat Parameters formatType
Description Set the format of the report to either PDF or Excel Type enumFormat {excel, pdf} Description An enumerator of either value defining either excel or pdf

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1.1.1.1 Method
SetDateFilter Parameters dateFrom
Description Set the to and from date filter Type DateTime Description The date from
dateTo
DateTime
The date To
6.4.2.4 EnroEnllmentReport
The EnrollmentReport class will represent Beneficiaries grouped by County and Aid Code Group. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.
6.4.2.5 CapitationReport
The CapitationReport class will represent Beneficiaries grouped by Aid Code Group, HCP, Rate, Term date and County. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.6 ExpendituresByFundingSourceReport
The ExpendituresByFundingSourceReport class will represent Amounts paid, broken down by State Fiscal Year and Quarter of Payment Date, HCP and Model Type, for Funding Sources: Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.
6.4.2.7 ExpendeturesByWaiverAuthorityReport
The ExpendeturesByWaiverAuthorityReport class will represent Waiver Amounts paid per State Fiscal Year and Quarter, broken down by HCP, Claim Sch. Number, Payment Type, Funding Source and Aid code group for each waiver. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.
6.4.2.8 PermReport
The PermReport class will represent expenditures by HCP, Aid Code Group, Aid Code, Rate, and Beneficiary. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.9 PlanPaymentHistoryReport
The PlanPaymentHistoryReport class will represent expenditures by Month of Payment or Month of Service/. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.
6.4.2.10
ContractEncumbranceAndExpenditureReport
The ContractEncumbranceAndExpenditureReport class will represent expenditures by Contract. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.11
OMCAndPHPClaimScheduleReport
The ContractEncumbranceAndExpenditureReport class will represent Payments by Date of Payment. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.12
PACEClaimScheduleReport
The PACEClaimScheduleReport class will represent Payments by Date of Payment (Hierarchy: Program Type, Managed Care Plan Name, Funding Source, Quarterly). Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.13
RateSheetReport
The RateSheetReport class will represent Payment Rates per Aid Code Group (or Supplemental Payment Rate), per HCP, and per current Effective Date(s). Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.
6.4.2.14
HealthPlanPaidInvoiceReport
The HealthPlanPaidInvoiceReport class will represent Payments by Date of Payment (Hierarchy: HCP, Invoice No., Monthly). Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.4.2.15
BeneficiaryPaymentHistorySummaryReport
The HealthPlanPaidInvoiceReport class will represent a summary of payment history per Beneficiary. Invoice Types will be both Medi-Cal Only and Medicare Part D. The invoice statuses will be Pending through 820 Sent.

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6.5 RemittanceAdviceMgmt
The RemittanceAdviceMgmt component will handle the internal processing of gathering invoices from the system and generating and 820 Remittance Advice. The invoices should have the status of Paid, meaning that Accounting and SCO have paid out the invoices to the Vendor. The component will then transform the invoice data into an 820 Remittance Advice XML document suitable for processing in XEngine to produce the actual 820 EDI document.
6.5.1 Use Case 5.1 Process and Send 820 Transactions

Requirement Specification The Process and Send 820 Transactions process produces HIPAA-compliant 820 transactions that show the beneficiary, invoice and payment data for Trading Partners to receive from an SFTP site. . Process Model

o o If the invoice payee is a beneficiary or a beneficiary representative, do NOT generate an 820 transaction for invoice. If an 820 transaction does not pass SNIP validations, system halts processing of the transaction and posts SNIP Error Report. System logs an error for System Administrator.

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6.5.2 Class Diagram

Processed820 -InvoiceInfoList +GetRemittanceAdvice()
RemittanceAdviceMgmt +Process()
InvoiceMgmt
6.5.2.1 RemittanceAdviceMgmt
The RemittanceAdviceMgmt class will manage and start the processing of a new remittance advice file (the 820 EDI file). With a warrant number, invoices with the status of Paid will be processed and sent into XEngine to create the EDI file. Method Process Parameters warrantNumber Long Description Starts the process the generating the remittance advice. Type Description The warrant number to be processed against
Output XmlDocument
Description An XML document validated against the 820 XEngine Schema
6.5.2.2 Processed820
The Processed820 class will be used create the remittance advice. The format of the remittance advice will be an XML document validated against the 820 XEngine schema. Method GetRemittanceAdvice Description This method will create an return the XML format of the 820 XEngine remittance advice

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Output XmlDocument
Description An XML document validated against the 820 XEngine Schema
6.6 InvoiceMgmt
The InvoiceManagement component will handle generation of all supported invoices. The component will be used by the capitation process and, invoice recalculation. All supported invoices can be grouped in three logical groups: capitation invoices, supplemental invoices, and adjustment invoices. Though all these invoices generate same kind of output, each group has different source of input data. The caller of the component has to load required input data.
6.6.1 Use Case 2.1 Generate Managed Care Invoices

Requirement Specification The Process Invoices process begins with the generation of all Managed Care invoices for the current enrollment month based on the completion of processing the Beneficiary Enrollment file. The invoices are then made available for review and approval by the Managed Care Department. They are then manually printed by the user and provided to the DHCS Accounting department. Additionally, HIPP/BCCTP Department staff manually creates invoices and print them out for the DHCS Accounting Department. Contract and Beneficiary Adjustments are also available for the user in this process, which will ultimately be shown on the appropriate invoice(s). The invoices are now ready for payment reconciliation, which is described in the next section: Process Payments.
Process Model
820 Phase 2 System
1.2 Calculate Capitation
Retrieve Current Month Capitation Data
Identify Invoice Type
Populate Header and Footer Information
Populate Current Month Capitation Information
Populate Previious Quarter Capitation Information
Populate Quarterly Rate Adjustment Amounts
System withholds 7% for Sacramento GMC Dental
Populate Advance Payments & Advance Adjustments
Populate Total Capitation Amounts & Funding Breakdown
Set Invoice Status to Pending & Make Available on User Interface
CAPMAN Database
2.2 Review and Approve Invoices

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o o If Rate Adjustment is Negative, refer to Business Rule 2.1.21 for 25% Recoupment Cutoff logic. If a Rate Adjustment or Adjustments apply to a Service Month prior to the 12 previous service months (but no earlier than 24 months prior to current month), system creates a separate invoice apart from the 13month capitation invoices. Invoices are generated based on State Fiscal Year, Contract Number, HCP, and Invoice Type. Invoice format and calculations are the same as described in Steps 2 and 3, except Service Months do not include the current service month or the 12 prior service months. Rate Adjustments for Beneficiary-Based Supplemental Payments are calculated for service months up to 2 years prior to current month.

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6.6.2 Class Diagram

InvoiceManagerService -ContractList : ContractDataList +GetInvoiceDataByBene() : InvoiceInfoList +GetExpectedInvoices() : InvoiceInfoList +CalculateNewInvoices() : InvoiceInfoList #LoadApplicableContracts() +SaveInvoices() +UpdateInvoiceStatus() +ApplyAdjustments() : InvoiceInfo +PerformRateAdjustmentBeyondCapPerio d() : DateTime +RecalculateInvoice() : int refines
interface IInvoiceManagement +GetInvoiceTypeRange() : InvoiceTypeRange
CapitationInvoice refines +ApplyAdjustments() : InvoiceInfoList SupplementalInvoices #GetAdjustedRate() : decimal #GetSupplementalAidType() : short #LoadApplicableBeneficiaries()
AidsInvoice
MaternityInvoice
GmcDentalReleaseInv oice -Adjustment -LoadAdj()
AgnewsInvoice
SavingsSharingI nvoice
CraigBontaInvoice
AdvancePaymentInvoice
datatype EnumInvoiceTypes
struct InvoiceInfo
structContractData
struct BeneEligibilityInfo +ServiceDate : DateTime +hcpId : short +AidCodeId : short +PaymentTypeId : short
structInvoiceTypeRange +StartRange : EnumInvoiceTypes +EndRange : EnumInvoiceTypes
1 InvoiceInfoList
1 ContractDataList
6.6.2.1 IInvoiceManagement
Every supported invoice class will inherit IInvoiceManagement. Method GetInvoiceTypeRange Description Provides a range of invoice types.

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Output InvoiceTypeRange
Description Start and end value of an invoice type range.
6.6.2.2 InvoiceManagerService
The InvoiceManagerService will be an abstract base class. It will contain business logic that is common for all types of invoices. Method GetInvoiceDataByBene Parameters BeneficiariesId Description Provides historical invoices for a list of beneficiaries. Type List<integer> Description A list of beneficiary Ids whose historical invoices are needed. The end date for historical invoices date range (often capitation date). Count of historical months for which the data is needed. A range invoice types that should be extracted.
LatestDate
DateTime
MonthsInHistory
Integer
Range
InvoiceTypeRange
Output InvoiceInfoList
Description A list of historical invoices.
Method GetExpectedInvoices
Description Provides a list of expected invoices based on provided eligibility information of a beneficiary and already loaded applicable contract information. Type DateTime Description Capitation date.
Parameters CapitationDate
EligibilityInfo
BeneEligibilityInfo
Provides a beneficiarys eligibility information including the service month for which the expected invoices will be identified.

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HistoricalCapitationData
InvoiceInfoList
List of historical capitation data, it will be required for supplemental invoices.
Description A list of expected invoices.
Method CalculateNewInvoices
Description Using provided lists of historical and expected invoices, provides a list of actual invoices that should to be saved in the database. Type InvoiceInfoList Description A list of historical invoices.
Parameters HistoricalInvoices
ExpectedInvoices
InvoiceInfoList
A list of expected invoices.
Description A list of actual invoices that should be saved.
Method LoadApplicableContracts Parameters CapitationDate
Description This method will be a protected abstract method; hence every derived class should provide its implementation. Type DateTime Description Capitation date.
Output None
Description However the method populates applicable contract data in ContractList data member. Description This method will be a public virtual method. It will save the provided data (as input parameter) in tb_invoice_detail and tb_invoice tables. ApplyAdjustment method should be called before saving the invoices. invoicesToBeSaved input parameter should be grouped on capitation date, contract plan code, invoice type, and fiscal year to identify records for tb_invoice table. Type Description
Method SaveInvoices
Parameters

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InvoicesToBeSaved
InvoiceInfoList
List of InvoiceInfo records that needs to be saved. Capitation date.
CapitationDate
DateTime
Output None
Description However the method will throw exceptions and the caller is expected to handle it. Description This method will be a public method; It will save Pending tb_invoice_status records for invoices of a specific capitation date and invoice type range. Type DateTime Description Capitation date.
Method UpdateInvoiceStatus
range
InvoiceTypeRange
Type of invoices whose status needs to be saved.
Output None
Description However the method will throw exceptions and the caller is expected to handle it. Description This method will perform Adjustment on every invoice that is getting saved. Type InvoiceInfo Description An invoice detail data that needs to be saved.
Method ApplyAdjustments Parameters InvoiceInfoRecord
Output None
Description However the method will throw exceptions and the caller is expected to handle it.
Method PerformRateAdjustmentBeyondCapPeriod
Description This method will perform rate adjustment calculation for 24 service months before the oldest service month of the current capitation. Type Description
Parameters

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CapitationDate
DateTime
Capitation date.
Output None
Description However the method will throw exceptions and the caller is expected to handle it. Description This method will be a public method; It will save Pending tb_invoice_status records for invoices of a specific capitation date and invoice type range. Type integer Description Invoice that needs to be recalculated..
Method RecalculateInvoice
Parameters InvoiceId
Output None
Description However the method will throw exceptions and the caller is expected to handle it.
6.6.2.3 CapitationInvoice
The CapitationInvoice will be a class used by capitation process to generate capitation invoices. It must be derived from InvoiceManagerService and IInvoiceManagement. Most of the business logic required for generation of capitation invoice will exist in InvoiceMethodService base class. Any logic specific to capitation invoices should be implemented in this class. Method LoadApplicableContracts Parameters CapitationDate Description Override this inherited method to extract contracts that are applicable for capitation invoices. Type DateTime Description Capitation date.
Output None
Description However the method populates applicable contract data in ContractList data member.
Method
Description

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GetExpectedInvoices
Override this method to identify expected capitation invoices. The expected capitation invoices can be identified by locating applicable contract for a beneficiary. No historical invoice information will be needed here. Type DateTime Description Capitation date.
EligibilityInfo
BeneEligibilityInfo
Provides a beneficiarys eligibility information including the service month for which the expected invoices will be identified. Ignore this parameter.
InvoiceInfoList
Method ApplyAdjustments
Description This method will apply adjustments that are required for capitation invoices. It includes GM Dental Withhold, Advance Payment, and Recoupment Balance. Note that the adjustments are applicable to only capitation invoices. Any applicable adjustment should be applied on the related invoice. Type DateTime Description Capitation date.
Invoices
InvoiceInfoList
List of invoices that should be saved in the database.
Output InvoiceInfoList.
Description List of adjusted invoices that should be saved in the database.
Method
Description

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CalculateNewInvoices
Override this method only to apply the adjustment on capitation invoices. The methods should call base implementation of the method and output of the call should be sent as parameter to ApplyAdjustment method. The output of the ApplyAdjustment should be returned to the caller. Type InvoiceInfoList Description A list of historical invoices.
Parameters HistoricalInvoices
ExpectedInvoices
InvoiceInfoList
Description A list of actual adjusted invoices that should be saved.
6.6.2.4 SupplementalInvoice
The SupplementalInvoice will be an abstract base class for all supplemental and adjustment invoices. It will be derived from InvoiceManagerService, so that all common business logic of invoice generation can be utilized. Every class derived from SupplementalInvoice should also inherit IInvoiceManagement. Method LoadApplicableBeneficiary Parameters StartServiceDate Description Provides supplemental eligibility information of a list of beneficiaries for a date range. Type DateTime Description Start date of date range.
EndServiceDate
DateTime
End date of date range.
BeneficiaryIds
List<integer>
A list of beneficiary ids whose supplemental eligibility is required.
Output SupplementalInfoList
Description A list that contains supplemental eligibility information of all beneficiaries whose id was provided as input parameter. Description
Method

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GetAdjustedRate
This method will be a protected abstract method. Every derived class should provide its implementation. The implementation should provide adjusted rate for the applicable supplemental eligibility of a beneficiary. Type Decimal Description Effective supplemental rate.
Parameters SupplementalRate
CapitaionPaid
Decimal
Capitation amount that was paid to the beneficiary.
Output adjustedRate
Description Adjusted Rate that should be saved in the database.
Method GetSupplementalAidType
Description This method will be a protected abstract method. Every derived class should provide its implementation. The implementation should provide type of supported supplemental eligibility. Type Description
Parameters none
Output supplementalType
Description Type of supported supplemental eligibility.
Method LoadApplicableContracts
Description Override this inherited method to extract contracts that are applicable for supplemental invoices. Since supplemental eligibility has its own applicable contract data, use GetSupplementalAidType method in this common implementation to identify type of supplemental eligibility whose contract data needs to be loaded. Type DateTime Description Capitation date.
Output None
Description However the method populates applicable contract data in ContractList data member. Description
Method

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GetInvoiceTypeRange Parameters None
Define this method as abstract, so that every non-abstract derived class must provide its implementation. Type Description
Description Returns range of the applicable invoice types.
Method GetExpectedInvoices
Description Override this method to identify expected supplemental invoices. The expected supplemental invoices can be identified by locating applicable contract for a beneficiary and the related capitation eligibility. Type DateTime Description Capitation date.
EligibilityInfo
BeneEligibilityInfo
Provides a beneficiarys eligibility information including the service month for which the expected invoices will be identified. List of historical capitation data.
InvoiceInfoList
6.6.2.5 AidsInvoice
The AidsInvoice will be a class used by processes to generate invoices for Aids. It must be derived from SupplemetalInvoice and IInvoiceManagement. Most of the business logic required for generation of this invoice will exist in InvoiceMethodService and SupplementalInvoice base classes. Any logic specific to aids invoices should be implemented in this class. Method GetAdjustedRate Parameters Description Provide specific implementation for this protected abstract method. Type Description

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SupplementalRate
Decimal
Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Method GetSupplementalAidType Parameters none
Description Provide specific implementation for this protected abstract method. Type Description
Method GetInvoiceTypeRange Parameters None
Description Implement this interface method. Type Description
6.6.2.6 AgnewsInvoice
The AgnewsInvoice will be a class used by processes to generate invoices for Agnews. It must be derived from SupplemetalInvoice and IInvoiceManagement. Most of the business logic required for generation of this invoice will exist in InvoiceMethodService and SupplementalInvoice base classes. Any logic specific to Agnews invoices should be implemented in this class. Method GetAdjustedRate Description Provide specific implementation for this protected abstract method.

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Type Decimal
Description Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Method GetSupplementalAidType Parameters none
6.6.2.7 MaternityInvoice
The MaternityInvoice will be a class used by processes to generate invoices for Maternity. It must be derived from SupplemetalInvoice and IInvoiceManagement. Most of the business logic required for generation of this invoice will exist in InvoiceMethodService and SupplementalInvoice base classes. Any logic specific to Maternity invoices should be implemented in this class. Method GetAdjustedRate Description Provide specific implementation for this protected abstract method.

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Type Decimal
Description Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Method GetSupplementalAidType Parameters None
6.6.2.8 CraigBontaInvoice
The CraigBontaInvoice will be a class used by processes to generate invoices for CraigBonta. It must be derived from SupplemetalInvoice and IInvoiceManagement. Most of the business logic required for generation of this invoice will exist in InvoiceMethodService and SupplementalInvoice base classes. Any logic specific to CraigBonta invoices should be implemented in this class. Method Description

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LoadApplicableBeneficiary
Override implementation of this virtual method. This implementation should provide Craig Vs. Bonta eligibility information of a list of beneficiaries for a date range. Type DateTime Description Start date of date range.
Parameters StartServiceDate
EndServiceDate
DateTime
BeneficiaryIds
List<integer>
Description A list that contains supplemental eligibility information of all beneficiaries whose id was provided as input parameter.
Method GetAdjustedRate Parameters SupplementalRate
Description Provide specific implementation for this protected abstract method. Type Decimal Description Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate

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6.6.2.9 GmcDentalReleaseInvoice
The GmcDentalReleaseInvoice will be a class used by processes to generate invoices for GMC Detnal Release. It must be derived from SupplemetalInvoice and IInvoiceManagement. However this invoice is different from all other supplemental invoices, the following methods should be overridden to provide the specific implementation. Method LoadApplicableBeneficiary Description Override implementation of this virtual method. This implementation should provide GMC Dental Release eligibility information of a list of beneficiaries for a date range. Type DateTime Description Start date of date range.
Parameters StartServiceDate
EndServiceDate
DateTime
BeneficiaryIds
List<integer>
Description A list that contains supplemental eligibility information of all beneficiaries whose id was provided as input parameter.
Method GetAdjustedRate Parameters

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SupplementalRate
Decimal
Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Method LoadAdj Parameters None
Description Load Adjustment data specific to GMC Dental Release. Type Description
Output none
Description However populate the extracted data in Adjustment data member.
Method GetExpectedInvoices Parameters CapitationDate
Description Override this virtual method to identify expected invoices for GMC Dental Release. Type DateTime Description Capitation date.

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EligibilityInfo
BeneEligibilityInfo
Provides a beneficiarys eligibility information including the service month for which the expected invoices will be identified. List of historical capitation data, it will be required for supplemental invoices.
InvoiceInfoList
Method CalculateNewInvoices Parameters HistoricalInvoices
Description Override this virtual method to identify actual invoices for GMC Dental Release. Type InvoiceInfoList Description A list of historical invoices.
ExpectedInvoices
InvoiceInfoList
6.6.2.10
SavingSharingInvoice
The SavingSharingInvoice will be a class used by processes to generate invoices for Savings Sharing Disbursement. It must be derived from SupplemetalInvoice and IInvoiceManagement. However this invoice is different from all other supplemental invoices, the following methods should be overridden to provide the specific implementation.

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Method GetAdjustedRate Parameters SupplementalRate
Description Provide specific implementation for this protected abstract method. Type Decimal Description Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Description Load Adjustment data specific to Savings Sharing Disbursement. Type Description
Output none
Method CalculateNewInvoices Parameters
Description Override this virtual method to identify actual invoices for Saving Sharing Disbursement. Type Description

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HistoricalInvoices
InvoiceInfoList
No historical invoices will be needed to identify actual invoices that need to be saved. A list of expected invoices.
ExpectedInvoices
InvoiceInfoList
6.6.2.11
AdvancePaymentInvoice
The AdvancePaymentInvoice will be a class used by processes to generate invoices for Advance Payments. It must be derived from SupplemetalInvoice and IInvoiceManagement. However this invoice is different from all other supplemental invoices, the following methods should be overridden to provide the specific implementation. Method GetAdjustedRate Parameters SupplementalRate Description Provide specific implementation for this protected abstract method. Type Decimal Description Effective supplemental rate.
CapitaionPaid
Decimal
Output adjustedRate
Method
Description

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GetSupplementalAidType Parameters None
Provide specific implementation for this protected abstract method. Type Description
Description Load Adjustment data specific to Advance Payments. Type Description
Output none
Method CalculateNewInvoices Parameters HistoricalInvoices
Description Override this virtual method to identify actual invoices for Advance Payments. Type InvoiceInfoList Description No historical invoices are needed to identify the actual invoices that need to be saved. A list of expected invoices.
ExpectedInvoices
InvoiceInfoList
Output
Description

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InvoiceTypeRange
Returns range of the applicable invoice types.
6.7
CapitationMgmt
The CapitationMgmt component will handle import of MMCD data into the 820 database. It will compute every eligible beneficiarys current as well prior months capitation. Also, it will generate data for capitation invoices.
6.7.1 Use Case 1.2 Calculate Capitation

Requirement Specification The Calculate Capitation process begins with the receipt and processing of the Beneficiary Enrollment files, where the Managed Care Health Care Plans (HCPs) and their enrolled beneficiary data for the current month plus 12 prior months is supplied. The HCP and beneficiary data is captured and used to calculate the capitation. This is where the System calculates the current months enrollment data, and then compares the previous twelve months enrollment on the current file to the previous twelve months in history. The outcome is capturing and calculating the net eligibles per HCP for use in the next process of generating Managed Care invoices.
Process Model
820 Phase 2 System

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6.7.2 Class Diagram

CapitationProcessor -historicalInvoices : InvoiceInfoList -ExpectedInvoices : InvoiceInfoList -InvoicesToBeSaved : InvoiceInfoList +ExecuteProcess() : bool -LoadStagedRecords() -ValidateStagedRecord() : bool -IdentifyNewInvoices() -SaveData()
datatype EnumInvoiceTypes StagingBeneficiary +ClientIndexNumber : string +MedsRenewalDate : string +LastName : string +FirstName : string +HCP : string +AidCode : string +Status : string +PaymentType : string
struct InvoiceInfo +FiscalYear : short +InvoiceTypeId : EnumInvoiceTypes +ContractPlanCode : int +Hcpid : short +AidCodeid : short +PaymentType : EnumPaymentType +Amount : decimal +Rate : decimal +ServiceDate : DateTime
datatype EnumPaymentType
1 InvoiceInfoList
6.7.2.1 CapitationProcessor
The CapitationProcessor class will be a sealed class and it will be responsible for the execution of the capitation process. Before executing the process, the caller should ensure that only latest MMCD enrollment data is available in TB_STAGING_BENEFICIARY and TB_STAGING_MONTHLY_INFO tables. The class would not contain any logic to ensure completeness or validity of the enrollment data. Status of the process will be logged-in an XML file for reporting purposes.
In addition to its public constructor, the class will contain only one public method. Method Description

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ExecuteProcess
This method will execute the entire capitation process that includes saving of MMCD enrollment data in CAPMAN database, calculation of capitation amount and saving of invoice data. Since the caller of this method does not have any information about the capitation date for which the process is being executed, the class will assume MedsRenewalDate of the very first enrollment record as the capitation date. Using the capitation date, start and end service date will be identified (13 month period). Once capitation and service dates are identified, the process will read MMCD enrollment data. Using the enrollment data, expected invoices will be identified by calling GetExpectedInvoices method of CapitationInvoice class. The returned expected invoices will be stored in expectedInvoices data member. The expected invoices will be compared against the historical invoices to find the invoices that should be saved in the database.
Parameters None
Type
Description
Output Bool
Description True if the process completes successfully otherwise false.
Method LoadStagedRecords
Description This private method will get MMCD enrollment data from staging database tables. Paging should be used to read the staged data. Type String Description Last read client identification number. This will help to implement paginated reading of the staged data.
Parameters LastReadCin
Output List<StagingBeneficiary>
Description A list of staged enrollment data.
Method
Description

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ValidateStagedRecord
This private method will perform validation of individual staged record. The method will be called for each record extracted by LoadStagedRecords method. A few of the critical validations that the method will perform: 1. MedsRenewalDate of the record should be same as the capitation date identified at the start of the process. 2. Client Index Number should not be null or empty and it must be exactly 9 characters long. 3. First Name and Last Name should not be null. 4. Hcp code and aid code must exist in CAPMAN database.
Parameters stagedRec
Type StagingBeneficiary
Description The staged record that should be validated.
Output bool
Description True if valid otherwise false.
Method IdentifyNewInvoices
Description This private method will load historical invoices in historicalInvoices data member. It will pass historicalInvoices and expectedInvoices as parameters to CalculateNewInvoices method of CapitationInvoice class to identify the actual invoices. The returned values will be saved in invoiceToBeSaved. Type Description
Parameters None
Output none
Description
Method SaveData
Description This private method should call saveInvoices method of CapitationInvoice object. It will save invoices in invoiceToBeSaved data memeber to tb_invoice and tb_invoice_detail tables. However, before calling the method ensure that all beneficiaries whose data is getting saved exist in CAPMAN database. Type Description
Parameters

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none
Output None
Description However an exception will be thrown if any error occurs during save and ExecuteProcess will catch it.

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6.7.3 Sequence Diagram Process Capitation
ProcessCapitation
CapitationProcessor
InvoiceManager
SQLProcedures
Receive MMCD File
Log MMCD File Receipt
Persisit MMCD to Staging
ExecuteProcess LoadStagedRecords List<StagingBeneficiaries>
LoadInvoiceDataByBene LoadInvoiceInfoList IList<InvoiceInfo> InvoiceInfoList
CalculateNewInvoices
SaveData
UpdateInvoiceStatus
LogInformation CapitationReporter
Log Invoice Processing Results
This sequence diagram illustrates how the MMCD file will be processed. 1. ProcessCapitation object receives the MMCD file in Receive MMCD File 2. ProcessCapitation object logs the file receipt in Log MMCD File Receipt

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3. ProcessCapitation object persists the MMCD file into staging tables in Persist MMCD to Staging 4. ProcessCapitation calls CapitationProcessor with function ExecuteProcess to start the calculation process 5. CapitationProcessor calls SQLProcedures with function LoadStageRecords to load the Beneficiary records from the staging tables 6. SQLProcedures returns a list of StagingBeneficiary objects loaded from the staging tables 7. CapitationProcessor calls InvoiceManager with function LoadInvoiceDataByBene to get the historical beneficiary records 8. InvoiceManager calls SQLProcedures with function LoadInvoiceInfoList to load historical beneficiary records 9. SQLProcedures returns a list of historical beneficiary records 10. InvoiceManager returns a list of historical beneficiary records 11. CapitationProcessor calls InvoiceManager with function CalculateNewInvoices to start the calculation using historical and current beneficiary records 12. CapitationProcessor saves the calculated beneficiary records with function SaveData 13. CapitationProcessor updates the invoice status to Pending with function UpdateInvoiceStatus 14. CapitationProcessor logs the processing information with function call LogInformation 15. CapitationProcessor returns object CapitationReporter which will contain the logged processing information 16. ProcessCapitation persist the processing results in Log Invoice Processing Results.
7 Data Objects
The Data Objects will be an in memory representation of the database and provide mechanism to retrieve and update data. The objects will be tightly coupled with the database and in most cases there will be a one-to-one relationship between a table and a data object. The Data Objects will be generated from the database using the Microsoft Entity Framework. Since the Data Objects are generated the description for each class is part of the Table Description in section 9.1 (no TB_ prefix is on the data objects).

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7.1 Contract Data

PaymentType AidCodeGroupType
1 1
PlanCodeOnPaymentType * * * 1 AidCodeGroup 1 1 1 CountyCodeType VendorType
* VendorInfo 1 * * * ContractPlanCode 1
* * ModelType 1
HealthCarePlanType
1 *
ContractFunding
* * 1 1 1 Contract * ContractType
WaiverType
* ContractFundingType
The Contract Data class diagram represents all classes within the scope of contract management.

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7.2 Beneficiary Data

SupplementalAidType
* BeneSupplementalInfo
BeneRiskFactor
1 Beneficiary 1 1 * 1
InvoiceDetail ModelType
* BeneficiaryNonmanagedCare
* 1
PaymentType
HealthCarePlanType
The Beneficiary Data class diagram represents all classes within the scope of beneficiary management.

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7.3 Invoice Data

HealthCarePlanType CountyCodeType 1 * 1
Warrant ContractPlanCode * 1 Invoice 1 * * 1 * * InvoiceDetail 1 InvoiceType InvoiceStatus 1 * *
1 Contract
* 1 VendorInfo
The Invoice Data class diagram represents all classes within the scope of invoice management.
8 Database
The following subsections describe the structure of database. It will contain the Entity Relationship Diagram and table description. The detailed data dictionary is in Appendix A.
8.1 Entity Relationship Diagram

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8.2 Table Descriptions

The following table lists each table in the database and semantically describes its purpose. Name TB_ADJUSTMENT TB_ADJUSTMENT_TYPE TB_AID_CODE TB_AID_CODE_GROUP TB_AID_CODE_GROUP_TYPE TB_AID_CODE_TYPE TB_BENE_RISK_FACTOR TB_BENE_SUPPLEMENTAL_INFO TB_BENEFICIARY TB_BENEFICIARY_ADJUSTMENT TB_BENEFICIARY_NONMANAGE D_CARE TB_CONTRACT Contract Management Contract Management Reference Table Reference Table Beneficiary Management Beneficiary Management Beneficiary Management Non-managed Care Management Non-managed Care Management Contract Management Contract Management Domain Contract Management Reference Table Description Details of Health Care Plan-Level adjustments within each Contract Reference Table detailing the type of the adjustment (GMC Dental, Payment Received) Join table to determine what aid codes are in what aid codes group per contract Join table of Aid Code Groups eligible within a Contract. Also contains rate effective dates Reference Table of Aid Code Group Names (Blind, Aged, Disabled) Aid Code Reference Table listing all Aid Codes in MEDS Risk Factor of a Beneficiary with versioning Join table of Beneficiary Eligibility for Supplemental Aid Beneficiary Reference Information for both Managed and Non-Managed Care Non-Managed Care Adjustments at the Beneficiary Level Supplemental Beneficiary Information when Beneficiary is in Non-Managed Care (HIPP/BCCTP) High Level Contract Details, detailing Contract Number and Contract Change History The change type of the contract, denoting the most recent change as being an original, a change order, or an amendment. Funding within a contract, detailing the amount of funding each payment type receives Reference table that enumerates the funding breakdown of the contract encumbrance Join Table of Contract and the Plan Codes enrolled within the contract, and any potential waiver eligibility for the Plan Codes
TB_CONTRACT_CHANGE_TYPE
TB_CONTRACT_FUNDING
Contract Management Reference Table
TB_CONTRACT_FUNDING_TYPE Contract Management
TB_CONTRACT_PLAN_CODE

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Name TB_CONTRACT_PLAN_SUPPLEM ENTAL_INFO TB_CONTRACT_TYPE TB_COUNTY_CODE_TYPE TB_DATABASE_UPDATE_SCRIPT TB_ETHNICITY_CODE_TYPE TB_FUNDING_TYPE TB_GENDER_CODE_TYPE TB_HEALTH_CARE_PLAN_TYPE TB_INVOICE TB_INVOICE_CHANGE_TYPE
Domain Contract Management Reference Table Reference Table Reference Table Reference Table Reference Table Reference Table Reference Table Invoice Management Reference Table
Description Join Table of Contract Health Plan Eligibility for Supplemental Aid and accompanying rates Reference details of what is the type of the Contract (Primary or Hyde) Reference Table of All County Codes ITSD Required table used for database update DML / DDL scripts Reference Table enumerating all valid ethnicity codes Reference Table of Funding Types Reference Table to hold all possible Gender Codes from MEDS Reference Table of 3-Digit Health Care Plan (HCP) Codes All Invoice-related details and additional details received from CMS64 file Reference Table to hold all possible values for Change Type in Invoice Detail Table Table to hold invoice payment details for beneficiaries Invoice Status Audit Table Reference Table of Invoice Types (Primary Medi-Cal, Medicare Part D, HYDE) The Model / Sub-Model Type of the Health Plan (COHS, PHP, PACE, SCAN) Non-Managed Care (HIPP/BCCTP) Coverage Information Table Reference Table of Non-Managed Coverage Type (Medical, Dental, Vision) Reference Table of Non-Managed Care Program Type (HIPP or BCCTP) Eligibility of Coverage for Non-Managed Care Vendors Reference Table of the Aid Code Group Payment Type (Healthy Families, MediCal Only, Medicare Part D) The program mapped against the plan types used within the program, with rates given Staging Table to hold raw beneficiary data from MMCD Record
TB_INVOICE_DETAIL TB_INVOICE_STATUS TB_INVOICE_TYPE TB_MODEL_TYPE TB_NONMANAGED_COVERAGE TB_NONMANAGED_COVERAGE_ TYPE TB_NONMANAGED_PROGRAM_T YPE TB_NONMANAGED_VENDOR_CO VERAGE TB_PAYMENT_TYPE TB_PLAN_CODE_ON_PAYMENT_ TYPE TB_STAGING_BENEFICIARY
Monthly Beneficiary Details Invoice Management Invoice Management Reference Table Non-Managed Care Management Non-Managed Care Management Non-Managed Care Management Non-Managed Care Management Reference Table
Contract Management Beneficiary Management

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Name TB_STAGING_MONTHLY_INFO TB_STATUS_TYPE TB_SUPPLEMENTAL_AID_TYPE TB_VENDOR_INFO TB_VENDOR_TYPE TB_WAIVER_TYPE TB_WARRANT
Domain Beneficiary Management Invoice Management Reference Table Contract Management Reference Table Reference Table
Description Staging Table to hold raw beneficiary monthly records from MMCD Record Invoice Status Reference Table (Pended, Approved) Supplemental Aid Reference Table (AIDS, Craig v Bonta, AGNEWS) Additional Vendor Contact Information for Vendors to be Paid in 820 Invoice Managed Care Company Name Reference Table Reference Table of Waivers (Sacramento GMC, Santa Barbara Regional Health) Warrant Information received from CD102 Warrant file
Invoice Management
9 User Interface
The user interface will be comprised of the web pages that will be accessed using a standard web browser. Contracts, beneficiaries and invoices will be managed through the user interface. The following sections are based on prototypes implemented with windows standard forms and do not reflect aesthetical presentations, but rather should reflect fields and flow needed to implement the user interface requirements. The field mapping and control tables reflect what is presented in the prototype user interface. Actual implementation may aggregate and streamline the functionality denoted in the prototype.
9.1 Site Map

The Site Map illustrates the user interface pages and the entire website navigation.

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Home
Invoice Search
Beneficiary Search
Contract Search
Vendor Search
Report Search
Reference Table Search
Invoice Summary
PrePayment
Beneficiary Summary
Contract Summary
Vendor Summary
Beneficiary Coverage
Beneficiary Adjustment
Beneficiary Payment History
Vendor Payment History
Change
HCP
Disbursement Register
Plan-Based Payments
9.2 Master Page

The 820 Phase 2 Master Page will dictate a consistent layout. The layout will be consistent for the header, footer, and navigation panes, and will define the area for 820 Phase 2 content pages.
9.3
Master Page Layout

Master Page for 820 Phase 2 System will conform to the web page design standards and will consist of the header, footer, navigation and content page areas.
9.3.1 Header
The header section of the 820 Phase 2 Master Page will contain the menu for navigating the system.

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Controls
Control Link Label Menu Control Description Used for the skip to sub-section to allow user to quickly navigate to a desired page. Used for the navigation sub-section that contains links to all pages in the system.
9.3.2 Footer
The footer section of the 820 Phase 2 Master Page will consist of internal and external link sub-section. The internal link sub-section allows user to navigate to back to the top of the page, 820 Phase 2 Help Page, 820 Phase 2 Contact Page, and 820 Phase 2 Site Map. The external link sub-section allows user to navigate to conditions of use and privacy policy pages.
Controls
Control Link Label Description Used for the internal and external sub-sections to allow user to quickly navigate to a desired page.
9.3.3 Content Page

The content page section of the 820 Phase 2 Master Page consists of content page navigation and content page sub-sections. The content page navigation sub-section displays quick navigation links to the desired pages on the content page level. The content page sub-section displays the actual content page.

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9.4
Site Constraints
The page is ADA compliant and conforms to the ADA standards.
9.5 Invoice Search

Invoice Search content page will allow users to search for managed care and non-managed care invoices. Managed care users will be required to search by invoice status, HCP, invoice amount, state fiscal year, capitation month, or payment month. Non-managed care users will be required to search by program, beneficiary CIN, invoice status, payee name, invoice number, vendor code, vendor name, and case ID.

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9.5.1 Interface Rules

Invoice Search page will be accessible by users with appropriate roles and rights. Only the users who have invoice search rights will be able to view and execute the actions on the page. Furthermore, users with managed care rights will be able to see managed care information, and users with non-managed care rights will be able to see non-managed care information. The page is ADA compliant and conforms to the ADA standards.
9.5.2 Field to Database Mapping

Component Invoice Status HCP Invoice Amount Input TB_STATUS_TYPE.Status_Na me TB_HEALTH_CARE_PLAN_T YPE.Name TB_INVOICE.Invoice_Amount Description Status of the invoice. HCP of the invoice. Amount of the invoice.

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Component State Fiscal Year Service Month Payment Month Invoice Number Vendor Code Contract Number Model Type Invoice Type Program Beneficiary CIN Payee Name Vendor Name Case ID
Input TB_INVOICE.Fiscal_Year TB_INVOICE.Service_Month TB_INVOICE.Payment_Date TB_INVOICE.Invoice_Number TB_VENDOR_INFO.Vendor_C ode TB_CONTRACT.Contract_Nu mber TB_MODEL_TYPE.Model_Na me TB_INVOICE_TYPE.Invoice_T ype TB_NONMANAGED_PROGR AM_TYPE.Name TB_BENEFICIARY.CIN TB_VENDOR_INFO.Other_Na me TB_VENDOR_INFO.Vendor_N ame TB_BENEFICIARY_NONMAN AGED_CARE.Case_Id
Description State fiscal year of the invoice. Service month of the invoice. Payment month of the invoice. Number of the invoice. Invoice vendor code. Contract number of the invoice. Model type of the invoice. Type of the invoice. Invoice program. Invoice beneficiary CIN. Invoice payee name. Invoice vendor name. Beneficiary case ID on the invoice.
9.5.3 Controls
Control Input Button Input Button Input Button Input Button Text Field Text Field Text Field Text Field Display Search Clear View Invoices Approve All Invoice Amount Beneficiary CIN Payee Name Vendor Name Description Finds invoice results according to input criteria. Clears the input fields and the search queue. Views invoices based on selection criteria in the invoice queue. Approves all invoices in the invoice queue. Allows user to input amount for the invoice. Allows user to input beneficiary CIN for the invoice. Allows user to input payee name for the invoice. Allows user to input vendor name for the invoice.

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Control Text Field Drop Down Box Drop Down Box Drop Down Box Drop Down Box Drop Down Box Drop Down Box Radio Button Radio Button Data Grid View
Display Case ID Invoice Status HCP State Fiscal Year Month Year Program Capitation Month Payment Month N/A
Description Allows user to input case ID for the invoice. Allows user to select status for the invoice. Allows user to select HCP for the invoice. Allows user to select state fiscal year for the invoice. Allows user to select month for the invoice. Allows user to select year for the invoice. Allows user to select program for the invoice. Allows user to select capitation month for the invoice. Allows user to select payment month for the invoice. Displays search results: Invoice Number, HCP, Vendor Number, Contract Number, Invoice Status, Capitation Month, Payment Month, Model Type, Invoice Type, Total Invoice Amount, and State Fiscal Year
9.5.4 Error Conditions

Invoice Search page will validate users input when the Search button is clicked. Additionally, a warning message will be displayed informing user of invoices in Payment Error status. For managed care, if either HCP, invoice status, invoice amount, state fiscal year, capitation month, or payment month are not entered then a validation message will be displayed informing user to input at least one combination of fields. Furthermore, invoice amount will be validated for proper format. For non-managed care, if no fields are entered then a validation message will be displayed informing user to input or select at least one field.
9.6 Invoice Summary

Invoice Summary content page will allow users to view and modify status of an invoice. Users will additionally enter the adjustment amount and reason to an invoice that is in Payment Error status. Non-managed care users will also update payment information by providing a revolving fund number, date, and amount.

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Invoice Summary page will be accessible by users with appropriate roles and rights. Only the users who have invoice view and update rights will be able to view and execute the actions on the page. Furthermore, users with managed care rights will be able to see managed care information, and users with non-managed care rights will be able to see non-managed care information. The page is ADA compliant and conforms to the ADA standards.

Component Action Comments Invoice Status Input TB_STATUS_TYPE.Status_Na me TB_INVOICE_STATUS.Comm ents TB_STATUS_TYPE.Status_Na me Description Status action of the invoice. Comments of the invoice status. Status of the invoice.

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Component Date of Action User Name Adjustment Amount Adjustment Reason Revolving Fund Number
Input TB_INVOICE_STATUS.Status _Date TB_INVOICE_STATUS.Audit_ User TB_ADJUSTMENT.Amount TB_ADJUSTMENT.Reason TB_WARRANT.Warrant_Numb er_Begin and TB_WARRANT.Warrant_Numb er_End TB_WARRANT.Warrant_Date
Description Date when the status was added to the invoice. User who added the status to the invoice. Amount to be adjusted for invoice in Payment Error status. Reason for adjusting the invoice in Payment Error status. Revolving fund number for the invoice in Approved status. Assumption is that accounting will not provide warrant number for the invoice. Revolving fund date for the invoice in Approved status. Assumption is that accounting will not provide warrant date for the invoice. Revolving fund amount for the invoice in Approved status. Assumption is that accounting will not provide warrant amount for the invoice.
Revolving Fund Date
Revolving Fund Amount
TB_WARRANT.Warrant_Amou nt
9.6.3 Controls
Control Input Button Input Button Input Button Input Button Input Button Input Button Input Button Input Button Input Button Input Button Display View Previous Invoice View Next Invoice View Detail View Summary Print Export Submit Save Adjustment Cancel Adjustment Save Payment Update Description Navigates to the previous invoice in selection queue. Navigates to the next invoice in selection queue. Displays invoice with detailed information. Displays invoice with summarized information. Prints the invoice. Exports the invoice. Submits the status change on the invoice. Saves Amount and Reason entries for the invoice. Cancels Amount and Reason entries for the invoice. Saves payment update entries for the invoice.

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Control Input Button Input Button Input Button Drop Down Box Text Field Text Field Text Field Text Field Text Field Text Field
Display Cancel Payment Update Recalculate Back To Search Action Comments Adjustment Amount Reason Revolving Fund Number Revolving Fund Date Revolving Fund Amount
Description Cancels payment update entries for the invoice. Recalculates information on the invoice. Navigates user back to the search page. Allows user to select a status for the invoice. Allows user to input status comment for the invoice. Allows user to input adjustment amount for the invoice. Allows user to input adjustment reason for the invoice. Allows user to input revolving fund number for the invoice. Allows user to input revolving fund date for the invoice. Allows user to input revolving fund amount for the invoice.

Invoice Summary page will validate users input when action buttons are clicked. For a submit action, if an item from the action list was not selected then a validation message will be displayed informing user to select required value. For the save action, if adjustment amount and reason values are not entered then a validation message will be displayed informing user to enter required values. Furthermore, for non-managed care users, if a revolving fund number, date, or amount are not entered then a validation message will be displayed informing user to enter required values.
9.7 Pre Payment

Invoice Pre-Payment content page will allow non-managed care users to create pre-payment invoices. Users may enter into date period fields in order to specify the time frame of the prepayment invoices.

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Invoice Pre-Payment page will be accessible by users with appropriate roles and rights. Only the users who will have invoice view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.

Component Due Date From Due Date To Input TB_PRE_PAYMENT.Due_Dat e_From TB_PRE_PAYMENT.Due_Dat e_To Description Due date from of the prepayment. Due date to of the pre-payment.

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9.7.3 Controls
Control Input Button Input Button Text Field Text Field Save Cancel Due Date From Due Date To Display Description Saves pre-payment information. Cancels pre-payment information. Allows user to input due date from for the prepayment. Allows user to input due date to for the pre-payment.

Invoice Pre-Payment page will validate users input when Save button is clicked. If the date period fields are not entered then a validation message will be displayed informing user to enter required values.
9.8 Beneficiary Search

Beneficiary Search content page will allow users to search for managed and non-managed care beneficiaries. Managed care users will not be able to view non-managed care beneficiaries and vice versa. Managed care users are required to search by beneficiary CIN or last name and date of birth or the HCP. Additionally, users will be able to narrow down the search by specifying beneficiary primary eligibility, beneficiary first name, beneficiary supplemental eligibility, and supplemental eligibility dates. Non-managed care users will be able to search by program, Case ID, CIN, policy number, first name, and last name. Additionally, users may add a new non-managed care beneficiary.

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Beneficiary Search page will be accessible by users with appropriate roles and rights. Only the users who have beneficiary search rights will be able to view and execute the actions on the page. Furthermore, users with managed care rights will be able to see managed care information, and users with non-managed care rights will be able to see non-managed care information. The page is ADA compliant and conforms to the ADA standards.
9.8.2 Fields to Database Mappings

Component CIN First Name Last Name Date of Birth Input TB_BENEFICIARY.CIN TB_BENEFICIARY.NameFirst TB_BENEFICIARY.NameLast TB_BENEFICIARY.DOB Description CIN number of the beneficiary. First name of the beneficiary. Last name of the beneficiary. Date of birth of the beneficiary.

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Component HCP Primary Eligibility Supplemental Eligibility Supplemental Eligibility From Supplemental Eligibility To Birth Date From Birth Date To Policy Number Case ID Program
Input TB_HEALTH_CARE_PLAN_T YPE.Name TB_MONTHLY_BENE_AID_C ODE.Medicare_Status TB_SUPPLEMENTAL_AID_TY PE.Supplemental_Code TB_BENE_SUPPLEMENTAL_I NFO.Effective_Date_From TB_BENE_SUPPLEMENTAL_I NFO.Effective_Date_From TB_BENEFICIARY.DOB TB_BENEFICIARY.DOB TB_NONMANAGED_COVERA GE.Policy_Num TB_BENEFICIARY_NONMAN AGED_CARE.Case_Id TB_NONMANAGED_PROGR AM_TYPE.Name
Description HCP of the beneficiary. Primary eligibility of the beneficiary. Supplemental eligibility of the beneficiary. Supplemental eligibility from of the beneficiary. Supplemental eligibility to of the beneficiary. Date of birth from of the beneficiary. Date of birth to of the beneficiary. Policy number of the beneficiary. Case ID of the beneficiary. Program of the beneficiary.
9.8.3 Controls
Control Input Button Input Button Drop Down Box Drop Down Box Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Display Search Clear HCP Primary Eligibility Supplemental Eligibility Program CIN Last Name Date of Birth Case ID Description Finds beneficiary results according to input criteria. Clears the input fields and the search queue. Allows user to select beneficiarys HCP. Allows user to select beneficiarys primary eligibility. Allows user to select beneficiarys supplemental eligibility. Allows user to select beneficiarys program. Allows user to input beneficiarys CIN number. Allows user to input beneficiarys last name. Allows user to input beneficiarys date of birth. Allows user to input beneficiarys case ID.

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Control Text Field Text Field Text Field Text Field Data Grid View
Display Policy Number First Name Supplemental Eligibility From Supplemental Eligibility To N/A
Description Allows user to input beneficiarys policy number. Allows user to input beneficiarys first name. Allows user to input beneficiarys supplemental eligibility date from. Allows user to input beneficiarys supplemental eligibility date to. Displays search results for managed care: CIN, First Name, Last Name, HCP, Date of Birth, Supplementary Eligibility, and Primary Eligibility. Displays search results for non-managed care: CIN, First Name, Last Name, Program, Policy Number, and Case ID.

Beneficiary Search page will validate users input when search action is initiated. For managed care, if either CIN or last name and date of birth or HCP are not entered then a validation message will be displayed informing user to input at least one combination of fields. Furthermore, supplemental eligibility dates will be validated for proper format. For non-managed care, if either of the fields is not entered then a validation message will be displayed informing user to input at least one combination of fields.
9.9 Beneficiary Summary

Beneficiary Summary content page will allow users to view and modify details of a managed care or a non-managed care beneficiary. Managed care users will not be able to view nonmanaged care beneficiaries and vice versa. Managed care users will be able to view beneficiary information and add beneficiary supplemental information. Non-managed care users will be able to view and add beneficiary information and beneficiary eligibility information.

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Beneficiary Summary page will be accessible by users with appropriate roles and rights. Only the users who have beneficiary view and update rights will be able to view and execute the actions on the page. Furthermore, users with managed care rights will be able to see managed care information, and users with non-managed care rights will be able to see nonmanaged care information. The page is ADA compliant and conforms to the ADA standards.
9.9.2 Components
Component CIN Last Name First Name Input TB_BENEFICIARY.CIN TB_BENEFICIARY.Name_Last TB_BENEFICIARY.Name_First Description CIN number of the beneficiary. Last name of the beneficiary. First name of the beneficiary.

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Component Middle Initial Gender Date of Birth Date of Death Alien Status Medical HCP Dental HCP Primary Eligibility Risk Factor Case ID Program Case Status Case Termination Date Supplemental Eligibility Type Supplemental Eligibility Effective Date From Supplemental Eligibility Effective Date To Supplemental Eligibility Diagnosis Date Supplemental Eligibility Diagnosis
Input TB_BENEFICIARY.Name_Mid dle_Initial TB_BENEFICIARY.Gender_Co de TB_BENEFICIARY.Date_Of_Bi rth TB_BENEFICIARY.Date_Of_D eath TB_BENEFICIARY.Alien_Code TB_HEALTH_CARE_PLAN_T YPE.Name TB_HEALTH_CARE_PLAN_T YPE.Name TB_MONTHLY_BENE_AID_C ODE.Medicare_Status TB_BENE_RISK_FACTOR.Ris k_Factor TB_BENEFICIARY_NONMAN AGED_CARE.Case_Id TB_NONMANAGED_PROGR AM_TYPE.Name TB_BENEFICIARY_NONMAN AGED_CARE.Case_Status TB_BENEFICIARY_NONMAN AGED_CARE.Case_Terminati on_Date TB_SUPPLEMENTAL_AID_TY PE.Supplemental_Code TB_BENE_SUPPLEMENTAL_I NFO.Effective_Date_From TB_BENE_SUPPLEMENTAL_I NFO.Effective_Date_To TB_BENE_SUPPLEMENTAL_I NFO.Diagnosis_Date TB_BENE_SUPPLEMENTAL_I NFO.Diagnosis
Description Middle initial of the beneficiary. Gender code of the beneficiary. Date of birth of the beneficiary. Date of death of the beneficiary. Alien code of the beneficiary. Medical HCP of the beneficiary. Dental HCP of the beneficiary. Primary eligibility of the beneficiary. Risk factor of the beneficiary. Case ID of the beneficiary. Program of the beneficiary. Case status of the beneficiary. Case termination date of the beneficiary. Supplemental eligibility type of the beneficiary. Supplemental eligibility effective date from of the beneficiary. Supplemental eligibility effective date to of the beneficiary. Supplemental eligibility diagnosis date of the beneficiary. Supplemental eligibility diagnosis of the beneficiary.

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Component Supplemental Eligibility Delivery Date Supplemental Eligibility User Name Supplemental Eligibility Updated On Beneficiary Payment History Report Beneficiary CIN Beneficiary Payment History Report Last Name Beneficiary Payment History Report First Name Beneficiary Payment History Report - MI Beneficiary Payment History Report - Date of Birth Beneficiary Payment History Report Gender Beneficiary Payment History Report - Date of Death Beneficiary Payment History Report - Model Type Beneficiary Payment History Report - HCP Name Beneficiary Payment History Report - HCP Code Beneficiary Payment History Report - Aid Code Group Beneficiary Payment History Report - Aid Code Beneficiary Payment History Report - Rates Beneficiary Payment History Report Invoice Number Beneficiary Payment History Report Invoice Date
Input TB_BENE_SUPPLEMENTAL_I NFO.Delivery_Date TB_BENE_SUPPLEMENTAL_I NFO.Audit_User TB_BENE_SUPPLEMENTAL_I NFO.Audit_Date TB_BENEFICIARY.CIN
Description Supplemental eligibility delivery date of the beneficiary. User name that created/updated the record. Date when the supplemental eligibility was updated. CIN of the beneficiary. Last name of the beneficiary.
TB_BENEFICIARY.Name_Last
TB_BENEFICIARY.Name_First TB_BENEFICIARY.Name_Midd le_Initial TB_BENEFICIARY.Date_Of_Bi rth TB_BENEFICIARY.Gender_Co de TB_BENEFICIARY.Date_Of_D eath TB_MODEL_TYPE.Model_Nam e TB_HEALTH_CARE_PLAN_TY PE.Name TB_HEALTH_CARE_PLAN_TY PE.Health_Care_Plan_Code TB_AID_CODE_GROUP_TYP E.Aid_Code_Group_Name TB_AID_CODE_TYPE.Aid_Cod e TB_PLAN_CODE_ON_PAYME NT_TYPE.Rate TB_INVOICE.Invoice_Number
First name of the beneficiary.
Middle initial of the beneficiary. Date of birth of the beneficiary.
Gender of the beneficiary.
Date of death of the beneficiary.
Model type of the invoice.
HCP name of the invoice.
HCP code of the invoice.
Aid code group of the invoice.
Aid code of the invoice.
Rates of the invoice. Number of the invoice.
TB_INVOICE.Payment_Date
Date of the invoice.

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Component Beneficiary Payment History Report Service Month Beneficiary Payment History Report - Claim Schedule Number Beneficiary Payment History Report Warrant Number Beneficiary Payment History Report - Date of Warrant Beneficiary Payment History Report Payment Type Beneficiary Payment History Report - Paid Amount
Input TB_INVOICE.Capitation_Month
Description Service month of the invoice.
TB_INVOICE.Claim_Schedule_ Number TB_WARRANT.Warrant_Numb er_Begin and TB_WARRANT.Warrant_Numb er_End TB_WARRANT.Warrant_Date
Claim schedule number of the invoice. Warrant number of the invoice.
Date of warrant of the invoice.
TB_INVOICE_TYPE.Invoice_Ty pe TB_INVOICE.Invoice_Amount
Payment type of the invoice.
Paid amount of the invoice.
9.9.3 Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Save Cancel Print Export Select supplemental eligibility Select Diagnosis Program Case Status Case ID Program Case Status Case Termination Date Display Description Saves supplemental eligibility information entered for the beneficiary. Cancels the supplemental eligibility information entered for the beneficiary. Prints beneficiary payment history report. Exports beneficiary payment history report to Excel or PDF. Allows user to select supplemental eligibility for the beneficiary. Allows user to select diagnosis for the beneficiary. Allows user to select program for the beneficiary. Allows user to select case status for the beneficiary. Allows user to input case ID for the beneficiary. Allows user to input program for the beneficiary. Allows user to input case status for the beneficiary. Allows user to input case termination date for the beneficiary.

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Control Text Field Text Field Text Field Text Field Text Field Report
Display Risk Factor Effective Date From Effective Date To Diagnosis Date Date of Delivery Beneficiary Payment History
Description Allows user to input risk factor for the beneficiary. Allows user to input supplemental effective date from for the beneficiary. Allows user to input supplemental effective date to for the beneficiary. Allows user to input supplemental diagnosis date for the beneficiary. Allows user to input supplemental date of delivery for the beneficiary. Displays beneficiary information in header section: Beneficiary CIN, Last Name, First Name, MI, Date of Birth, Gender, and Date of Death Displays historical beneficiary payment information: Model Type, HCP Name, HCP Code, Aid Code Group, Aid Code, Rates, Invoice Date, Service Month, Claim Schedule Number, Warrant Number, Date of Warrant, Payment Type, and Paid Amount

Beneficiary Summary page will validate users input when a save action is initiated. For managed care if either effective dates, or delivery date for maternity supplemental information, or diagnosis and diagnosis dates for AIDS supplemental information are not entered then a validation message will be displayed informing user to input required fields. Furthermore, effective dates will be validated for proper format. For non-managed care if either of the fields is not entered then a validation message will be displayed informing user to input required fields. Furthermore, case termination dates will be validated for proper format.
9.10 Beneficiary Coverage

Beneficiary Coverage content page will allow users to add coverage information for a nonmanaged care beneficiary. This page also captures the monthly premium amount for the nonmanaged care beneficiary.

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9.10.1
Interface Rules
Beneficiary Coverage page will be accessible by users with appropriate roles and rights. Only the users who have beneficiary update rights will be able to execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.10.2
Components
Component Vendor Code Coverage Type Group Number Policy Number Input TB_VENDOR_INFO.Vendor_C ode TB_NONMANAGED_COVERA GE_TYPE.Coverage_Name TB_NONMANAGED_COVERA GE.Group_Number TB_NONMANAGED_COVERA GE.Policy_Num Description Vendor code of the beneficiary coverage. Coverage type of the beneficiary coverage. Group number of the beneficiary coverage. Policy number of the beneficiary coverage.

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Component Premium Due Date Policy Start Date Policy Stop Date Policy Holder Name Payment Frequency Number of individuals covered on policy Premium Amount Monthly Premium Amount
Input TB_NONMANAGED_COVERA GE.Premium_Due_Date TB_NONMANAGED_COVERA GE.Policy_Start_Date TB_NONMANAGED_COVERA GE. Policy_Stop_Date TB_NONMANAGED_COVERA GE.Policy_Holder_Name TB_NONMANAGED_COVERA GE.Payment_Frequency TB_NONMANAGED_COVERA GE.Num_Covered TB_NONMANAGED_COVERA GE.Premium_Amount TB_NONMANAGED_COVERA GE.Monthly_Premium_Amount
Description Premium due date of the beneficiary coverage. Policy start date of the beneficiary coverage. Policy stop date of the beneficiary coverage. Policy holder name of the beneficiary coverage. Payment frequency of the beneficiary coverage. Number of individuals covered on policy. Premium amount of the beneficiary coverage. Monthly premium amount of the beneficiary coverage. Monthly premium amount is calculated by multiplying the payment frequency and premium amount up to a year, and then dividing it by 12.
9.10.3
Controls
Control Input Button Input Button Input Button Drop Down Box Text Field Text Field Text Field Text Field Text Field Text Field Display Save Edit Cancel Payment Frequency Vendor Code Coverage Type Group Number Policy Number Policy Holder Name Premium Due Date Description Saves coverage information entered for the beneficiary. Edits coverage information for the beneficiary. Cancels the changes to coverage information entered for the beneficiary. Payment Frequency of the beneficiary coverage. Vendor Code of the beneficiary coverage. Coverage Type of the beneficiary coverage. Group Number of the beneficiary coverage. Policy Number of the beneficiary coverage. Policy Holder Name of the beneficiary coverage. Premium Due Date of the beneficiary coverage.

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Control Text Field Text Field Text Field Text Field
Display Policy Start Date Policy Stop Date Premium Amount Monthly Premium Amount
Description Policy Start Date of the beneficiary coverage. Policy Stop Date of the beneficiary coverage. Premium Amount of the beneficiary coverage. Monthly Premium Amount of the beneficiary coverage.
9.10.4
Error Conditions
Beneficiary Coverage page will validate users input when an action is initiated. If any of the fields are not entered then a validation message will be displayed informing user to input required fields.
9.11 Beneficiary Adjustment

Beneficiary Adjustment content page will allow users to add adjustment information for a nonmanaged care beneficiary in the CAPMAN system. Users may add overpayments, underpayments, or payments received types of adjustment to a non-managed care beneficiary.

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9.11.1
Interface Rules
Beneficiary Adjustment page will be accessible by users with appropriate roles and rights. Only the users who have beneficiary update rights will be able to execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.11.2
Components
Component Adjustment Reason Adjustment Amount Premium Payment Period From Premium Payment Period To Input TB_BENEFICIARY_ADJUSTM ENT.Adjustment_Reason TB_BENEFICIARY_ADJUSTM ENT.Adjustment_Amount TB_BENEFICIARY_ADJUSTM ENT.Premium_Payment_From TB_BENEFICIARY_ADJUSTM ENT.Premium_Payment_To Description Reason for the beneficiary adjustment. Amount for the beneficiary adjustment. Premium payment period from for the beneficiary adjustment. Premium payment period to for the beneficiary adjustment.

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Component Check Date
Input TB_BENEFICIARY_ADJUSTM ENT.Check_Date TB_BENEFICIARY_ADJUSTM ENT.Check_Number N/A
Description Check date for the beneficiary adjustment. Used for payment received adjustment reason. Check number for the beneficiary adjustment. Used for payment received adjustment reason. Generate invoice indicator for the adjustment. If the indicator is checked, then a new invoice will be created with the adjustment, otherwise the adjustment will be shown on the next automated invoice created for the beneficiary.
Check Number
Generate Invoice
9.11.3
Controls
Control Input Button Input Button Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Check Box Save Cancel Adjustment Reason Check Date Premium Payment Period From Premium Payment Period To Adjustment Amount Check Number Generate Invoice Display Description Saves adjustment information entered for the beneficiary. Cancels the changes to adjustment information entered for the beneficiary. Reason of the beneficiary adjustment. Check date of the beneficiary adjustment. Premium payment period from of the beneficiary adjustment. Premium payment period to of the beneficiary adjustment. Amount of the beneficiary adjustment. Check number of the beneficiary adjustment. Generate invoice indicator for the adjustment.
9.11.4
Error Conditions
Beneficiary Adjustment page will validate users input when an action button is initiated. If either premium payment period date from, premium payment period date to, adjustment amount, or adjustment reason is not entered then a validation message will be displayed informing user to input required fields. Furthermore, check number and check dates will be required for payment received adjustment reason.

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9.12 Beneficiary Payment History

Beneficiary Payment History content page will allow users to view payment history information for a non-managed care beneficiary in the CAPMAN system.
9.12.1
Interface Rules
Beneficiary Payment History page will be accessible by users with appropriate roles and rights. Only the users who have beneficiary view rights will be able to execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.12.2
Components
Component From To Input TB_INVOICE.Payment_Date TB_INVOICE.Payment_Date Description From date of the payment history report. To date of the payment history report.

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Component Beneficiary Payment History Report Beneficiary CIN Beneficiary Payment History Report Case Id Beneficiary Payment History Report Last Name Beneficiary Payment History Report First Name Beneficiary Payment History Report - MI Beneficiary Payment History Report - Date of Birth Beneficiary Payment History Report Program Beneficiary Payment History Report Gender Beneficiary Payment History Report Invoice Number Beneficiary Payment History Report Invoice Status Beneficiary Payment History Report Invoice Date Beneficiary Payment History Report Invoice Approved By Beneficiary Payment History Report Invoice Amount Beneficiary Payment History Report Program Beneficiary Payment History Report Type of Coverage Beneficiary Payment History Report Vendor Name Beneficiary Payment History Report Vendor Code
Input TB_BENEFICIARY.CIN
Description CIN of the beneficiary.
TB_BENEFICIARY_NONMANA GED_CARE.Case_Id TB_BENEFICIARY.Name_Last
Case Id of the beneficiary. Last name of the beneficiary.
TB_BENEFICIARY.Name_First TB_BENEFICIARY.Name_Midd le_Initial TB_BENEFICIARY.Date_Of_Bi rth TB_NONMANAGED_PROGR AM_TYPE.Name TB_BENEFICIARY.Gender_Co de TB_INVOICE.Invoice_Number
First name of the beneficiary.
Middle initial of the beneficiary. Date of birth of the beneficiary.
Program of the beneficiary.
Gender of the beneficiary.
Number of the invoice.
TB_STATUS_TYPE.Status_Na me TB_INVOICE.Payment_Date
Status of the invoice.
TB_INVOICE_STATUS.Audit_ User TB_INVOICE.Invoice_Amount
Audit user of the invoice.
Amount of the invoice. Program of the invoice.
TB_NONMANAGED_PROGR AM_TYPE.Name TB_NONMANAGED_COVERA GE_TYPE.Coverage_Name TB_VENDOR_INFO.Vendor_N ame TB_VENDOR_INFO.Vendor_C ode
Type of coverage of the invoice.
Vendor name of the invoice.
Vendor code of the invoice.

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Component Beneficiary Payment History Report Warrant Number Beneficiary Payment History Report - Date of Warrant Beneficiary Payment History Report Warrant Amount
Input TB_WARRANT.Warrant_Numb er_Begin and TB_WARRANT.Warrant_Numb er_End TB_WARRANT.Warrant_Date
Description Warrant number of the invoice.
Date of warrant of the invoice.
TB_INVOICE.Invoice_Amount
Paid amount of the invoice.
9.12.3
Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Report Display View Clear Print Export From To HIPP/BCCTP Beneficiary Payment History Description Displays payment history report according to From and To dates. Clears the From and To dates. Prints the payment history report. Exports the payment history report. From date of the payment history report. To date of the payment history report. Displays beneficiary information in header: From and To dates, Beneficiary CIN, Case ID, Last Name, First Name, MI, Date of Birth, Program, and Gender Displays beneficiary payment history in detail: Invoice Number, Invoice Status, Invoice Date, Invoice Approved By, Premium Payment Amount, Program, Type of Coverage, Vendor Name, Vendor Code, Warrant Number, Date of Warrant, and Warrant Amount
9.12.4
Error Conditions
Beneficiary Payment History page will validate users input when View button is clicked. If either of the From and To dates are not entered then a validation message will be displayed informing user to select required fields.

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9.13 Contract Search

Contract Search content page will allow users to search for managed care contracts. Users will be required to search by managed care plan name, contract number, health care plan, term date from, term date to, county code, and contract type. Additionally, the page will allow users to initiate creation of a new contract.
9.13.1
Interface Rules
Contract Search page will be accessible by users with appropriate roles and rights. Only the users who have contract search rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.13.2
Fields to Database Mapping

Component Managed Care Plan Name Input TB_VENDOR_INFO.Vendor_N ame Description Name of the managed care plan.

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Component Contract Number Health Care Plan Term Date From Term Date To County Code
Input TB_CONTRACT.Contract_Nu mber TB_HEALTH_CARE_PLAN_T YPE.Name TB_CONTRACT.Effective_Dat e_From TB_CONTRACT.Effective_Dat e_To TB_COUNTY_CODE_TYPE.C ounty_Code and TB_COUNTY_CODE_TYPE.C ounty_Name TB_CONTRACT_TYPE.Contra ct_Type_Name
Description Number of the contract. Name of the health care plan. Contract term date from. Contract term date to. Contract county code.
Contract Type
Contract type.
9.13.3
Controls
Control Input Button Input Button Input Button Drop Down Box Text Field Drop Down Box Text Field Text Field Drop Down Box Drop Down Box Data Grid View Display Search Clear Add New Contract Managed Care Plan Name Contract Number Health Care Plan Term Date From Term Date To County Code Contract Type N/A Description Finds contract results according to input criteria. Clears the input fields and the search queue. Allows user to create a new contract. Allows user to select contract managed care plan name. Allows user to input contract number. Allows user to select contract health care plan number and name. Allows user to input contract term date from. Allows user to input contract term date to. Allows user to select contract county code. Allows user to select contract type. Displays search results: Managed Care Plan Name, Contract Number, Health Care Plan, Term Date From, Term Date To, County Code, and Contract Type.

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9.13.4
Error Conditions
Contract Search page will validate users input when Search button is clicked. Additionally, term dates will be validated for proper format.
9.14 Contract Summary

Contract Summary content page will allow user to view and modify details of a managed care contract. User will be able to view current contract information, view historical contract information, and add new amendment or change order.
9.14.1
Interface Rules
Contract Summary page will be accessible by users with appropriate roles and rights. Only the users who have contract view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.

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9.14.2

Component Managed Care Plan Name Contract Number Federal Tax ID (EIN) Model Type Model Subtype Vendor Code Contract Type Term Date From Term Date To Total Encumbrance Amount Primary Encumbrance Amount Healthy Family Encumbrance Amount Mailing Address City/State/Zip Input TB_VENDOR_INFO.Vendor_N ame TB_CONTRACT.Contract_Nu mber TB_VENDOR_INFO.EIN TB_MODEL_TYPE.Model_Na me TB_MODEL_TYPE.Model_Na me TB_VENDOR_INFO.Vendor_C ode TB_CONTRACT_TYPE.Contra ct_Type_Name TB_CONTRACT.Effective_Dat e_From TB_CONTRACT.Effective_Dat e_To TB_CONTRACT.Encumbrance _Amount TB_CONTRACT_FUNDING.A mount TB_CONTRACT_FUNDING.A mount TB_VENDOR_INFO.Address TB_VENDOR_INFO.City and TB_VENDOR_INFO.Zip and TB_VENDOR_INFO.Code TB_VENDOR_INFO.Other_Ad dress TB_VENDOR_INFO. Other_City and TB_VENDOR_INFO. Other_Zip and TB_VENDOR_INFO. Other_Code TB_VENDOR_INFO.Contract_ Manager Description Managed care plan name of the contract. Number of the contract. EIN of the contract vendor. Model type of the contract. Model subtype of the contract. Code of the contract vendor. Type of the contract. Term date from of the contract. Term date to of the contract. Total encumbrance amount of the contract. Primary encumbrance amount of the contract. Healthy family encumbrance amount of the contract. Mailing address of the contract. City/State/Zip of the contract.
Correspondence Address City/State/Zip
Correspondence address of the contract. Correspondence City/State/Zip of the contract.
Contract Manager Name
Contract manager name of the contract.

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Component Contract Manager Phone Number Other Contact Name Other Contact Phone Number Advance Payment Eligibility Advance Payment From Advance Payment To Override 25% Recoupment Cutoff Recoupment Duration Index Object PCA HCP County Code
Input TB_VENDOR_INFO.Contract_ Manager_Phone TB_VENDOR_INFO.Other_Co ntract_Manager TB_VENDOR_INFO.Other_Co ntract_Manager_Phone TB_CONTRACT.Advance_Pay ment TB_CONTRACT.Advance_Pay ment_From TB_CONTRACT.Advance_Pay ment_To TB_CONTRACT.Override_Rec oupment_Cutoff TB_CONTRACT. Recoupment_Duration TB_CONTRACT.Index TB_CONTRACT.Object TB_CONTRACT.PCA TB_HEALTH_CARE_PLAN_T YPE.Name TB_COUNTY_CODE_TYPE.C ounty_Code and TB_COUNTY_CODE_TYPE.C ounty_Name TB_WAIVER_TYPE.Waiver_N ame TB_CONTRACT.Amendment_ Num or TB_CONTRACT.Change_Orde r_Num TB_CONTRACT.Effective_Dat e_From TB_CONTRACT.Effective_Dat e_To TB_CONTRACT.Comment
Description Contract manager phone number of the contract. Other contact name of the contract. Other contact phone number of the contract. Advance payment eligibility of the contract. Advance payment from of the contract. Advance payment to of the contract. Override 25% recoupment cutoff of the contract. Recoupment duration for the contract. Index of the contract. Object of the contract. PCA of the contract. HCP of the contract. County code of the HCP.
Waiver Name Amendment/CO Number
Waiver name of the HCP. Amendment/Change order number of the amendment or change order. Term date from of the amendment or change order. Term date to of the amendment or change order. Comments of the amendment or change order.
Term Date From Term Date To Comments

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9.14.3
Controls
Control Input Button Input Button Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Text Field Text Field Text Field Display Add Amendment Add Change Order View Disbursements Add HCP Save Cancel Contract Type Model Type Model Subtype Managed Care Plan Name Contract Number Federal Tax ID (EIN) Vendor Code Term Date From Term Date To Total Encumbrance Amount Primary Encumbrance Amount Healthy Family Encumbrance Amount Mailing Address City/State/Zip Correspondence Address Description Navigates user to the amendment page in the add mode. Navigates user to the change order page in the add mode. Navigates user to the disbursement register page. Navigates user to the HCP page in the add mode. Saves information entered for the contract. Cancels information entered for the contract. Allows user to select type of the contract. Allows user to input model type for the contract. Allows user to input model subtype for the contract. Allows user to input managed care plan name for the contract. Allows user to input contract number for the contract. Allows user to input federal tax id for the contract. Allows user to input vendor code for the contract. Allows user to input term date from for the contract. Allows user to input term date to for the contract. Allows user to input total encumbrance amount for the contract. Allows user to input primary encumbrance amount for the contract. Allows user to input Healthy Family encumbrance amount for the contract. Allows user to input mailing address for the contract. Allows user to input city, state, and zip for the contract. Allows user to input correspondence address for the contract.
Build a table of the list of controls that are used in the header.
Text Field
Text Field
Text Field Text Field Text Field

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Control Text Field Text Field Text Field Text Field Text Field Text Field Text Field Text Field Text Field
Display City/State/Zip Contract Manager Name Contract Manager Phone Number Other Contact Name Other Contact Phone Number Advance Payment Eligibility Advance Payment From Advance Payment To Override 25% Recoupment Cutoff Recoupment Duration Index Object PCA Health Care Plans Contract History
Description Allows user to input correspondence city, state, and zip for the contract. Allows user to input contract manager name for the contract. Allows user to input contract manager phone number for the contract. Allows user to input other contact name for the contract. Allows user to input other contact phone number for the contract. Allows user to input advance payment eligibility for the contract. Allows user to input advance payment from for the contract. Allows user to input advance payment to for the contract. Allows user to input override 25% recoupment cutoff for the contract. Allows user to input recoupment duration for the contract. Allows user to input index for the contract. Allows user to input object for the contract. Allows user to input PCA for the contract. Displays HCP, county code, and waiver name for each HCP on the contract. Displays amendment/change order number, term date from, term date to, and comments for each HCP on the contract.
Text Field Text Field Text Field Text Field Data Grid View Data Grid View
9.14.4
Error Conditions
Contract Summary page will validate users input when save is initiated. If either of the input fields are not entered then a validation message will be displayed informing user to input required fields. Furthermore, there needs to be at least one HCP selected for a new contract.
9.15 Contract Change

Contract Change content page will allow user to view and add amendments and change orders of a managed care contract. User will be able to view current and historical

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amendment and change order information, and add a new amendment or change order to an existing contract version.
9.15.1
Interface Rules
Contract Change page will be accessible by users with appropriate roles and rights. Only the users who have contract view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.15.2

Component Vendor Code Managed Care Plan Name Contract Number Input TB_VENDOR_INFO.Vendor_C ode TB_VENDOR_INFO.Vendor_N ame TB_CONTRACT.Contract_Nu mber Description Vendor code of the contract. Managed care plan name of the contract. Number of the contract.

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Component Amendment/Change Order Number
Input TB_CONTRACT.Amendment_ Number or TB_CONTRACT.Change_Orde r_Number TB_CONTRACT.Encumbrance _Amount TB_CONTRACT.Effective_Dat e_From TB_CONTRACT.Effective_Dat e_To TB_CONTRACT.Comment TB_HEALTH_CARE_PLAN_T YPE.Name TB_COUNTY_CODE_TYPE.C ounty_Code TB_WAIVER_TYPE.Waiver_N ame
Description Number of the amendment or change order.
Encumbrance Amount Effective Date From Effective Date To Comments HCP Name County Code Waiver Name
Encumbrance amount of the amendment or change order. Effective date from of the amendment or change order. Effective date to of the amendment or change order. Comments of the amendment or change order. Name of the HCP. County code of the HCP. Waiver name of the HCP.
9.15.3
Controls
Control Input Button Input Button Input Button Link Label Link Label Link Label Text Field Text Field Text Field Text Field Data Grid View Display Add new HCP Save Cancel Edit Contract Edit HCP Delete HCP Amendment/Change Order Number Encumbrance Amount Effective Date From Effective Date To Health Care Plans Description Navigates user to contract HCP content page in add mode. Saves changes to the amendment or change order. Cancels changes to the amendment or change order. Navigates user to contract summary content page in edit mode. Navigates user to contract HCP content page in edit mode. Deletes the HCP. Allows user to input the number for the amendment or change order. Allows user to input the encumbrance amount for the amendment or change order. Allows user to input the effective date from for the amendment or change order. Allows user to input the effective date to for the amendment or change order. Displays HCP, county code, and waiver name for each HCP on the contract version.

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9.15.4
Error Conditions
Contract Change page will validate users input when save action is initiated. If either of the input fields is not entered then a validation message will be displayed informing user to input required fields. Furthermore, at least one HCP needs to be added to the amendment or change order before user can save the changes.
9.16 Contract HCP

Contract HCP content page will allow user to view and modify details of a managed care. User will be able to view HCP information under a contract, modify an existing HCP in case of an amendment or change order, and add a new HCP.
9.16.1
Interface Rules
Contract HCP page will be accessible by users with appropriate roles and rights. Only the users who have contract view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.

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9.16.2

Component HCP County Code Waiver Name Waiver Number Payment Type Aid Code Group Rate Effective Date From Effective Date To Aid Code Supplemental Eligibility Type Medi-Cal Only Rate Input TB_HEALTH_CARE_PLAN_T YPE.Name TB_COUNTY_CODE_TYPE.C ounty_Code TB_WAIVER_TYPE.Waiver_N ame TB_WAIVER_TYPE.Waiver_N umber TB_PAYMENT_TYPE.Paymen t_Type TB_AID_CODE_GROUP_TYP E.Aid_Code_Group_Name TB_PLAN_CODE_ON_PAYM ENT_TYPE.Rate TB_AID_CODE_GROUP.Rate _Effective_Date_From TB_AID_CODE_GROUP.Rate _Effective_Date_To TB_AID_CODE_TYPE.Aid_Co de TB_SUPPLEMENTAL_AID_TY PE. TB_CONTRACT_PLAN_SUPP LEMENTAL_INFO.MediCal_O nly_Rate TB_CONTRACT_PLAN_SUPP LEMENTAL_INFO.MediCare_ Rate TB_CONTRACT_PLAN_SUPP LEMENTAL_INFO.Effective_Da te_From TB_CONTRACT_PLAN_SUPP LEMENTAL_INFO.Effective_Da te_To Description Name of the HCP. County code of the HCP. Waiver name of the HCP. Waiver number of the HCP. Payment type of the HCP. Aid code group of the HCP. Rate of the aid code group in the HCP. Effective date from of the aid code group rate in the HCP. Effective date to of the aid code group rate in the HCP. Aid code of the aid code group in the HCP. Supplemental eligibility type of the HCP. Medi-Cal only rate of the supplemental eligibility in the HCP. Medicare Part D rate of the supplemental eligibility in the HCP. Effective date from of the supplemental eligibility in the HCP. Effective date to of the supplemental eligibility in the HCP.
Medicare Part D Rate Effective Date From
Effective Date To
9.16.3
Controls
Control Input Button Display Submit Description Submits the change to the HCP.

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Control Input Button Input Button Input Button Drop Down Box Drop Down Box Drop Down Box Drop Down Box Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Text Field Text Field Text Field Checked List Box Add Save
Display
Description Adds the supplemental eligibility to the HCP. Saves changes to the HCP. Cancels changes to the HCP. Allows user to select name of the HCP. Allows user to select county code of the HCP. Allows user to select an action to change the HCP. Allows user to select payment type of the HCP. Allows user to select aid code group of the HCP. Allows user to select supplemental eligibility type of the HCP. Allows user to input the rate for the aid code group. Allows user to input the effective date from for the aid code group rate. Allows user to input the effective date to for the aid code group rate. Allows user to input the Medi-Cal Only rate for the supplemental eligibility. Allows user to input the Medicare Part D rate for the supplemental eligibility. Allows user to input the effective date from for the supplemental eligibility. Allows user to input the effective date to for the supplemental eligibility. Allows user to select aid codes for the aid code group.
Cancel HCP County Code Action Payment Type Aid Code Group Supplemental Eligibility Type Rate Effective Date From Effective Date To Medi-Cal Only Rate Medicare Part D Rate Effective Date From Effective Date To Aid Code
9.16.4
Error Conditions
Contract HCP page will validate users input when action buttons are initiated. If either of the input fields is not entered when Submit or Add buttons are clicked, then a validation message will be displayed informing user to input required fields. Furthermore, at least one payment type needs to be added to the HCP before user can save the changes.

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9.17 Contract Disbursement Register

Contract Disbursement Register content page allows user to view contract disbursement registers. Additionally, user can transfer funds between different funding types on the contract.
9.17.1
Interface Rules
Contract Disbursement Register page will be accessible by users with appropriate roles and rights. Only the users who have contract view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.17.2

Component From Funding Type Input TB_PAYMENT_TYPE.Paymen t_Type Description Funding type to deduct money from.

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Component To Funding Type Amount Disbursement Register Type State Fiscal Year
Input TB_PAYMENT_TYPE.Paymen t_Type TB_CONTRACT_FUNDING.A mount N/A TB_INVOICE.Fiscal_Year and TB_CONTRACT.Effective_Dat e_From
Description Funding type to add money to. Amount to be transferred between the funding types. Disbursement register type to be viewed. State fiscal year to be displayed on the disbursement register.
9.17.3
Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Drop Down Box Drop Down Box Text Field Display Transfer View Print Export From Funding Type To Funding Type Disbursement Register Type State Fiscal Year Amount Description Transfers the amount from the From Funding Type to the To Funding Type. Displays a disbursement register based on the selection criteria. Prints the disbursement register. Exports the disbursement register. Allows user to select from funding type of the contract. Allows user to select to funding type of the contract. Allows user to select type of the disbursement register. Allows user to select state fiscal year of the disbursement register. Allows user to input the amount to be transferred from the From Funding Type to the To Funding Type. Displays the Contract, Healthy Families, and the REG disbursement registers.
Report
Disbursement Register
9.17.4
Error Conditions
Contract Disbursement Register page will validate users input when transfer action is initiated. If either of the transfer input fields is not entered then a validation message will be displayed informing user to input required fields. Furthermore, disbursement register selection values will be validated when view action is initiated.

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9.18 Contract Plan-Based Payments

Contract Plan-Based Payments content page will allow user to add contract plan-based payments. Additionally, a user will be able to view current GMC Dental Withhold/Release disbursement register when GMD Dental 7% Withhold Release adjustment type is selected.
9.18.1
Interface Rules
Contract Plan-Based Payments page will be accessible by users with appropriate roles and rights. Only the users who have contract view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.18.2

Component Plan-Based Payment/Adjustment Type Input TB_ADJUSTMENT_TYP E.Name Description Adjustment type to be added to the HCP.

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Component HCP Effective Date From Effective Date To Amount Reason Payment Percentage
Input TB_HEALTH_CARE_PLA N_TYPE.Name TB_ADJUSTMENT.Effecti ve_Date_From TB_ADJUSTMENT.Effecti ve_Date_To TB_ADJUSTMENT.Amoun t TB_ADJUSTMENT.Reaso n TB_ADJUSTMENT_TYP E.Withhold_Percentage TB_PAYMENT_TYPE.Pa yment_Type TB_ADJUSTMENT.Check _Number TB_ADJUSTMENT.Check _Date TB_ADJUSTMENT.Perce ntage_Reason TB_INVOICE.Service_Dat e
Description Name of the HCP. Effective date from of the planbased payment/adjustment. Effective date to of the planbased payment/adjustment. Amount of the plan-based payment/adjustment. Reason of the plan-based payment/adjustment. Payment percentage of the GMC dental plan-based payment/adjustment. Payment type of the initial advance plan-based payment/adjustment. Check number of the payment received for the plan. Check date of the payment received for the plan. Payment percentage and corresponding reason of the payment received for the plan. Date of service of the invoice.
Payment Type Check Number Check Date Payment Percentage and Corresponding Reason Service Date
9.18.3
Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Save Cancel Print Export Plan-Based Payment/Adjustment Type HCP Display Description Saves the plan-based payment/adjustment. Cancels the plan-based payment/adjustment. Prints the GMC Dental Withhold Release register. Exports the GMC Dental Withhold Release register. Allows user to select type of the plan-based payment/adjustment. Allows user to select name of the HCP which the plan-based payment/adjustment will be applied to.
Drop Down Box

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Control Drop Down Box
Display Payment Type
Description Allows user to select payment type which the plan-based payment/adjustment will be applied to. Allows user to input the effective date from for the plan-based payment/adjustment. Allows user to input the effective date to for the plan-based payment/adjustment. Allows user to input the amount for the planbased payment/adjustment. Allows user to input the reason for the planbased payment/adjustment. Allows user to input the payment percentage for the plan-based payment/adjustment. Allows user to input the check number for the plan-based payment/adjustment. Allows user to input the check date for the plan-based payment/adjustment. Allows user to input the comments for the plan-based payment/adjustment. Displays the GMC Dental Withhold Register.
Text Field Text Field Text Field Text Field Text Field
Effective Date From Effective Date To Amount Reason Payment Percentage
Text Field Text Field Text Field Report
Check Number Check Date Comments GMC Dental Withhold Register
9.18.4
Error Conditions
Contract Plan-Based Payments page will validate users input when save action is initiated. If either of the input fields is not entered then a validation message will be displayed informing user to input required fields.
9.19 Vendor Search

Vendor Search content page will allow users to search for non-managed care vendors. Users will be required to search by a vendor by vendor code, vendor name, or vendor status.

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9.19.1
Interface Rules
Vendor Search page will be accessible by users with appropriate roles and rights. Only the users who have vendor search rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.19.2

Component Vendor Code Vendor Name Vendor Status Contact Name Input TB_VENDOR_INFO.Ve ndor_Code TB_VENDOR_INFO.Ve ndor_Name TB_VENDOR_INFO.Ve ndor_Status TB_VENDOR_INFO.Co ntract_Manager Description Code of the vendor. Name of the vendor. Status of the vendor. Contact name of the vendor

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Component Vendor Type
Input TB_VENDOR_INFO.Ve ndor_Type
Description Type of the vendor.
9.19.3
Controls
Control Input Button Input Button Input Button Text Field Text Field Drop Down Box Data Grid View Display Search Clear Add Vendor Vendor Code Vendor Name Vendor Status N/A Description Finds vendor results according to input criteria. Clears the input fields and the search queue. Allows user to add a new vendor. Allows user to input vendors code. Allows user to input vendors name. Allows user to select vendors status. Displays search results: Vendor Code, Vendor Name, Contact Name, Vendor Type, and Vendor Status.
9.19.4
Error Conditions
Vendor Search page will validate users input when search action is initiated. If either vendor code or vendor name or vendor status is not entered then a validation message will be displayed informing user to input at least one combination of fields.
9.20 Vendor Summary

Vendor Summary content page will allow users to view and modify details of a non-managed care vendor. Users may view and update vendor information and beneficiary representative detail section.

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9.20.1
Interface Rules
Vendor Summary page will be accessible by users with appropriate roles and rights. Only the users who have vendor view and update rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.20.2

Component Vendor Code Vendor Name Vendor Type Type of Coverage Input TB_VENDOR_INFO.Vendor_C ode TB_VENDOR_INFO.Vendor_N ame TB_VENDOR_INFO.Vendor_T ype TB_NONMANAGED_COVERA GE_TYPE.Coverage_Name Description Code of the vendor. Name of the vendor. Type of the vendor. Type of coverage of the vendor.

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Component Mailing Address City/State/Zip
Input TB_VENDOR_INFO.Address TB_VENDOR_INFO.City and TB_VENDOR_INFO.Zip and TB_VENDOR_INFO.State TB_VENDOR_INFO.EIN TB_VENDOR_INFO.Contract_ Manager TB_VENDOR_INFO.Vendor_S tatus TB_VENDOR_INFO.First_Nam e TB_VENDOR_INFO.Last_Nam e TB_VENDOR_INFO.Organizati on_Name
Description Mailing address of the vendor. City, State and Zip of the vendor.
Federal Tax ID (EIN) Contact Name Vendor Status First Name Last Name Organization Name
Federal tax ID of the vendor. Contact Name of the vendor. Status of the vendor. First name of the beneficiary representative. Last name of the beneficiary representative. Organization name of the beneficiary representative.
9.20.3
Controls
Control Input Button Input Button Drop Down Box Drop Down Box Text Field Text Field Text Field Text Field Text Field Text Field Text Field Display Save Cancel Vendor Type Type of Coverage Federal Tax ID (EIN) Vendor Code Vendor Name Mailing Address City/State/Zip Contact Name Vendor Status Description Saves information entered for the vendor. Cancels the information entered for the vendor. Allows user to select a type for the vendor. Allows user to select type of coverage for the vendor. Allows user to input federal tax ID for the vendor. Allows user to input code for the vendor. Allows user to input name for the vendor. Allows user to input mailing address for the vendor. Allows user to input city, state and zip for the vendor. Allows user to input contact name for the vendor. Allows user to input status for the vendor.

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Control Text Field Text Field Text Field
Display First Name Last Name Organization Name
Description Allows user to input first name for the beneficiary representative. Allows user to input last name for the beneficiary representative. Allows user to input organization name for the beneficiary representative.
9.20.4
Error Conditions
Vendor Summary page will validate users input when save action is initiated. If either of the vendor fields are not entered then a validation message will be displayed informing user to input required fields.
9.21 Vendor Payment History

Vendor Payment History content page will allow users to view payment history information for a non-managed care vendor in the CAPMAN system.

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9.21.1
Interface Rules
Vendor Payment History page will be accessible by users with appropriate roles and rights. Only the users who have vendor view rights will be able to execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.21.2

Component From To Vendor Payment History Report Vendor Name Vendor Payment History Report Vendor Code Vendor Payment History Report Contact Name Vendor Payment History Report Vendor Address Vendor Payment History Report Invoice Number Vendor Payment History Report Invoice Status Vendor Payment History Report Invoice Date Vendor Payment History Report Invoice Approved By Vendor Payment History Report Premium Payment Amount Vendor Payment History Report Type of Coverage Vendor Payment History Report Program Input TB_INVOICE.Payment_Date TB_INVOICE.Payment_Date TB_VENDOR_INFO.Vendor_N ame TB_VENDOR_INFO.Vendor_C ode TB_VENDOR_INFO.Other_Na me TB_VENDOR_INFO.Address and TB_VENDOR_INFO.City and TB_VENDOR_INFO.Zip and TB_VENDOR_INFO.State TB_INVOICE.Invoice_Number Description From date of the payment history report. To date of the payment history report. Name of the vendor.
Code of the vendor.
Contact name of the vendor.
Address of the vendor.
Number of the invoice.
TB_STATUS_TYPE.Status_Na me TB_INVOICE.Payment_Date
Status of the invoice.
TB_INVOICE_STATUS.Audit_ User
User who approved the invoice.
Premium payment amount of the invoice.
TB_NONMANAGED_COVER AGE_TYPE.Coverage_Name TB_NONMANAGED_PROGR AM_TYPE.Name
Type of coverage of the invoice.
Program of the invoice.

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Component Vendor Payment History Report Case ID Vendor Payment History Report Vendor Name Vendor Payment History Report Warrant Number Vendor Payment History Report Warrant Date Vendor Payment History Report Warrant Amount
Input TB_BENEFICIARY_NONMAN AGED_CARE.Case_Id TB_VENDOR_INFO.Vendor_N ame TB_WARRANT.Warrant_Numb er_Begin and TB_WARRANT.Warrant_Numb er_End TB_WARRANT.Warrant_Date
Description Case ID of the invoice.
Vendor name of the invoice.
Warrant number of the invoice.
Warrant date of the invoice.
TB_INVOICE.Invoice_Amount
Warrant amount of the invoice.
9.21.3
Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Report Display View Clear Print Export From To HIPP/BCCTP Vendor Payment History Description Displays payment history report according to From and To dates. Clears the From and To dates. Prints the payment history report. Exports the payment history report. From date of the payment history report. To date of the payment history report. Displays vendor information in header: From and To dates, Vendor Name, Vendor Code, Vendor Type, Vendor Address, and Contact Name Displays vendor payment history in detail: Invoice Number, Invoice Status, Invoice Date, Invoice Approved By, Premium Payment Amount, Program, Type of Coverage, Program, CIN, Payee Name, Warrant Number, Date of Warrant, and Warrant Amount
9.21.4
Error Conditions
Vendor Payment History page will validate users input when view action is initiated. If either of the From and To dates are not entered then a validation message will be displayed informing user to select required fields.

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9.22 Report Search

Report Search content page will allow users to search for managed care reports. Users will be required to search by report type, month from, year from, month from, and month to. For Plan Payment History report user will be required to select month of payment or month of service values. Once the report is generated based on the input criteria, page will allow users to export the report as an Excel or PDF file.
9.22.1
Interface Rules
Report Search page will be accessible by users with appropriate roles and rights. Only the users who have report search and view rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.22.2

Component Report Type N/A Input Description Type of the report.

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Component Month From
Input TB_MONTHLY_BENE_AID_C ODE.Capitation_Month or TB_INVOICE.Payment_Date TB_MONTHLY_BENE_AID_CO DE.Capitation_Month or TB_INVOICE.Payment_Date TB_MONTHLY_BENE_AID_CO DE.Capitation_Month or TB_INVOICE.Payment_Date TB_MONTHLY_BENE_AID_CO DE.Capitation_Month or TB_INVOICE.Payment_Date TB_INVOICE.Payment_Date
Description Depending on the report, the date will be matched either against Capitation Dates or Payment Dates. Depending on the report, the date will be matched either against Capitation Dates or Payment Dates. Depending on the report, the date will be matched either against Capitation Dates or Payment Dates. Depending on the report, the date will be matched either against Capitation Dates or Payment Dates. Depending on the selection for plan payment history report, the date will be matched either against Capitation Dates or Payment Dates. This selection only appears for the Plan Payment History report type. Depending on the selection for plan payment history report, the date will be matched either against Capitation Dates or Payment Dates. This selection only appears for the Plan Payment History report type.
Year From
Month To
Year To
Month of Payment
Month of Service
TB_MONTHLY_BENE_AID_CO DE.Capitation_Month
9.22.3
Controls
Control Input Button Input Button Input Button Input Button Drop Down Box Drop Down Box Display View Clear Print Export Report Type Month From Description Generates report according to input criteria. Clears the input fields. Allows user to print the report. Allows user to export the report to Excel or PDF. Allows user to select report type. Allows user to select month from.

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Control Drop Down Box Drop Down Box Drop Down Box Radio Button Radio Button
Display Year From Month To Year To Month of Payment Month of Service
Description Allows user to select year from. Allows user to select month to. Allows user to select year to. Allows user to select month of payment. Allows user to select month of service.
9.22.4
Error Conditions
Report Search page will validate users input when a view action is initiated. If either of report type, month from, month to, year from, year to are not selected then a validation message will be displayed informing user to select the missing criteria. Additionally, month of payment and month of service values will be validated if plan payment history is selected.
9.23 Reference Table Search

Reference Table Search content page will allow users to search for managed care reference tables in the CAPMAN system. Users will be required to search by reference table name. Once the reference table is displayed based on the input criteria, the page will allow users to export the reference table as an Excel or PDF file.

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9.23.1
Interface Rules
Reference Table Search page will be accessible by users with appropriate roles and rights. Only the users who have reference table search and view rights will be able to view and execute the actions on the page. The page is ADA compliant and conforms to the ADA standards.
9.23.2

Component Reference Table Name N/A Input Description Reference Table name.
9.23.3
Controls
Control Input Button Display View Description Displays reference table according to input criteria.

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Control Input Button Input Button Input Button Drop Down Box
Display Clear Print Export Reference Table Name N/A
Description Clears the input fields. Allows user to print the reference table. Allows user to export the reference table to Excel or PDF. Allows user to select reference table name.
Data Grid View
Search results will vary based on the reference table name selection.
9.23.4
Error Conditions
Reference Table Search page will validate users input the view action is initiated. If reference table name is not selected then a validation message will be displayed informing user to select the missing criteria.

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10 Network Requirements
The physical architecture for the 820 Phase 2 project describes the platform, server and hardware configuration of the 820 Phase 2 project. Topics in this section include: Solution Platforms Environments Network configuration Communication protocols Security and firewall requirements Server configurations Hardware requirements Load balancing & server redundancy
10.1 Solution Platforms

This section aims to describe the software tools and server platforms used to implement the 820 Phase 2 project. The solution platform is the basis for the operation of the completed 820 Phase 2 system. All operating systems, server products and user applications necessary to design, develop, implement and support the day to day operations of the system are to be described. Effort has been invested to ensure a consistent Microsoft tool platform is used to implement the 820 Phase 2 system project. Four separate platform contexts are used to describe the software used to implement the 820 Phase 2 project: Server Platform Developer Platform Analyst Platform User Platform
10.1.1
Server Platform
As the core of the solution, the server platform represents to operating systems, databases and application platforms that host and operate the 820 Phase 2 system. Instances of these servers and applications will be implemented in all project environments. All systems use the 64-bit versions of the operating system and server applications where available. The system components will be implemented using the following software application stack: Microsoft Windows Server 2003 R2 (Service Pack 2) x64 .NET 2.0 (SP2), .NET 3.0 (SP2), .NET 3.5 (SP1) IIS 6.0 Microsoft SQL Server 2008 Enterprise x64 (SP1) SQL Server Reporting Services Microsoft BizTalk Server 2009 Enterprise x64 Business Rules Engine Edifecs XEngine version 6.6

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Figure 10-1: BizTalk Platform
Operating System
Each server in the system implementation uses Windows Server 2003 R2 Enterprise Edition as the core operating system. The 64-bit version of the operating system is required to provide the server applications with access to a greater amount of RAM. The enterprise edition of Windows Server 2003 R2 is required to license the installation of the operating system on multi-processor systems. The server configurations incorporate the ITSD standards and guidelines for Windows 2003 based servers. In addition to the base operating system, each server configured to support the 820 Phase 2 project also includes additional services or packages available with Windows Server 2003. Some of the additional services and packages include: .NET 2.0, 3.0, 3.5 and IIS 6.0. Windows Server Clustering is used on many servers in the production environment to support redundant or load balanced server configurations.
Database Server
SQL Server 2008 x64 Edition provides the data foundation layer for both BizTalk 2009 and all other data model implementations. The size of the beneficiary history tables requires the use of SQL Server 2008 Enterprise Edition in the production environments. System reports produced through SQL Server 2008 Reporting Services (SSRS) rely on the information in the 820 Phase 2 system database to generate reports for the system consumers. SSRS will be used to manage report definitions, execute reports, render reports and assist with distribution.

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User Interface
User interfaces into the system will be implemented through ASP.NET web sites hosted on IIS. All user interfaces follow both the ITSD web-application architecture guidelines as well as the industry accepted standards for web-based application, and will be accessible through Internet Explorer 6.0 or greater. The User Interface will also be designed and developed to adhere to ADA accessibility guidelines.
BizTalk Server
BizTalk Server 2009 is the Microsoft server platform that provides the core services and tools used to implement the 820 Phase 2 system. BizTalk provides the system interfaces to external systems, implements system orchestrations, explicitly defines business rules and integrates all external platforms used by the system through being a flow manager. System processes are implemented as orchestrations on the BizTalk server, coordinating a series of service implementations to execute the business functionality contained within each process. BizTalk Server 2009 Enterprise Edition is required for the production environment, addressing the licensing restrictions of operating BizTalk on a multi-CPU system as well as providing the required redundant and load balance configuration capabilities.
XEngine Server
A 3rd-party HIPAA/EDI validation engine, Edifecs XEngine will be used to compliment the orchestration framework provided by the BizTalk Server. XEngine is a complete HIPAA/EDI validation and translation product. XEngine will be used to perform X12 implementation guide based validations of all EDI transactions in accordance with the validation rules outlined the DHCS 820 Companion Guide. The engine is capable of validating transactions up to WEDI-SNIP level 7, and allows for any number of EDI schemas to be validated and translated by the system. XEngine will be implemented as an integration component on the BizTalk platform, providing validation and translation services for outbound 820 EDI Transactions.
10.1.2
Developer Platform
The developer platform is the set of operating systems and products necessary to design, develop, and maintain the 820 Phase 2 solution. A standard suite of Microsoft Office tools, such as Microsoft Office, Visio and Project, are assumed to be available to all developers.
Developer Tools
In addition to the Office suite, the developers use a suite consisting of the following Microsoft development products: Visual Studio 2008 (SP1) Team Foundation Server Explorer (SP1) BizTalk Server 2009 SQL Management Studio 2008 (SP1)
Visual Studio is an industry standard IDE for producing software to run on Microsofts application platforms. Team Foundation Server Explorer is an extension to Visual Studio to integrate source

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code control and SDLC management into the IDE. BizTalk Server 2009 is a secondary application necessary to support the development BizTalk Server components. Non-Microsoft development tools to be used include: Edifecs SpecBuilder
SpecBuilder is a desktop product used in conjunction with the XEngine server to develop EDI specifications and implementation guides. Self-documenting and user friendly, the interface allows analysts and developers to implement as many versions of EDI implementation guides as necessary.
Developer Toolkit Additions

The following tools are utilized by 820 Phase 2 developers to support the development process and provide development automation: Team Foundation Server Power Tools MSBuild MS Visual Studio Test Edition
MS Test Edition and Test Edition designer are used by development staff to implement and automate execution of unit tests to validate code implementations. MS Test Edition provides the execution framework for ensuring all unit test cases are executed.
Developer Desktop Configuration

Each developer machine will use Microsoft Windows XP as the operating system. In order to promote a more efficient use of resources and provide a more agile development environment, VMWare Server or Player will be used to host virtualized instances of Windows Server 2003 R2 on top of the base operating system. Each virtual host will contain: IIS 6.0 BizTalk Server 2009 SQL Server 2008 (SP1) SQL Client Tools Visual Studio 2008 (SP1) Team Foundation Server Explorer (SP1) Microsoft Visio 2003 XMLSpy 2008

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Figure 10-2: Developer Workspace
Preconfigured virtual development environments are to be built for the 820 Phase 2 project and distributed to all software developers working on the project. Licensing for the virtualized software development environment is covered through Microsofts MSDN subscription program, granting licensed developers unrestricted access to Microsoft products and platforms for development and testing purposes.
10.1.3
Analyst Platform
Testing and validation of the 820 Phase 2 system requires some non-standard software to be installed on the analysts desktop PC system. This software includes: Edifecs SpecBuilder SQL Server 2008 Client tools Snag-It
Furthermore, analysts require remote access to the desktops of servers in the server environments to utilize the following applications: BizTalk Server Administration BizTalk Health and Administration Tool SQL Server 2008 Client tools
These tools support review and tracing the day-to-day operations of the BizTalk server application and allow testers to restart suspended processes, retrieve or update system metrics, and monitor general system health. The SQL tools allow them to query the CAPMAN Database to view actual stored data.
10.1.4
User Platform
Daily operation of the 820 Phase 2 system after roll-out and deployment does not require any software application not included in ITSDs standard desktop PC system build, as documented in Information Technology Hardware and Software Standards (Revised May 9, 2008). Specific products required for users to inquire and operate the 820 Phase 2 system include:

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MS Internet Explorer v6 SP2 Adobe Acrobat Reader 8.x MS Office 2003 Professional SP3
10.2 Server Platforms

The 820 Phase 2 system has four operating environments: Production Staging Test Development
In an effort to reduce hardware cost and increase the agility of system configurations, server virtualization technology will be utilized to consolidate multiple server instances onto individual physical hardware systems in all environments. ITSD will be utilized to host the Development and Test environments in a virtualized infrastructure. Staging and Production will be hosted with DTS, and the physical requirements will be aligned with the COEMS service offering. Specifications for all environments, including host configuration, virtual system instances, and network requirements are included in this section.
10.2.1
Development and Test Environment
Using the advantages provided by virtualization, the Development and Test environments share the same physical hardware. This section will present both environments. A total of eight server instances on four physical systems are required to support the two environments. The 820 Phase 2 project is going to reuse four existing server instances, and require the addition of four new server instances for the Development and Test environments.
Server Instances
Four server instances are required for the development environment. These server instances include: 1 x IIS 6.0 Server 1 x Microsoft BizTalk Server 2009 1 x Edifecs XEngine Server 1 x Microsoft SQL Server 2008 Four server instances are required for the Test environment. These server instances include: 1 x IIS 6.0 Server 1 x Microsoft BizTalk Server 2009 1 x Edifecs XEngine Server 1 x Microsoft SQL Server 2008 Environment Development Development Development Server Name DHSOHCHIP30 DHSOHCWEB30 DHOHCEECSQLIP35 Host Edifecs XEngine Server IIS 6.0 SQL Server 2008 Pre-existing Yes Yes No

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Environment Development Test Test Test Test
Server Name DHOHCEECBIZIP35 DHSOHCHIP20 DHSOHCWEB20 DHOHCEECSQLIP25 DHOHCEECBIZIP25
Host BizTalk Server 2009 Edifecs XEngine Server IIS 6.0 SQL Server 2008 BizTalk Server 2009
Pre-existing No Yes Yes No No

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Virtual Server Instance Requirements

The following table details the hardware resources required by both of the environments. In alignment with the virtualization strategy, hardware resources are detailed by both environment and as commoditized totals across both environments.
Server Name DHSOHCHIP30 DHSOHCWEB30 DHOHCEECSQLIP35 DHOHCEECBIZIP35 DHSOHCHIP20 DHSOHCWEB20 DHOHCEECSQLIP25 DHOHCEECBIZIP25
Operating System Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Windows 2003 R2 Total:
# CPU Cores 2 2 2 2 2 2 2 2 16
RAM (GB) 4 4 4 4 4 4 4 4 32
Hard Drive Space 120 60 200 60 120 60 200 60 880
Virtual Machine Software Requirements

The following table identifies the primary software applications and support packages that must be installed on the each of the virtual server instances. Specific version of system utilities, patches and development frameworks have been included where possible.
DHSOHCWEB20 DHSOHCWEB30 Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5
DHSOHCHIP20 DHSOHCHIP30 Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5
DHOHCEECBIZIP25 DHOHCEECBIZIP35 Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Windows SharePoint Services 3.0 Microsoft Visual Studio 2008 SQL Server Client Tools
DHOHCEECSQLIP25 DHOHCEECSQLIP35 Windows Server 2003 R2 Standard Edition x 64 SP2 SQL Server 2008 x 64 with Service Pack 1 SQL Server 2008 Reporting Services SQL Server 2008 Analysis Services SQL Server Notification Services 2.0 with Service Pack 1 SQL Server 2008 Integration Services
SQL Server Analysis Services

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DHSOHCWEB20 DHSOHCWEB30 Microsoft Message Queuing Service (MSMQ) Windows SharePoint Services 3.0
DHSOHCHIP20 DHSOHCHIP30 Edifecs XEngine
DHOHCEECBIZIP25 DHOHCEECBIZIP35 Microsoft Office Excel 2007 Microsoft Office InfoPath 2007 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5 Microsoft Visual Studio 2008 Service Pack 1 Microsoft Data Access Components (MDAC) 2.8 Service Pack 1 SQLXML 4.0 Microsoft XML Core Services (MSXML) 6.0 Microsoft Office Web Components 11 ADO.NET 9.0, 10.0 Microsoft Management Console (MMC) 3.0 Internet Explorer 7.0 ASP.NET 2.0 Visual C# MS Document Explorer 2008 and KB953196 Patch Enterprise Single Sign-On Server
DHOHCEECSQLIP25 DHOHCEECSQLIP35 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5 SQLXML 3.0 with Service Pack 3
JRE 6 x64
SQLXML 4.0 with Service Pack 1
Other System Requirements

Existing ITSD infrastructure is utilized to support the 820 Phase 2 project. This includes the Source Code Control (SCC) and SFTP host software. Microsoft Team Foundation Server 2005 is used as the SCC platform for the 820 Phase 2 project. The ITSD WSU provides a hosted TFS offering, and has been used to host the projects source code. Multiple 820 Phase 2 system interfaces require the use of an SFTP server to exchange files with external system. ITSD provides an SFTP server offer with the GlobalScape software. The same SFTP host is used for all environments, with separate user accounts configured to secure access across environments. The following table identifies the other systems supporting the development and test environments

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Environment Dev and Test Dev
Server Name eft.dhcs.ca.gov DHSSACTFS01
Role GlobalScape SFTP Server Team Foundation Server (SCC)
Physical System Requirements

The eight system instances required for both environments are allocated across three physical servers. DHCS-ITSD currently has host servers to support the virtual server instances. Four instances will be reused, while four new instances will be added to the existing environment to support the development of the 820 Phase 2 system. The VMWare host configuration relies on the availability of a SAN and FBA connectivity for the servers indicated. Approximately 520 GB of disk space is required on the SAN for the physical servers in both environments for the additional four virtual instances. Some of disk space will be reallocated from existing server instances, which are not fully utilizing resources. Physical servers are assumed to have local hard disks of adequate size to provide the space listed in either a RAID 1, 10 or 5 configurations. Utilizing virtualization requires that VMWare ESX Server is used as the base operating system for the servers described above. ESX Server provides a more efficient utilization of hardware resources across the physical hardware.
Network Configuration
The virtualized development and test environments can be described through a traditional physical network model. Virtual systems will appear within the network the same as within the physical system, and the same architecture constraints and requirements will be enforced. A variety of network protocols are required to be supported between the server instances in the environments, including: HTTP SFTP SQL
Within each environment (i.e. Dev & QA), unrestricted network access is required between the core individual server instances. Security credential authentication and permission management rely on an Active Directory login within each environment. Forms-based authentication is to be used for access to web-based interfaces hosted on the web servers, with authentication managed through the intranet AD domain. In support of the traditional 3-tier design identified in ITSD standards, three tiers of platforms, UI, Application and Database are to be used in the development and test environment. For simplicity of construction and configuration of the environments, all BizTalk, XEngine, web servers and SQL Server databases will exist on the same (v)Lan segment.

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10.2.2
Staging and Production Environment
Using the advantages provided by virtualization, the Staging and Production environments share the same physical hardware. This section will present both environments. A total of twenty server instances on three physical systems supported by a SAN are required to support the two environments. The 820 Phase 2 project is going to reuse four physical existing server instances, and require the addition of sixteen new virtual server instances for the Staging and Production environments. The staging environment mirrors the configuration of production environment, with clustered and redundant server topology.
Server Instances
Ten server instances are required for the Staging environment. These server instances include: 2 x IIS 6.0 Server 2 x Microsoft BizTalk Server 2009 2 x Edifecs XEngine Server (one licensed server currently exists) 4 x Microsoft SQL Server 2008 Ten server instances are required for the Production environment. These server instances include: 2 x IIS 6.0 Server 2 x Microsoft BizTalk Server 2009 2 x Edifecs XEngine Server (one licensed server currently exists) 4 x Microsoft SQL Server 2008 Since the Production and Staging servers will be virtualized there is an option to deploy two less SQL servers into the environments. By using the VMware and vSphere product stack single SQL database instances can be configured for high availability and redundancy.. If this option is viable then the physical host servers need to run on Intel 31xx, 33xx, 52xx, 54xx, 55xx, 74xx chip sets. By using the virtualization configuration it would reduce the need to set up a Microsoft Active/Passive cluster, which is notoriously difficult to configure and manage. Environment Staging Staging Staging Staging Staging Staging Staging Staging Staging Staging Server Name DHSEAPPHIP21 DHSEAPPHIP22 DHOHCGOLSQLIS21 DHOHCGOLSQLIS22 DHOHCGOLSQLIS23 DHOHCGOLSQLIS24 DHOHCGOLBIZIS21 DHOHCGOLBIZIS22 DHOHCGOLAPPIS21 DHOHCGOLAPPIS22 Host Edifecs XEngine Server Edifecs XEngine Server SQL Server 2008 SQL Server 2008 SQL Server 2008 SQL Server 2008 BizTalk Server 2009 BizTalk Server 2009 IIS 6.0 IIS 6.0 Pre-existing Yes Yes* No No No No No No No No

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Environment Production Production Production Production Production Production Production Production Production Production
Server Name DHSEAPPHIP01 DHSEAPPHIP02 DHOHCGOLSQLIP01 DHOHCGOLSQLIP02 DHOHCGOLSQLIP03 DHOHCGOLSQLIP04 DHOHCGOLBIZIP01 DHOHCGOLBIZIP02 DHOHCGOLAPPIP01 DHOHCGOLAPPIP02
Host Edifecs XEngine Server Edifecs XEngine Server SQL Server 2008 SQL Server 2008 SQL Server 2008 SQL Server 2008 BizTalk Server 2009 BizTalk Server 2009 IIS 6.0 IIS 6.0
Pre-existing Yes Yes* No No No No No No No No
*Physical server exists but does not have a license for Edifecs XEngine Server.

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Virtual Server Instance Requirements

The following table details the hardware resources required by both of the environments. In alignment with the virtualization strategy, hardware resources are detailed by both environment and as commoditized totals across both environments. The allocation of resources for the virtual instances maps directly to the resource allocation of the physical hosts. The virtual servers can be allocated the resources, but after the system has been in production the resources can be reallocated depending on usage. For instance, 1008 GB of hard drive space can be provisioned for use by a SQL server, but the actual physical use can be smaller. The disk space that is allocated for each server should be thinly provisioned, especially for the SQL servers. Thin provisioning allows the servers to grow automatically as needed with out taking the systems down or disrupting users. When the servers are initially configured, space is pre-allocated but the servers only use the space needed to store the actual data. The following pre-existing physical servers are not in the virtual server instance requirements: Server Name DHSEAPPHIP21 DHSEAPPHIP22 DHSEAPPHIP01 DHSEAPPHIP02 Operating System Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Total: # CPU Cores 2 2 2 2 8 RAM (GB) 32 32 32 32 128 Hard Drive Space 252 252 252 252 1008
Virtual server instance requirements: Server Name DHSEAPPHIP21 DHSEAPPHIP22 DHOHCGOLSQLIS21 DHOHCGOLSQLIS22 DHOHCGOLSQLIS23 DHOHCGOLSQLIS24 DHOHCGOLBIZIS21 DHOHCGOLBIZIS22 DHOHCGOLAPPIS21 DHOHCGOLAPPIS22 DHSEAPPHIP01 Operating System Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit # CPU Cores 2 2 2 2 2 2 2 2 2 2 2 RAM (GB) 32 32 16 16 8 8 16 16 16 16 32 Hard Drive Space 252 252 500 Shared 120 Shared 120 120 80 80 252

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Server Name DHSEAPPHIP02 DHOHCGOLSQLIP01 DHOHCGOLSQLIP02 DHOHCGOLSQLIP03 DHOHCGOLSQLIP04 DHOHCGOLBIZIP01 DHOHCGOLBIZIP02 DHOHCGOLAPPIP01 DHOHCGOLAPPIP02
Operating System Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Windows 2003 R2 64 Bit Total:
# CPU Cores 2 4 4 2 2 8 8 2 2 48
RAM (GB) 32 32 32 16 16 64 64 16 16 368
Hard Drive Space 252 7500 Shared 504 Shared 252 252 120 120 9768
Virtual Software Requirements

The following table identifies the primary software applications and support packages that must be installed on the each of the virtual server instances. Specific version of system utilities, patches and development frameworks have been included where possible.
DHOHCGOLAPPIS21 DHOHCGOLAPPIS22 DHOHCGOLAPPIP01 DHOHCGOLAPPIP02
DHSEAPPHIP21 DHSEAPPHIP22 DHSEAPPHIP01 DHSEAPPHIP02
DHOHCGOLBIZIS21 DHOHCGOLBIZIS22 DHOHCGOLBIZIP01 DHOHCGOLBIZIP02
Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5
Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5
Windows Server 2003 R2 Standard Edition x 64 SP2 Microsoft Internet Information Services (IIS) 6.0 Windows SharePoint Services 3.0 Microsoft Visual Studio 2008 SQL Server Client Tools
DHOHCGOLSQLIS21 DHOHCGOLSQLIS22 DHOHCGOLSQLIS23 DHOHCGOLSQLIS24 DHOHCGOLSQLIP01 DHOHCGOLSQLIP02 DHOHCGOLSQLIP03 DHOHCGOLSQLIP04 Windows Server 2003 R2 Standard Edition x 64 SP2 SQL Server 2008 x 64 with Service Pack 1 SQL Server 2008 Reporting Services SQL Server 2008 Analysis Services SQL Server Notification Services 2.0 with Service Pack 1 SQL Server 2008 Integration Services
SQL Server Analysis Services

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DHOHCGOLAPPIS21 DHOHCGOLAPPIS22 DHOHCGOLAPPIP01 DHOHCGOLAPPIP02
DHSEAPPHIP21 DHSEAPPHIP22 DHSEAPPHIP01 DHSEAPPHIP02
DHOHCGOLBIZIS21 DHOHCGOLBIZIS22 DHOHCGOLBIZIP01 DHOHCGOLBIZIP02
Microsoft Message Queuing Service (MSMQ) Windows SharePoint Services 3.0
Edifecs XEngine JRE 6 x64
Microsoft Office Excel 2007 Microsoft Office InfoPath 2007 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5 Microsoft Visual Studio 2008 Service Pack 1 Microsoft Data Access Components (MDAC) 2.8 Service Pack 1 SQLXML 4.0 Microsoft XML Core Services (MSXML) 6.0 Microsoft Office Web Components 11 ADO.NET 9.0, 10.0 Microsoft Management Console (MMC) 3.0 Internet Explorer 7.0 ASP.NET 2.0 Visual C# MS Document Explorer 2008 and KB953196 Patch Enterprise Single Sign-On Server
DHOHCGOLSQLIS21 DHOHCGOLSQLIS22 DHOHCGOLSQLIS23 DHOHCGOLSQLIS24 DHOHCGOLSQLIP01 DHOHCGOLSQLIP02 DHOHCGOLSQLIP03 DHOHCGOLSQLIP04 Microsoft Management Console (MMC) 3.0 Microsoft .NET Framework 1.1 Microsoft .NET Framework 2.0 Microsoft .NET Framework 3.0/3.5 SQLXML 3.0 with Service Pack 3
SQLXML 4.0 with Service Pack 1
10.2.2.1 Network Configuration

The virtualized staging and production environments can be described through a traditional physical network model. Virtual systems will appear within the network the same as within the physical system, and the same architecture constraints and requirements will be enforced.

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A variety of network protocols are required to be supported between the server instances in the environments, including: HTTP SFTP SQL
Within each environment unrestricted network access is required between the core individual server instances. Security credential authentication and permission management relies on an Active Directory within each environment. Authentication will be enforced by the DHCS intranet Active Directory, as the 820 Phase 2 system is a trusted application and will not be accessed directly by entities outside of DHCS. Forms-based authentication is to be used for access to web-based interfaces hosted on the web servers, with authentication managed through the intranet AD domain. In support of the traditional 3-tier design identified in ITSD standards, three tiers of platforms, UI, Application and Database are to be used in the development and test environment. For simplicity of construction and configuration of the environments, all BizTalk, XEngine, web servers will exist on the same (v)LAN segment. The SQL Server databases can exist on a separate (v)LAN segment, although it may not be necessary to do so since the 820 Phase 2 systems is a trusted application. The system performs data intensive calculations on beneficiary history and stores much of the data in cache while performing the calculations. If the SQL servers are to be placed on a separate (v)LAN segment, it is recommended that communication not go through a firewall. Packet inspection has the potential to degrade performance and increase latency. Ports that will need to be open between server instances in the environments include (if the servers are on different subnets): 22030 between the application servers and SQL servers 22030 between the BizTalk Servers and the SQL servers 5000-5020 - between the BizTalk Servers and the SQL servers 23 - between the BizTalk Servers and the SFTP server

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As California Department of Health Care Services, 820 Phase 2 System, 2009

For Internal Use Only - 169 -

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Other System Requirements

Multiple 820 Phase 2 system interfaces require the use of an SFTP server to exchange files with external system. ITSD provides an SFTP server offer with the GlobalScape software. The same SFTP host is used for all environments, with separate user accounts configured to secure access across environments. The following table identifies the other systems supporting the staging and production environments Environment Staging Production Server Name eft.dhcs.ca.gov eft.dhcs.ca.gov Role GlobalScape SFTP Server GlobalScape SFTP Server
Physical System Requirements

Sixteen of the Staging and Production system instances required for the environments are allocated across three physical servers. DHCS-ITSD does not have host servers to support the virtual server instances in the COEMS environment. Four physical server instances will be reused. The physical servers host XEngine server, there is only one active staging server and one active production server. It is recommended that the staging and production servers that are used as back-up servers, have licensed versions of XEngine server installed, and that they are load balanced with the existing XEngine servers. The VMWare host configuration relies on the availability of a SAN and FBA connectivity for the servers indicated. Approximately 9.8 TB of accessible disk space is required on the SAN to host the virtual server instances for production and staging. Physical servers are assumed to have local hard disks of adequate size to provide the space listed in either a RAID 1, 5, 6, or 10 configurations. Conservative calculation estimates of required SQL Server storage follow: 4.5 million beneficiaries * ~150 bytes = ~ 675MB raw data table size for Capitation Direct copies from the CAP13REC: 4.5million * 36 * 13 rows * ~ 100 bytes / row = ~ 210GB 4MB archived invoices as blobs * 36 * 50 rows = ~ 8GB for invoice archival Auditing: Estimating 100 changes / day + 10 changes per invoice gives 10MB for auditing Payment History: 1000 payments * 36 months, plus estimates for table storage gives 10MB Invoice / Contract Report Storage: 1000 rows per month = ~ 40MB
Total ~ 250 GB operational data Logging (double the size) ~ 500 GB Utilizing virtualization requires that VMWare ESX Server is used as the base operating system for the servers described above. ESX Server provides a more efficient utilization of hardware resources across the physical hardware. Server Name DHOHCGOLESXIP01 Server Model Dell Poweredge R900 # CPU Cores 4 Quad Core RAM (GB) 128 Hard Drive Space 292

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Server Name DHOHCGOLESXIP02 DHOHCGOLESXIP03 DHOHCGOLUTLIP01 DHOHCGOLSANIP01 DHOHCGOLSANIP02
Server Model Dell Poweredge R900 Dell Poweredge R900 Dell R710 Dell EqualLogic PS6000X Dell EqualLogic PS6000X
# CPU Cores 4 Quad Core 4 Quad Core 2 Quad Core N/A N/A
RAM (GB) 128 128 16 N/A N/A
Hard Drive Space 292 292 584 6.4 TB 6.4 TB
The following servers will host the VM Ware virtual server instances: DHOHCGOLESXIP01 DHOHCGOLESXIP02 DHOHCGOLESXIP03
The DHOHCGOLUTLIP01 server will be used to manage the VM Ware ESX servers. The following servers will form the SAN: DHOHCGOLSANIP01 DHOHCGOLSANIP02

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10.3 Scalability, Load Balancing & Redundancy

The implementation of the 820 Phase 2 project will take advantage of Microsoft Network Load Balancing Services (NLB) to allow the system to scale without the traditional incremental penalty imposed on growing systems. Since NLB is a naturally load-balanced solution, allowing new hardware or virtual server instances to be added transparently to the current implementation and providing a full-factor increase in system performance. NLB presents a virtual computer, with a single DNS and IP that systems or users connect to, while NLB distributes processes across the servers in the NLB cluster.
NLB Cluster
10.3.1
IIS
All web services and the web site can be deployed across the scalable web farm. NLB clustering is an active/active configuration, all servers act in unison as a single virtual server. Processes are distributed across servers using a distributed clustering technique.
10.3.2
SQL Server / Reporting Services
SQL Server clustering will be used to remove a single point of failure from the data persistence layer. SQL clustering is an active/passive configuration, one server acts as the host while the other is reserved for a failover. All data is stored on the SAN, so there is little chance for data loss. Again, since the Production and Staging servers will be virtualized there is an option to deploy two less SQL servers into the environments. By using the VMware and vSphere product stack single SQL database instances can be configured for high availability and redundancy.

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Microsoft recommends separating SQL data and log files onto their own disk volumes on the SAN. Having the volumes separate also removes the risk of loosing both files if the volume fails. The SQL server should also be configured to disable the automatic shrinking of the database. When SQL server shrinks a database it automatically de-allocates disk space and can leave unallocated disk space on the NTFS file system in fragments.
10.3.3
XEngine
The XEngine Servers can be deployed across the scalable application farm. NLB clustering is an active/active configuration, all servers act in unison as a single virtual server. Processes are distributed across servers using a distributed. The XEngine Servers are not currently configured in a cluster; it is recommended that they are clustered, as multiple systems will be utilizing them.
10.3.4
BizTalk
Load balancing can be achieved through either hardware or software. Individual BizTalk components can be deployed across one or more physical system while remaining logically transparent to the rest of the system. Further redundancy or load balancing can be achieved with the use a hardware based load balancing to distribute incoming transactions to more than one receiving server. In the case of the 820 Phase 2 system, it is recommended that the BizTalk servers utilize Microsoft NLB clustering. The BizTalk components will be deployed in a single application, removing the complexity of distributing multiple applications across BizTalk servers. The NLB cluster will distribute 820 Phase 2 BizTalk load equally to the two servers.
10.4 Security and Recovery

The 820 Phase 2 system processes and stores Personal Health Information (PHI) data and at the same time allows authenticated users access to that data. The two primary security issues that are addressed by the 820 Phase 2 system include prevention of data loss, and prevention of malicious use of the 820 Phase 2 system. Data loss prevention is addressed through having a regularly conducted backup system. Malicious use prevention is addressed through password protection, firewalls, and authentication logic.
10.4.1
System Security
The 820 Phase 2 system utilizes authentication, authorization, and access and application level security. It complies with all applicable Department security policies and requirements as well as those specified in the ISO/SR1 (Information Systems Security Requirements for Projects) document. The system includes following security components: Network Security DMZ and Domain Web application security (Active Directory and Security roles) SFTP support Network Security:

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Security credential authentication and permission management relies on an Active Directory within each environment and the intranet security model across environments and departments. Formsbased authentication is used for access to internal facing web-based interfaces hosted on the web servers, with authentication managed through the intranet AD domain. DMZ and Domain: The 820 Phase 2 system is located behind the DMZ (Demilitarized Zone) which adds an additional layer of security to the network location of the system. DMZ is a physical sub network that contains and exposes only the SFTP interfaces of 820 Phase 2 system to the outside-untrusted network. The external parties only have access to the SFTP folders in the DMZ, rather than the whole domain where 820 Phase 2 database and application reside. Web application security: Users gain access to the 820 Phase 2 website by possessing a valid Active Directory credential. The user enters their username and password combination and submits the form to gain their credential. The username and password are validated against the Active Directory system maintained in DHCSs intranet. The 820 Phase 2 system will not retain any username or password information. Users that successfully gain access via the login screen will be granted access to the website based on the security roles they are associated with in the 820 Phase 2 system. Security roles are only maintained in 820 Phase 2, and do not rely on Active Directory once the username and password have been authenticated. Managing user security in the 820 Phase 2 website is achieved through an administration GUI screen, where users may be added, removed, and assigned different security roles. When a new user is added to the application a corresponding entry in Active Directory must also be present. SFTP Support: 820 Phase 2 system uses the SFTP (Secure File Transfer Protocol) to communicate with MEDS file interface partner. SFTP in 820 Phase 2 system is utilized as a security network protocol that provides MEDS file exchange functionality. This security layer will prevent eavesdropping and tampering of MEDS exchange data. External systems also pickup files from folder locations on the SFTP server.
10.4.2
Backup and Recovery
It is necessary to have regularly conducted backups and execute required data and software backups, to ensure the ability to quickly resume normal operations in case of disasters, failures of storage media, or corruption of data. Also backup data needs to be tested regularly to ensure the validity. ITSD department will decide on which media the backup data will be stored. Whether that is magnetic tape, hard disk, optical disk or remote backup, it will be their decision. The standard ISO Operational Recovery Plan (ORP) draft will be completed for review by the ISO group and will be included as part of the Maintenance and Administration Document. The ORP Strategy document is a standard document used to guide the recovery from disaster or isolated hardware failures. Following components need to be included in the backup of the 820 Phase 2 application: 820 Phase 2 database

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BizTalk database XEngine configuration database SFTP adapter database Image of 820 Phase 2 business application server slice Image of 820 Phase 2 application server slice Image of 820 Phase 2 XEngine server Companion Guide 820 Phase 2 transaction files
As the staging and production environment are virtualized, VM Ware has a set tools and the capacity to be used as part of the Backup and Recovery strategy. Prior to any code deployment or patch to a virtual server a snapshot of the server should be taken to guard against an unforeseen system change making the 820 Phase 2 system inoperable.

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Appendix A Data Dictionary

10.5 Table Details
The following subsections describe, in detail, each set of properties for each table in the database. These properties include collation, schema, columns, indexes and foreign keys.
10.5.1
Table TB_ADJUSTMENT
The TB_ADJUSTMENT table provides details of Health Care Plan-Level adjustments within each Contract.
10.5.1.1
Properties
The following table describes the table level properties for the table TB_ADJUSTMENT. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
10.5.1.2
Columns
The following table describes the columns in the table TB_ADJUSTMENT. Name Adjustment_Id Amount Reason Effective_Date_From Effective_Date_To Adjustment_Type_Id Data Type int identity money varchar(256) date date int Allow Nulls False False True False False False Description Unique Key of TB_ADJUSTMENT Amount of the Adjustment An explanation stating the reason for the adjustment that has been made Adjustment Effective Date From Adjustment Effective Date To Type of the Adjustment

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Name Check_Number Check_Date Contract_Plan_Code_Id Invoice_Type_Id
Data Type varchar(32) datetime int smallint
Allow Nulls True True False True
Description Check Number if Adjustment includes a Check Date of Check if Adjustment includes a Check Contract/Health Care Plan receiving the Adjustment The type of the invoice receiving the adjustment
10.5.1.3
Indexes
The following table describes the indexes on the table TB_ADJUSTMENT. Name pkc_TB_ADJUSTMENT_Adjustment_Id ixn_TB_ADJUSTMENT__Adjustment_Type_Id ixn_TB_ADJUSTMENT__Contract_Plan_Code _Id Columns Adjustment_Id Adjustment_Type_Id Contract_Plan_Code_Id Unique True False False Clustered True False False
10.5.1.4
Foreign Keys
The following table describes the foreign keys on the table TB_ADJUSTMENT. Name
FK_TB_ADJUSTMENT_TYPE__Adj ustment_Type_Id__TO__TB_ADJU STMENT__Adjustment_Type_Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _ADJUSTMENT__Contract_Plan_C ode_Id FK_TB_INVOICE_TYPE__Invoice_T ype_Id__TO__TB_ADJUSTMENT__ Invoice_Type_Id
Column
Adjustment_Type_Id
Foreign Table
TB_ADJUSTMENT_T YPE TB_CONTRACT_PLA N_CODE
Foreign Column
Adjustment_Type_Id
Contract_Plan_Code_I d
Contract_Plan_Code_Id
Invoice_Type_Id
TB_INVOICE_TYPE
Invoice_Type_Id
10.5.2
Table TB_ADJUSTMENT_TYPE
The TB_ADJUSTMENT_TYPE table is a reference table detailing what is the type of the adjustment.
Properties
The following table describes the table level properties for the table TB_ADJUSTMENT_TYPE.

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Property Collation Schema
Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_ADJUSTMENT_TYPE. Name Adjustment_Type_Id Name Withhold_Percentage Data Type smallint varchar(128) decimal(5,2) Allow Nulls False False True Description Unique Key of TB_ADJUSTMENT_TYPE The reason for and/or nature of an adjustment Percentage of Withholding for adjustments requiring percentage adjustments
Indexes
The following table describes the indexes on the table TB_ADJUSTMENT_TYPE. Name pkc_TB_ADJUSTMENT_TYPE__Adjustment_ Type_Id Columns Adjustment_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_ADJUSTMENT_TYPE. Name
FK_TB_ADJUSTMENT_TYPE__Adj ustment_Type_Id__TO__TB_ADJU STMENT__Adjustment_Type_Id
Column
Adjustment_Type_Id
Foreign Table
TB_ADJUSTMENT
Foreign Column
Adjustment_Type_Id
10.5.3
Table TB_AID_CODE
The TB_AID_CODE table is a join table to determine what aid codes are in what aid codes group per contract.
Properties
The following table describes the table level properties for the table TB_AID_CODE.

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Columns
The following table describes the columns in the table TB_AID_CODE. Name Aid_Code_Type_Id Aid_Code_Group_Id Data Type smallint int Allow Nulls False False Description Partial Unique Key Referencing the Aid Code Reference Table Partial Unique Key Referencing the Aid Code Group Reference Table
Indexes
The following table describes the indexes on the table TB_AID_CODE. Name pkc_TB_AID_CODE__Aid_Code_Type_Id__Ai d_Code_Group_Id Columns Aid_Code_Type_Id Aid_Code_Group_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_AID_CODE. Name
FK_TB_AID_CODE_GROUP__Aid_ Code_Group_Id__TO_TB_AID_CO DE_Aid_Code_Id FK_TB_AID_CODE_TYPE__Aid_Co de_Type_Id__TO__TB_AID_CODE_ _Aid_Code_Type_Id
Column
Aid_Code_Group_Id
Foreign Table
TB_AID_CODE_GRO UP TB_AID_CODE_TYPE
Foreign Column
Aid_Code_Group_Id
Aid_Code_Type_Id
And_Code_Type_Id
10.5.4
Table TB_AID_CODE_GROUP
The TB_AID_CODE_GROUP is a join table showing what aid code groups are eligible within a contract, and also records effective dates for rates.
Properties
The following table describes the table level properties for the table TB_AID_CODE_GROUP.

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Columns
The following table describes the columns in the table TB_AID_CODE_GROUP. Name Aid_Code_Group_Id Contract_Plan_Code_Id Aid_Code_Group_Type_I d Rate_Effective_Date_Fro m Data Type int identity int smallint Allow Nulls False False False Description Unique Key of TB_AID_CODE_GROUP The Contract / Plan Code this Aid Code Group Falls Under The Aid Code Group Name, the collection of aid codes under the same payment rate category The starting date of the Service Months for which payments are made The ending date of the Service Month for which payments are made. If null, the rate remains effective until either the 'Rate_Effective_Date_From' of the next rate or the Contract Effective_Date_To date, whichever date is first
date
True
Rate_Effective_Date_To
date
True
Indexes
The following table describes the indexes on the table TB_AID_CODE_GROUP. Name pkc_TB_AID_CODE_GROUP__Aid_Code_Gro up_Id ixn_TB_AID_CODE_GROUP__Aid_Code_Gro up_Type_Id ixn_TB_AID_CODE_GROUP__Contract_Plan_ Code_Id Columns Aid_Code_Group_Id Aid_Code_Group_Type_I d Contract_Plan_Code_Id Unique True False False Clustered True False False
Foreign Keys
The following table describes the foreign keys on the table TB_AID_CODE_GROUP. Name Column Foreign Table Foreign Column

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Name
FK_TB_AID_CODE_GROUP_TYPE __Aid_Code_Group_Type_Id__TO_ TB_AID_CODE_GROUP_Aid_Code _Group_Type_Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _AID_CODE_GROUP__Contract_Pl an_Code_Id FK_TB_AID_CODE_GROUP__Aid_ Code_Group_Id__TO_TB_AID_CO DE_Aid_Code_Id FK_TB_AID_CODE_GROUP__Aid_ Code_Group_Id__TO__TB_PLAN_ CODE_ON_PAYMENT_TYPE__Aid _Code_Group_Id
Column
Aid_Code_Group_Typ e_Id
Foreign Table
TB_AID_CODE_GRO UP_TYPE
Foreign Column
Aid_Code_Group_Type _Id
TB_CONTRACT_PLA N_CODE
Aid_Code_Group_Id
TB_AID_CODE
Aid_Code_Group_Id
Aid_Code_Group_Id
TB_PLAN_CODE_ON _PAYMENT_TYPE
Aid_Code_Group_Id
10.5.5
Table TB_AID_CODE_GROUP_TYPE
The TB_AID_CODE_GROUP_TYPE table is a reference table of all Aid Code Group names.
Properties
The following table describes the table level properties for the table TB_AID_CODE_GROUP_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_AID_CODE_GROUP_TYPE. Name Aid_Code_Group_Type_I d Aid_Code_Group_Name Data Type smallint varchar(64) Allow Nulls False False Description Unique Key of TB_AID_CODE_GROUP_TYPE Name of the collection of aid codes under the same payment rate category
Indexes
The following table describes the indexes on the table TB_AID_CODE_GROUP_TYPE. Name Columns Unique Clustered

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Name pkc_TB_AID_CODE_GROUP_TYPE__Aid_Co de_Group_Type_Id
Columns Aid_Code_Group_Type_I d
Unique True
Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_AID_CODE_GROUP_TYPE. Name
FK_TB_AID_CODE_GROUP_TYPE __Aid_Code_Group_Type_Id__TO_ _TB_INVOICE_DETAIL__Aid_Code _Group_Type_Id FK_TB_AID_CODE_GROUP_TYPE __Aid_Code_Group_Type_Id__TO_ TB_AID_CODE_GROUP_Aid_Code _Group_Type_Id
Column
Foreign Table
TB_INVOICE_DETAIL
Foreign Column
TB_AID_CODE_GRO UP
10.5.6
Table TB_AID_CODE_TYPE
The TB_AID_CODE_TYPE table is a reference table of all aid codes used in MEDS.
Properties
The following table describes the table level properties for the table TB_AID_CODE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_AID_CODE_TYPE. Name Aid_Code_Type_Id Data Type smallint Allow Nulls False Description Unique Key of TB_AID_CODE_TYPE

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Name
Data Type
Allow Nulls
Description The aid code used to bill for services through the Medi-Cal claims processing systems and for other non Medi-Cal programs that need to verify eligibility through Eligibility Verification System (EVS). This is used to determine beneficiary eligibility and payment rates. The Name of the Aid Code Additional Aid Code Description Details Funding of the Aid Code
Aid_Code
char(2)
False
Aid_Code_Name Description Funding_Type
varchar(128) varchar(1024) smallint
False True True
Indexes
The following table describes the indexes on the table TB_AID_CODE_TYPE. Name pkc_TB_AID_CODE_TYPE__Aid_Code_Type_ Id ixn_TB_AID_CODE_TYPE__Aid_Code Columns Aid_Code_Type_Id Aid_Code Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_AID_CODE_TYPE. Name
FK_TB_AID_CODE_TYPE__Aid_Co de_Type_Id__TO__TB_AID_CODE_ _Aid_Code_Type_Id FK_TB_FUNDING_TYPE__Funding _Type_Id__TO__TB_AID_CODE_T YPE__Funding_Type_Id FK_TB_AID_CODE_TYPE__Aid_Co de_Type_Id__TO__TB_INVOICE_D ETAIL__Aid_Code_Type_Id
Column
Aid_Code_Type_Id
Foreign Table
TB_AID_CODE
Foreign Column
Aid_Code_Type_Id
Funding_Type_Id
TB_FUNDING_TYPE
Funding_Type_Id
Aid_Code_Type_Id
TB_INVOICE_DETAIL
Aid_Code_Type_Id
10.5.7
Table TB_BENE_RISK_FACTOR
The TB_BENE_RISK_FACTOR table provides a version-able risk factor for all beneficiaries in Managed Care.

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Properties
The following table describes the table level properties for the table TB_BENE_RISK_FACTOR. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_BENE_RISK_FACTOR. Name Bene_Risk_Factor_Id Data Type int identity Allow Nulls False Description Unique Key of TB_BENE_RISK_FACTOR A number that represents a beneficiary's likelihood of developing an illness. This number is determined by MMCD based on analysis of the beneficiary's physical and behavioral health factors. (defaults to 1.000) Beneficiary that the Risk Factor is associated with Audit Field to denote who was the user to change the record. Can be System User. Last Modified Time of Risk Factor. Defaults to Current Date.
Risk_Factor
decimal(7,4)
False
Beneficiary_Id Audit_User Last_Modified
int varchar(128) datetime
False False False
Indexes
The following table describes the indexes on the table TB_BENE_RISK_FACTOR. Name pkc_TB_BENE_RISK_FACTOR__Bene_Risk_ Factor_Id ixn_TB_BENE_RISK_FACTOR__Beneficiary_I d Columns Bene_Risk_Factor_Id Beneficiary_Id Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_BENE_RISK_FACTOR. Name Column Foreign Table Foreign Column

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Name
FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENE_RISK_FACT OR__Beneficiary_Id
Column
Beneficiary_Id
Foreign Table
TB_BENEFICIARY
Foreign Column
Beneficiary_Id
10.5.8
Table TB_BENE_SUPPLEMENTAL_INFO
The TB_BENE_SUPPLEMENTAL_INFO is a join table denoting Beneficiary Eligibility for Supplemental Aid.
Properties
The following table describes the table level properties for the table TB_BENE_SUPPLEMENTAL_INFO. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_BENE_SUPPLEMENTAL_INFO. Name Bene_Supplemental_Info _Id Beneficiary_Id Supplemental_Aid_Type _Id Effective_Date_From Effective_Date_To Delivery_Date Data Type int identity int smallint date date date Allow Nulls False False False True True True Description Unique Key of TB_BENE_SUPPLEMENTAL_INF O Beneficiary that has the supplemental aid. Supplemental Aid that Beneficiary is eligible for. Effective Date of Beneficiary eligibility for Supplemental Aid End Effective Date of Beneficiary eligibility for Supplemental Aid Delivery Date of Beneficiary Supplemental Aid (used in Maternity Only) Date of Diagnosis of Supplemental Aid (used in AIDS only) Audit field to denote who was the last user to create / modify the supplemental record.
Diagnosis_Date
date
True
Audit_User
varchar(128)
False

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Name Diagnosis Audit_Date
Data Type varchar(128) datetime
Allow Nulls False False
Description Additional Diagnosis Information of Beneficiary Supplemental Aid. Audit Date is the date of last change to the Beneficiary Supplemental Information
Indexes
The following table describes the indexes on the table TB_BENE_SUPPLEMENTAL_INFO. Name pkc_TB_BENE_SUPPLEMENTAL_INFO__Ben e_Supplemental_Info_Id ixn_TB_BENE_SUPPLEMENTAL_INFO__Ben eficiary_Id ixn_TB_BENE_SUPPLEMENTAL_INFO__Sup plemental_Aid_Type_Id Columns Supplemental_Info_Id Beneficiary_Id Supplemental_Aid_Type_ Id Unique True False False Clustered True False False
Foreign Keys
The following table describes the foreign keys on the table TB_BENE_SUPPLEMENTAL_INFO. Name
FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENE_SUPPLEME NTAL_INFO__Beneficiary_Id FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_BENE_SUPPLEMENTAL_I NFO__Supplemental_Aid_Type_Id
Column
Beneficiary_Id
Foreign Table
TB_BENEFICIARY
Foreign Column
Beneficiary_Id
Supplemental_Aid_Ty pe_Id
TB_SUPPLEMENTAL _AID_TYPE
Supplemental_Aid_Typ e_Id
10.5.9
Table TB_BENEFICIARY
The TB_BENEFICIARY table holds reference information for both Managed and Non-Managed Care.
Properties
The following table describes the table level properties for the table TB_BENEFICIARY. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo

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Columns
The following table describes the columns in the table TB_BENEFICIARY. Name Beneficiary_Id Data Type int identity Allow Nulls False Description Unique Key of TB_BENEFICIARY Unique Client Identification Number assigned by MEDS to each Beneficiary (CIN can be present for both Managed and Non-Managed Care) Beneficiary Last Name Beneficiary First Name Beneficiary Middle Initial if given Beneficiary Date of Birth (is null for unborn beneficiary) Deceased Beneficiary Date of Death MEDS-Assigned Gender Code (F/M/U) of Beneficiary MEDS-assigned Alien Code of Beneficiary Date Death Posted to MEDS of Deceased Beneficiary MEDS-assigned Last Modified Date of Beneficiary Information MEDS-assigned Ethnic Code of Beneficiary Audit field to denote who was the last user to create / modify the beneficiary record. Can be System User. Flag is '1' when Beneficiary is in Non-Managed Care, otherwise is null when Beneficiary is created through the Capitation Process.
CIN
char(9)
False
Name_Last Name_First Name_Middle_Initial Date_Of_Birth Date_Of_Death Gender_Code Alien_Code Date_Death_Posted Last_Modified Ethnicity_Code
varchar(64) varchar(64) char(1) date date char(1) char(1) date datetime char(1)
False False True True True True True True True True
Audit_User
varchar(128)
False
Nonmanaged_Beneficiar y
bit
True
Indexes
The following table describes the indexes on the table TB_BENEFICIARY. Name pkn_TB_BENEFICIARY__Beneficiary_Id ixn_TB_BENEFICIARY_CIN Columns Beneficiary_Id CIN, Nonmanaged_Beneficiary Unique True True Clustered False True

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Foreign Keys
The following table describes the foreign keys on the table TB_BENEFICIARY. Name
FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENE_SUPPLEME NTAL_INFO__Beneficiary_Id FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENEFICIARY_NO NMANAGED_CARE__Beneficiary_I d FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENE_RISK_FACT OR__Beneficiary_Id FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_INVOICE_DETAIL_ _Beneficiary_Id
Column
Beneficiary_Id
Foreign Table
TB_BENE_SUPPLEM ENTAL_INFO TB_BENEFICIARY_N ONMANAGED_CARE TB_BENE_RISK_FAC TOR TB_INVOICE_DETAIL
Foreign Column
Beneficiary_Id
Beneficiary_Id
Beneficiary_Id
Beneficiary_Id
Beneficiary_Id
Beneficiary_Id
Beneficiary_Id
10.5.10 Table TB_BENEFICIARY_ADJUSTMENT

The TB_BENEFICIARY_ADJUSTMENT table provides for Non-Managed care-related adjustments at the Beneficiary Level.
Properties
The following table describes the table level properties for the table TB_BENEFICIARY_ADJUSTMENT. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_BENEFICIARY_ADJUSTMENT. Name Beneficiary_Adjustment _Id Adjustment_Amount Adjustment_Reason Audit_User Data Type int identity smallmoney varchar(256) varchar(128) Allow Nulls False False True False Description Unique Key of TB_BENEFICIARY_ADJUSTMEN T Amount of the Adjustment The reason for an adjustment Audit field to denote who was the user to create an adjustment

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Name Check_Number Check_Date Premium_Payment_Fro m Premium_Payment_To Beneficiary_Nonmanage d_Care_Id
Data Type varchar(32) date date date int
Allow Nulls True True True True False
Description Check Number if Adjustment includes a Check Date of Check if Adjustment includes a Check For Premium Payments, duration of Premium Payment (From) For Premium Payments, duration of Premium Payment (To) Beneficiary Enrollment in NonManaged Care Identifier
Indexes
The following table describes the indexes on the table TB_BENEFICIARY_ADJUSTMENT. Name pkc_TB_BENEFICIARY_ADJUSTMENT__Ben eficiary_Adjustment_Id ixn_TB_BENEFICIARY_ADJUSTMENT__Bene ficiary_Nonmanaged_Care_Id Columns Beneficiary_Adjustment_I d Beneficiary_Nonmanaged _Care_Id Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_BENEFICIARY_ADJUSTMENT. Name
FK_TB_BENEFICIARY_NONMANA GED_CARE__Beneficiary_Nonman aged_Care_Id_TO_TB_BENEFICIA RY_ADJUSTMENT__Beneficiary_N onmanaged_Care_Id
Column
Beneficiary_Nonmana ged_Care_Id
Foreign Table
TB_BENEFICIARY_N ONMANAGED_CARE
Foreign Column
Beneficiary_Nonmanag ed_Care_Id
1.
Table TB_BENEFICIARY_NONMANAGED_CARE
The TB_BENEFICIARY_NONMANAGED_CARE table provides supplemental beneficiary information when a Beneficiary is enrolled in Non-Managed Care.
Properties
The following table describes the table level properties for the table TB_BENEFICIARY_NONMANAGED_CARE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo

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Columns
The following table describes the columns in the table TB_BENEFICIARY_NONMANAGED_CARE. Name Beneficiary_Nonmanage d_Care_Id Beneficiary_Id Data Type int identity int Allow Nulls False False Description Unique Key of TB_ BENEFICIARY_NONMANAGED_ CARE Non-managed beneficiary that is enrolled in non-managed care Beneficiary Identification code used by the HIPP unit in their internal case management Access Database. Users will enter Case ID into the 820 Phase 2 system to be used on HIPP, BCCTP and GHPP invoices Name of the non-managed program beneficiary is enrolled in HIPP, BCCTP and GHPP cases will be active or terminated. The case status determines whether invoices will be generated only for beneficiaries whose case status is 'Active'. Date of case termination for HIPP, BCCTP, and GHPP beneficiaries. After this date, the beneficiary is no longer eligible for HIPP unit payments for beneficiary Premium Payments. Audit field to denote who was the user to create non-managed beneficiary information. The Policy Number of the Beneficiary under Non-Managed care.
Case_Id
varchar(64)
True
Nonmanaged_Program_ Type_Id
smallint
False
Case_Status
varchar(32)
False
Case_Termination_Date
date
True
Audit_User
varchar(128)
False
Policy_Number
varchar(32)
True
Indexes
The following table describes the indexes on the table TB_BENEFICIARY_NONMANAGED_CARE. Name pkc_TB_BENEFICIARY_NONMANAGED_CAR E__Beneficiary_Nonmanaged_Care_Id ixn_TB_BENEFICIARY_NONMANAGED_CAR E__Beneficiary_Id ixn_TB_BENEFICIARY_NONMANAGED_CAR E__Nonmanaged_Program_Type_Id Columns Beneficiary_Nonmanaged _Care_Id Beneficiary_Id Nonmanaged_Program_ Type_Id Unique True True False Clustered True False False

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Foreign Keys
The following table describes the foreign keys on the table TB_BENEFICIARY_NONMANAGED_CARE. Name
FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_BENEFICIARY_NO NMANAGED_CARE__Beneficiary_I d FK_TB_NONMANAGED_PROGRA M_TYPE__Nonmanaged_Program_ Type_Id__TO__TB_BENEFICIARY_ NONMANAGED_CARE__Nonmana ged_Program_Type_Id FK_TB_BENEFICIARY_NONMANA GED_CARE__Beneficiary_Nonman aged_Care_Id__TO__TB_NONMAN AGED_COVERAGE__Beneficiary_ Nonmanaged_Care_Id FK_TB_BENEFICIARY_NONMANA GED_CARE__Beneficiary_Nonman aged_Care_Id_TO_TB_BENEFICIA RY_ADJUSTMENT__Beneficiary_N onmanaged_Care_Id
Column
Beneficiary_Id
Foreign Table
TB_BENEFICIARY
Foreign Column
Beneficiary_Id
Nonmanaged_Progra m_Type_Id
TB_NONMANAGED_ PROGRAM_TYPE
Nonmanaged_Program _Type_Id
TB_NONMANAGED_ COVERAGE
TB_BENEFICIARY_A DJUSTMENT
10.5.11 Table TB_CONTRACT

The TB_CONTRACT table provides high level contract details and contract change history.
Properties
The following table describes the table level properties for the table TB_CONTRACT. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT. Name Contract_Id Data Type int identity Allow Nulls False Description Unique Key of TB_CONTRACT

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Name Contract_Type_Id Contract_Number Contract_Change_Type_ Id Contract_Version
Data Type smallint varchar(32) smallint
Allow Nulls False False True
Description The type of the contract for managed care The unique number assigned to a contract Most Recent Type of Change to a Contract Unique incrementing number assigned per contract number that increments with each contract change The effective date of a contract (start date) The effective date of a contract (end date) An allocation of a set dollar amount towards a contract. Encumbrances may be made via a contract or amendment. (Never via a Change Order). Audit field to denote who was the user to create / change a contract Additional comments for when a comment is created / changed The number assigned to a contract amendment The number assigned to the contract change order A number used by DHCS accounting. This must appear on all MMCD and HIPP/BCCTP invoices. For MMCD, this number is entered on the user interface per contract. For HIPP, this number is fixed for all invoices produced by the HIPP unit. Value entered in contract management (for MMCD) and populated on the invoices. For HIPP, this is a fixed value for all invoices. Number included in all MMCD and HIPP invoice headers, used by accounting Is an advance payment on this contract Advance Payment Date Effective From Advance Payment Date Effective To
int
False
Effective_Date_From Effective_Date_To
date Date
False False
Encumbrance_Amount
money
False
Audit_User Comment Amendment_Num Change_Order_Num
varchar(128) varchar(512) varchar(32) varchar(32)
False True True True
Index
varchar(32)
True
Object
varchar(32)
True
PCA Advance_Payment Advance_Date_From Advance_Date_To
varchar(32) bit datetime datetime
True True True True

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Name
Data Type
Allow Nulls
Description Manual override performed in contract management. Overrides the Maximum Recoupment rule and distributes payments over an user-specified recoupment duration. The length of time (in months) across which a recovery of funds (recoupment) may be distributed Associates a Contract with a Policy Number
Override_Recoupment_ Cutoff
bit
True
Recoupment_Duration Policy_Num
varchar(64) varchar(64)
True True
Indexes
The following table describes the indexes on the table TB_CONTRACT. Name pkc_TB_CONTRACT__Contract_Id ixn_TB_CONTRACT__Contract_Type_Id ixn_TB_CONTRACT__Contract_Number Columns Contract_Id Contract_Type_Id Contract_Number Unique True False False Clustered True False False
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT. Name
FK_TB_CONTRACT_TYPE__Contr act_Type_Id__TO__TB_CONTRAC T__Contract_Type_Id FK_TB_CONTRACT__Contract_Id_ _TO__TB_CONTRACT_PLAN_COD E__Contract_Id FK_TB_CONTRACT__Contract_Id_ _TO__TB_CONTRACT_FUNDING__ Contract_Id FK_TB_CONTRACT__Contract_Id_ _TO__TB_VENDOR_INFO__Contra ct_Id FK_TB_CONTRACT_CHANGE_TYP E__Contract_Change_Type_Id__T O__TB_CONTRACT__Contract_Ch ange_Type_Id
Column
Contract_Type_Id
Foreign Table
TB_CONTRACT_TYP E TB_CONTRACT_PLA N_CODE TB_CONTRACT_FUN DING TB_VENDOR_INFO
Foreign Column
Contract_Type_Id
Contract_Id
Contract_Id
Contract_Id
Contract_Id
Contract_Id
Contract_Id
Contract_Change_Typ e_Id
TB_CONTRACT_CHA NGE_TYPE
Contract_Change_Type _Id

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10.5.12 Table TB_CONTRACT_CHANGE_TYPE

The TB_CONTRACT_CHANGE_TYPE table will enumerate all the possible change types to a contract (Original, Change Order, and Amendment).
Properties
The following table describes the table level properties for the table TB_CONTRACT_CHANGE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_CHANGE_TYPE. Name Contract_Change_Type_ Id Contract_Change_Type_ Name Data Type smallint identity varchar(64) Allow Nulls False False Description Unique Key of TB_CONTRACT_CHANGE_TYP E What is the type of change to the contract
Indexes
The following table describes the indexes on the table TB_CONTRACT_CHANGE_TYPE. Name pkc_TB_CONTRACT_CHANGE_TYPE__Contr act_Change_Type_Id Columns Contract_Change_Type_I d Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_CHANGE_TYPE. Name
FK_TB_CONTRACT_CHANGE_TYP E__Contract_Change_Type_Id__T O__TB_CONTRACT__Contract_Ch ange_Type_Id
Column
Contract_Change_Typ e_Id
Foreign Table
TB_CONTRACT
Foreign Column
Contract_Change_Type _Id

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10.5.13 Table TB_CONTRACT_FUNDING

The TB_CONTRACT_FUNDING table provides details of the division of funding within a contract.
Properties
The following table describes the table level properties for the table TB_CONTRACT_FUNDING. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_FUNDING. Name Contract_Funding_Id Contract_Id Funding_Amount Audit_User Contract_Funding_Type _Id Data Type int identity int money varchar(128) smallint Allow Nulls False False False False False Description Unique Key of TB_CONTRACT_FUNDING The Contract that has a funding division The amount that the Payment Type receives from the Contract Audit field to denote who was the user to create / change contract funding The Entity who is in charge of this particular funding
Indexes
The following table describes the indexes on the table TB_CONTRACT_FUNDING. Name pkc_TB_CONTRACT_FUNDING__Contract_F unding_Id ixn_TB_CONTRACT_FUNDING__Contract_Id Columns Contract_Funding_Id Contract_Id Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_FUNDING. Name
FK_TB_CONTRACT__Contract_Id_ _TO__TB_CONTRACT_FUNDING__ Contract_Id
Column
Contract_Id
Foreign Table
TB_CONTRACT
Foreign Column
Contract_Id

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Name
FK_TB_CONTRACT_FUNDING_TY PE__Contract_Funding_Type_Id__ TO__TB_CONTRACT_FUNDING__ Contract_Funding_Type_Id
Column
Contract_Funding_Typ e_Id
Foreign Table
TB_CONTRACT_FUN DING_TYPE
Foreign Column
Contract_Funding_Type _Id
10.5.14 Table TB_CONTRACT_FUNDING_TYPE

The TB_CONTRACT_FUNDING_TYPE is a reference table enumerating the funding breakdown of the encumbrance of the contract.
Properties
The following table describes the table level properties for the table TB_CONTRACT_FUNDING. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_FUNDING. Name Contract_Funding_Id Contract_Funding_Name Data Type smallint varchar(128) Allow Nulls False False Description Unique Key of TB_CONTRACT_FUNDING_TYP E The Name of the Contract Funding Entity
Indexes
The following table describes the indexes on the table TB_CONTRACT_FUNDING. Name pkc_TB_CONTRACT_FUNDING_TYPE__Contr act_Funding_Type_Id Columns Contract_Funding_Type_ Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_FUNDING. Name Column Foreign Table Foreign Column

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Name
FK_TB_CONTRACT_FUNDING_TY PE__Contract_Funding_Type_Id__ TO__TB_CONTRACT_FUNDING__ Contract_Funding_Type_Id
Column
Contract_Funding_Typ e_Id
Foreign Table
TB_CONTRACT_FUN DING
Foreign Column
Contract_Funding_Type _Id
10.5.15 Table TB_CONTRACT_PLAN_CODE

The TB_CONTRACT_PLAN_CODE table is a join table that shows the HCPs enrolled within a contract, and any potential waiver eligibility that the HCP might be under.
Properties
The following table describes the table level properties for the table TB_CONTRACT_PLAN_CODE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_PLAN_CODE. Name Contract_Plan_Code_Id Contract_Id Health_Plan_Code_Id Data Type int identity int smallint Allow Nulls False False False Description Unique Key of TB_CONTRACT_PLAN_CODE The contract under which this represents values The health care plan enrolled within the contract
Indexes
The following table describes the indexes on the table TB_CONTRACT_PLAN_CODE. Name pkc_TB_CONTRACT_PLAN_CODE__Contract _Plan_Code_Id ixn_TB_CONTRACT_PLAN_CODE__Contract _Id_Health_Care_Plan_Type_Id Columns Contract_Plan_Code_Id Contract_Id, Health_Care_Plan_Type_ Id Unique True True Clustered True False

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Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_PLAN_CODE. Name
FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_CONTRACT_PLAN_CODE __Health_Care_Plan_Type_Id FK_TB_CONTRACT__Contract_Id_ _TO__TB_CONTRACT_PLAN_COD E__Contract_Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _AID_CODE_GROUP__Contract_Pl an_Code_Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _CONTRACT_PLAN_SUPPLEMEN TAL_INFO__Contract_Plan_Code_I d FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _ADJUSTMENT__Contract_Plan_C ode_Id
Column
Health_Care_Plan_Ty pe_Id
Foreign Table
TB_HEALTH_CARE_ PLAN_TYPE
Foreign Column
Health_Care_Plan_Typ e_Id
Contract_Id
TB_CONTRACT
Contract_Id
TB_AID_CODE_GRO UP
TB_CONTRACT_PLA N_SUPPLEMENTAL_I NFO
TB_ADJUSTMENT
10.5.16 Table TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO

The TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO table is the join table showing Contract-Health Plan Eligibility for Supplemental Aid and the accompanying rates.
Properties
The following table describes the table level properties for the table TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO. Name Contract_Plan_Supplem ental_Info_Id Data Type int identity Allow Nulls False Description Unique Key of TB_CONTRACT_PLAN_SUPPLE MENTAL_INFO
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Name Supplemental_Aid_Type _Id Contract_Plan_Code_Id Payment_Type_Id Effective_Date_From Effective_Date_To Rate
Data Type smallint int smallint date date smallmoney
Allow Nulls False False False False False False
Description Supplemental Aid eligible under contract Contract / HCP eligible for supplemental aid Payment Type under which rates fall Beginning Effective Date of Supplemental Eligibility End Effective Date of Supplemental Eligibility Rate charged for Supplemental Program
Indexes
The following table describes the indexes on the table TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO. Name pkc_TB_ADJUSTMENT_Adjustment_Id ixn_TB_CONTRACT_PLAN_SUPPLEMENTAL _INFO__Supplemental_Aid_Type_Id ixn_TB_CONTRACT_PLAN_SUPPLEMENTAL _INFO__Contract_Plan_Code_Id ixn_TB_CONTRACT_PLAN_SUPPLEMENTAL _INFO__Payment_Type_Id Columns Adjustment_Id Supplemental_Aid_Type_ Id Contract_Plan_Code_Id Payment_Type_Id Unique True False False False Clustered True False False False
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_PLAN_SUPPLEMENTAL_INFO. Name
FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_CONTRACT_PLAN_SUPPL EMENTAL_INFO__Supplemental_A id_Type_Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _CONTRACT_PLAN_SUPPLEMEN TAL_INFO__Contract_Plan_Code_I d TB_PAYMENT_TYPE__Payment_T ype_Id__TO__TB_CONTRACT_PL AN_SUPPLEMENTAL_INFO__Pay ment_Type_Id
Column
Foreign Table
TB_SUPPLEMENTAL _AID_TYPE
Foreign Column
Payment_Type_Id
TB_PAYMENT_TYPE
Payment_Type_Id

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2.
Table TB_CONTRACT_TYPE
The TB_CONTRACT_TYPE table provides reference details as to what is the type of the contract.
Properties
The following table describes the table level properties for the table TB_CONTRACT_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_CONTRACT_TYPE. Name Contract_Type_Id Contract_Type_Name Data Type int varchar(128) Allow Nulls False False Description Unique Key of TB_CONTRACT_TYPE Description Details of the Contract Name
Indexes
The following table describes the indexes on the table TB_CONTRACT_TYPE. Name pkc_TB_CONTRACT_TYPE__Contract_Type_ Id Columns Contract_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_CONTRACT_TYPE. Name
FK_TB_CONTRACT_TYPE__Contr act_Type_Id__TO__TB_CONTRAC T__Contract_Type_Id FK_TB_CONTRACT_TYPE__Contr act_Type_Id__TO__TB_INVOICE_T YPE__Contract_Type_Id
Column
Contract_Type_Id
Foreign Table
TB_CONTRACT
Foreign Column
Contract_Type_Id
Contract_Type_Id
TB_INVOICE_TYPE
Contract_Type_Id
3.
Table TB_COUNTY_CODE_TYPE
The TB_COUNTY_CODE_TYPE table provides reference details of county code numbers and the counties given each number.

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Properties
The following table describes the table level properties for the table TB_COUNTY_CODE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_COUNTY_CODE_TYPE. Name County_Code_Type_Id County_Code County_Name Data Type smallint char(2) varchar(32) Allow Nulls False False False Description Unique Key of TB_COUNTY_CODE_TYPE Two-Digit Number that uniquely identifies a county Name of a County in California
Indexes
The following table describes the indexes on the table TB_COUNTY_CODE_TYPE. Name pkc_TB_COUNTY_CODE_TYPE__County_Co de_Type_Id ixn_TB_COUNTY_CODE_TYPE__County_Cod e Columns County_Code_Type_Id County_Code Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_COUNTY_CODE_TYPE. Name
FK_TB_COUNTY_CODE_TYPE__C ounty_Code_Type_Id__TO__TB_H EALTH_CARE_PLAN_TYPE__Cou nty_Code_Type_Id
Column
County_Code_Type_Id
Foreign Table
Foreign Column
County_Code_Type_Id

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10.5.17 Table TB_DATABASE_UPDATE_SCRIPT

The TB_DATABASE_UPDATE_SCRIPT table is a table required by ITSD to audit DML and DDL Changes to the OHC820 Database.
Properties
The following table describes the table level properties for the table TB_DATABASE_UPDATE_SCRIPT. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_DATABASE_UPDATE_SCRIPT. Name Database_Update_Script _Id Applied_Date_Time Script_Name Long_Description Data Type int identity datetime varchar(900) varchar(2000) Allow Nulls False False False False Description Unique Key of TB_DATABASE_UPDATE_SCRI PT Time of Script Update Name of Script Deployed Long Description details of database update script deployed
Indexes
The following table describes the indexes on the table TB_DATABASE_UPDATE_SCRIPT. Name pkc_TB_DATABASE_UPDATE_SCRIPT__Dat abase_Update_Script_Id Columns Database_Update_Script _Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_DATABASE_UPDATE_SCRIPT. Name Column Foreign Table Foreign Column

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4.
Table TB_ETHNICITY_CODE_TYPE
The TB_ETHNICITY_CODE_TYPE table is a reference table enumerating all valid ethnicity codes that come from the MEDS system.
Properties
The following table describes the table level properties for the table TB_ETHNICITY_CODE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_ETHNICITY_CODE_TYPE. Name Ethnicity_Code Ethnicity_Code_Name Data Type char(1) varchar(128) Allow Nulls False False Description Single Character Code that Uniquely Identifies an Ethnicity Code Description of the Ethnicity Code quoted from MEDS Manual
Indexes
The following table describes the indexes on the table TB_ETHNICITY_CODE_TYPE. Name pkc_TB_ETHNICITY_CODE_TYPE__Ethnicity _Code Columns Ethnicity_Code Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_ETHNICITY_CODE_TYPE. Name Column Foreign Table Foreign Column
10.5.18 Table TB_FUNDING_TYPE

The TB_FUNDING_TYPE table is a reference table that will show additional funding breakdowns per aid code groups.

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Properties
The following table describes the table level properties for the table TB_FUNDING_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_FUNDING_TYPE. Name Funding_Type_Id Funding_Type SGF_Percentage FFP_Percentage Additional_Funding_Per centage Data Type smallint varchar(64) decimal(6,3) decimal(6,3) decimal(6,3) Allow Nulls False False False False True Description Unique Key of TB_FUNDING_TYPE Name of the Funding Type State General Funding Percentage Breakdown Federal Funding Participation Percentage Breakdown Additional Federal Funding beyond FFP Percentage
Indexes
The following table describes the indexes on the table TB_FUNDING_TYPE. Name pkc_TB_FUNDING_TYPE__Funding_Type_Id Columns Funding_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_FUNDING_TYPE. Name
FK_TB_FUNDING_TYPE__Funding _Type_Id__TO__TB_AID_CODE_T YPE__Funding_Type_Id
Column
Funding_Type_Id
Foreign Table
TB_AID_CODE_TYPE
Foreign Column
Funding_Type_Id

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10.5.19 Table TB_GENDER_CODE_TYPE

The TB_GENDER_CODE_TYPE table is a reference table to hold all possible Gender Codes from MEDS.
Properties
The following table describes the table level properties for the table TB_ETHNICITY_CODE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_ETHNICITY_CODE_TYPE. Name Gender_Code Gender_Code_Name Data Type char(1) varchar(128) Allow Nulls False False Description Single Character Code that defines a gender Description of the Gender Code quoted from MEDS Manual
Indexes
The following table describes the indexes on the table TB_GENDER_CODE_TYPE. Name pkc_TB_GENDER_CODE_TYPE__Gender_Co de Columns Gender_Code Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_GENDER_CODE_TYPE. Name Column Foreign Table Foreign Column
10.5.20 Table TB_HEALTH_CARE_PLAN_TYPE

The TB_HEALTH_CARE_PLAN_TYPE table is a reference table that will store all Health Care Plan (HCP) numbers and names, and additional reference information about the HCP.

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Properties
The following table describes the table level properties for the table TB_HEALTH_CARE_PLAN_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_HEALTH_CARE_PLAN_TYPE. Name Health_Care_Plan_Type_ Id County_Code_Type_Id Health_Care_Plan_Code Health_Care_PlanName Vendor_Type_Id Model_Type_Id Notes Data Type smallint smallint char(3) varchar(128) smallint smallint varchar(255) Allow Nulls False False False False False False True Description Unique Key of TB_HEALTH_CARE_PLAN_TYP E County in which HCP is located A Unique three-digit number representing a Health Care Plan Name of the HCP Managed Care Plan name of the HCP Model Type of the HCP Additional HCP-level notes
Indexes
The following table describes the indexes on the table TB_HEALTH_CARE_PLAN_TYPE. Name pkc_TB_HEALTH_CARE_PLAN_TYPE__Healt h_Care_Plan_Type_Id ixn_TB_HEALTH_CARE_PLAN_TYPE__Healt h_Care_Plan_Code Columns Health_Care_Plan_Type_ Id Health_Care_Plan_Code Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_HEALTH_CARE_PLAN_TYPE. Name
FK_TB_COUNTY_CODE_TYPE__C ounty_Code_Type_Id__TO__TB_H EALTH_CARE_PLAN_TYPE__Cou nty_Code_Type_Id
Column
County_Code_Type_Id
Foreign Table
TB_COUNTY_CODE_ TYPE
Foreign Column
County_Code_Type_Id

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Name
FK_TB_VENDOR_TYPE__Vendor_ Type_Id__TO__TB_HEALTH_CARE _PLAN_TYPE__Vendor_Type_Id FK_TB_MODEL_TYPE__Model_Ty pe_Id__TO__TB_HEALTH_CARE_P LAN_TYPE__Model_Type_Id FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_WAIVER_TYPE__Health_ Care_Plan_Type_Id FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_CONTRACT_PLAN_CODE __Health_Care_Plan_Type_Id FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_INVOICE_DETAIL__Healt h_Care_Plan_Type_Id
Column
Vendor_Type_Id
Foreign Table
TB_VENDOR_TYPE
Foreign Column
Vendor_Type_Id
Model_Type_Id
TB_MODEL_TYPE
Model_Type_Id
TB_WAIVER_TYPE
TB_VOICE_DETAIL
10.5.21 Table TB_INVOICE

The TB_INVOICE table holds all invoice information, a physical copy of the invoice, and all invoicerelated information received in the CMS64 and CD102 files.
Properties
The following table describes the table level properties for the table TB_INVOICE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_INVOICE. Name Invoice_Id Invoice_Number Creation_Date Capitation_Month Data Type int identity bigint datetime date Allow Nulls False True False False Description Unique Key of TB_INVOICE Unique, system-generated consecutive number of the approved invoice Timestamp invoice was created Capitation Day and Month of the Invoice

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Name Invoice_Amount Invoice_Archive_Locatio n Payment_Date Fiscal_Year Sequence_Number Claim_Schedule_Numbe r Warrant_Id Invoice_Type_Id Contract_Plan_Code_Id Warrant_Number
Data Type money varchar(1024) datetime varchar(9) varchar(16) varchar(20) int smallint int bigint
Allow Nulls True True True True True True True False False True
Description Actual Amount on the Finalized Invoice Name / Path to the location of the Archived Invoice Date Invoice was paid (from CMS64) Fiscal Year of Payment (from CMS64) CMS64 Sequence Number of the Invoice Claim Schedule Number assigned to the invoice from accounting (from CMS64) Check Warrant Number from CD102 File to the Invoice The type of the invoice The contract details under which this invoice falls Calculated Warrant Number to the Invoice
Indexes
The following table describes the indexes on the table TB_INVOICE. Name pkc_TB_INVOICE__Invoice_Id ixn_TB_INVOICE__Warrant_Id ixn_TB_INVOICE__Invoice_Number ixn_TB_INVOICE__Claim_Schedule_Number Columns Invoice_Id Warrant_Id Invoice_Number Claim_Schedule_Number Unique True False False False Clustered True False False False
Foreign Keys
The following table describes the foreign keys on the table TB_INVOICE. Name
FK_TB_INVOICE_TYPE__Invoice_T ype_Id__TO__TB_INVOICE__Invoic e_Type_Id FK_TB_WARRANT__Warrant_Id__ TO__TB_INVOICE__Warrant_Id FK_TB_INVOICE__Invoice_Id__TO __TB_INVOICE_STATUS__Invoice_ Id
Column
Invoice_Type_Id Warrant_Id Invoice_Id
Foreign Table
TB_INVOICE_TYPE TB_WARRANT TB_INVOICE_STATU S
Foreign Column
Invoice_Type_Id Warrant_Id Invoice_Id

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Name
FK_TB_INVOICE__Invoice_Id__TO __TB_INVOICE_DETAILS__Invoice _Id FK_TB_CONTRACT_PLAN_CODE_ _Contract_Plan_Code_Id__TO__TB _INVOICE__Contract_Plan_Code_I d
Column
Invoice_Id
Foreign Table
TB_INVOICE_DETAIL S TB_CONTRACT_PLA N_CODE
Foreign Column
Invoice_Id
10.5.22 Table TB_INVOICE_CHANGE_TYPE

The TB_INVOICE_CHANGE_TYPE table is a reference Table to hold all possible values for change type in the TB_INVOICE_DETAIL Table.
Properties
The following table describes the table level properties for the table TB_INVOICE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS Dbo
Columns
The following table describes the columns in the table TB_INVOICE_CHANGE_TYPE. Name Change_Type Change_Type_Name Data Type char(1) varchar(128) Allow Nulls False False Description Single Character Key that uniquely defines TB_INVOICE_CHANGE_TYPE Description of Invoice Change
Indexes
The following table describes the indexes on the table TB_INVOICE_CHANGE_TYPE. Name pkc_TB_INVOICE_CHANGE_TYPE__Change_ Type Columns Change_Type Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_INVOICE_CHANGE_TYPE.

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Name
Column
Foreign Table
Foreign Column
10.5.23 Table TB_INVOICE_DETAIL

The TB_INVOICE_DETAIL table holds all monthly beneficiary capitation data and all resulting invoice payment details.
Properties
The following table describes the table level properties for the table TB_INVOICE_DETAIL. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_INVOICE_DETAIL. Name Beneficiary_Id Invoice_Id Service_Month Aid_Code_Group_Type_I d Aid_Code_Type_Id Health_Care_Plan_Type_ Id Amount Rate Data Type int int date smallint int int smallmoney smallmoney Allow Nulls False False False False False False False False Description Beneficiary for which these invoice details apply Invoice under which beneficiary is paid The month of service in which these changes are effective Aid code group under which beneficiary is eligible Aid code under which beneficiary is eligible Health Care Plan under which beneficiary is enrolled Amount to be Paid to Beneficiary in Capitation Period Rate at which Beneficiary is paid in capitation period Change Type is Enumerated Value to say Invoice Change Type ('N' for New Month, 'R' for Rate Change, 'E' for Elig Change)
Change_Type
char(1)
False

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Indexes
The following table describes the indexes on the table TB_INVOICE_DETAIL. Name pkc_TB_INVOICE_DETAIL__Beneficiary_Id__I nvoice_Id__Change_Type__Effective_Month ixn_TB_INVOICE_DETAIL__Aid_Code_Group _Type_Id ixn_TB_INVOICE_DETAIL__Aid_Code_Type_I d ixn_TB_INVOICE_DETAIL__Effective_Month ixn_TB_INVOICE_DETAIL__Health_Care_Plan _Type_Id Columns Beneficiary_Id, Invoice_Id, Change_Type, Effective_Month Aid_Code_Group_Type_I d Aid_Code_Type_Id Effective_Month Health_Care_Plan_Type_ Id Unique True Clustered True
False False False False
False False False False
Foreign Keys
The following table describes the foreign keys on the table TB_INVOICE_DETAIL. Name
FK_TB_INVOICE__Invoice_Id__TO __TB_INVOICE_DETAILS__Invoice _Id FK_TB_AID_CODE_TYPE__Aid_Co de_Type_Id__TO__TB_INVOICE_D ETAIL__Aid_Code_Type_Id FK_TB_AID_CODE_GROUP_TYPE __Aid_Code_Group_Type_Id__TO_ _TB_INVOICE_DETAIL__Aid_Code _Group_Type_Id FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_INVOICE_DETAIL__Healt h_Care_Plan_Type_Id FK_TB_BENEFICIARY__Beneficiar y_Id__TO__TB_INVOICE_DETAIL_ _Beneficiary_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_INVOICE_DE TAILS__Payment_Type_Id
Column
Invoice_Id
Foreign Table
TB_INVOICE
Foreign Column
Invoice_Id
Aid_Code_Type_Id
TB_AID_CODE_TYPE
Aid_Code_Type_Id
TB_AID_CODE_GRO UP_TYPE
TB_HEALTH_CARE_ PLAN_TYPE_ID
Beneficiary_Id
TB_BENEFICIARY
Beneficiary_Id
TB_PAYMENT_TYPE
Payment_Type_Id
TB_PAYMENT_TYPE
10.5.24 Table TB_INVOICE_STATUS

The TB_INVOICE_STATUS table will hold the status lifecycle of all invoices processed.
Properties
The following table describes the table level properties for the table TB_INVOICE_STATUS.

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Columns
The following table describes the columns in the table TB_INVOICE_STATUS. Name Invoice_Status_Id Invoice_Id Status_Date Audit_User Status_Type_Id Comments Data Type int identity int datetime varchar(128) smallint varchar(1024) Allow Nulls False False False False False True Description Unique Key of TB_INVOICE_STATUS Invoice receiving the status Timestamp of the invoice status Audit field to denote who was the last user to create invoice status. Can be System User. Status of the Invoice Additional Comments on the Invoice Status
Indexes
The following table describes the indexes on the table TB_INVOICE_STATUS. Name pkc_TB_INVOICE_STATUS__Invoice_Status_I d ixn_TB_INVOICE_STATUS__Invoice_Id_Statu s_Type_Id Columns Invoice_Status_Id Invoice_Id, Status_Type_Id Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_INVOICE_STATUS. Name
FK_TB_INVOICE__Invoice_Id__TO __TB_INVOICE_STATUS__Invoice_ Id FK_TB_STATUS_TYPE__Status_T ype_Id__TO__TB_INVOICE_STATU S__Status_Type_Id
Column
Invoice_Id
Foreign Table
TB_INVOICE
Foreign Column
Invoice_Id
Status_Type_Id
TB_STATUS_TYPE
Status_Type_Id

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10.5.25 Table TB_INVOICE_TYPE

The TB_INVOICE_TYPE table contains the various possible reference types of invoices.
Properties
The following table describes the table level properties for the table TB_INVOICE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_INVOICE_TYPE. Name Invoice_Type_Id Data Type smallint Allow Nulls False Description Unique Key of TB_INVOICE_TYPE Synonymous with Payment Type. An invoice is generated per contract, per HCP, per State Fiscal Year, and per Payment Type. The Invoice's Contract Type The Payment Method Used for the invoice The Supplemental Aid Type of the Invoice for Supplemental Invoices Flag to determine if Invoice is a Healthy-Family Specific Invoice Name of Nonmanaged Care Program for Nonmanaged Invoices For Nonmanaged Care Invoices, Flag to determine if Invoice is to a Single Beneficiary
Invoice_Type_Name
varchar(128)
False
Contract_Type_Id Payment_Type_Id Supplemental_Aid_Type _Id Healthy_Families_Type Nonmanaged_Program_ Type_Id Single_Beneficiary_Invoi ce_Type
smallint smallint smallint bit smallint
False False True False True
bit
False
Indexes
The following table describes the indexes on the table TB_INVOICE_TYPE. Name pkc_TB_INVOICE_TYPE___Invoice_Type_Id Columns Invoice_Type_Id Unique True Clustered True

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Foreign Keys
The following table describes the foreign keys on the table TB_INVOICE_TYPE. Name
FK_TB_INVOICE_TYPE__Invoice_T ype_Id__TO__TB_INVOICE__Invoic e_Type_Id FK_TB_CONTRACT_TYPE__Contr act_Type_Id__TO__TB_INVOICE_T YPE__Contract_Type_Id FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_INVOICE_TYPE__Supplem ental_Aid_Type_Id FK_TB_INVOICE_TYPE__Invoice_T ype_Id__TO__TB_ADJUSTMENT__ Invoice_Type_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_INVOICE_TYP E__Payment_Type_Id FK_TB_NONMANAGED_PROGRA M_TYPE__Nonmanaged_Program_ Type_Id__TO__TB_INVOICE_TYPE __Nonmanaged_Program_Type_Id
Column
Invoice_Type_Id
Foreign Table
TB_INVOICE TB_CONTRACT_TYP E TB_SUPPLEMENTAL _AID_TYPE
Foreign Column
Invoice_Type_Id
Contract_Type_Id
Contract_Type_Id
Invoice_Type_Id
TB_ADJUSTMENT
Invoice_Type_Id
Payment_Type_Id
TB_PAYMENT_TYPE
Payment_Type_Id
10.5.26 Table TB_MODEL_TYPE

The TB_MODEL_TYPE is a reference table to hold to details about the Model / Sub-Model Type of a HCP. If a HCP has both a model and a sub-model, the FK constraint will be from TB_HEALTH_CARE_PLAN_TYPE to TB_MODEL_TYPE for the sub-model, then the sub-model will have a self-referential FK constraint to a parent model type.
Properties
The following table describes the table level properties for the table TB_MODEL_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_MODEL_TYPE. Name Model_Type_Id Data Type smallint Allow Nulls False Description Unique Key of TB_MODEL_TYPE

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Name Model_Name Dental_Flag
Data Type varchar(128) bit
Description Name of the Model/Sub-Model Type For dental models and submodels, this flag is '1', else this flag is '0' If entry is a sub-model type, this value will refer to the Model_Type_Id of the regular Model Type
Primary_Model_Type_Id
smallint
True
Indexes
The following table describes the indexes on the table TB_MODEL_TYPE. Name pkc_TB_MODEL_TYPE__Model_Type_Id Columns Model_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_MODEL_TYPE. Name
FK_TB_MODEL_TYPE__Primary_M odel_Type_Id__TO__TB_MODEL_T YPE__Model_Tyspe_Id FK_TB_MODEL_TYPE__Model_Ty pe_Id__TO__TB_HEALTH_CARE_P LAN_TYPE__Model_Type_Id
Column
Primary_Model_Type_ Id Model_Type_Id
Foreign Table
TB_MODEL_TYPE TB_HEALTH_CARE_ PLAN_TYPE
Foreign Column
Model_Type_Id
Model_Type_Id
10.5.27 Table TB_NONMANAGED_COVERAGE

The TB_NONMANAGED_COVERAGE gives coverage information for beneficiaries enrolled in a nonmanaged care program.
Properties
The following table describes the table level properties for the table TB_NONMANAGED_COVERAGE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo

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Columns
The following table describes the columns in the table TB_NONMANAGED_COVERAGE. Name Nonmanaged_Coverage _Id Vendor_Info_Id Beneficiary_Nonmanage d_Care_Id Nonmanaged_Coverage _Type_Id Group_Number Policy_Number Data Type int identity int int smallint varchar(32) varchar(32) Allow Nulls False False False False True True Description Unique Key of TB_NONMANAGED_COVERAGE Vendor who is responsible for the non-managed coverage Beneficiary who is enrolled in the non-managed plan The type of non-managed coverage Medical, Dental, or Vision Insurance Group Number The policy number of the beneficiary enrolled in nonmanaged care coverage The date on which a beneficiary's insurance policy becomes effective. A beneficiary's policy must be effective in order for a premium payment to be made. The final date on which a beneficiary's insurance policy is effective. A beneficiary's policy must be effective in order for a premium payment to be made. The Date when a beneficiary's Premium Payment is due The Payment Amount due per a beneficiary's insurance policy Used to determine how often the payment will be made System calculates monthly payment amount based on Premium Amount and Payment Frequency
Policy_Start_Date
date
True
Policy_Stop_Date
date
True
Premium_Due_Date Premium_Amount Payment_Frequency Monthly_Premium_Amo unt
date money varchar(32)
True True True
money
True
Indexes
The following table describes the indexes on the table TB_NONMANAGED_COVERAGE. Name pkc_TB_NONMANAGED_COVERAGE__Nonm anaged_Coverage_Id ixn_TB_NONMANAGED_COVERAGE__Vendo r_Info_Id ixn_TB_NONMANAGED_COVERAGE__Benefi ciary_Nonmanaged_Care_Id Columns Nonmanaged_Coverage_ Id Vendor_Info_Id Beneficiary_Nonmanaged _Care_Id Unique True False False Clustered True False False

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Foreign Keys
The following table describes the foreign keys on the table TB_NONMANAGED_COVERAGE. Name
FK_TB_BENEFICIARY_NONMANA GED_CARE__Beneficiary_Nonman aged_Care_Id__TO__TB_NONMAN AGED_COVERAGE__Beneficiary_ Nonmanaged_Care_Id FK_TB_NONMANAGED_COVERAG E_TYPE__Nonmanaged_Coverage _Type_Id__TO__TB_NONMANAGE D_COVERAGE__Nonmanaged_Co verage_Type_Id FK_TB_VENDOR_INFO__Vendor_I nfo_Id__TO__TB_NONMANAGED_ COVERAGE__Vendor_Info_Id
Column
Foreign Table
Foreign Column
Nonmanaged_Covera ge_Type_Id
TB_NONMANAGED_ COVERAGE_TYPE
Nonmanaged_Coverag e_Type_Id
Vendor_Info_Id
TB_VENDOR_INFO
Vendor_Info_Id
10.5.28 Table TB_NONMANAGED_COVERAGE_TYPE

The TB_NONMANAGED_COVERAGE_TYPE is a small reference table to hold all the non-managed care coverage types.
Properties
The following table describes the table level properties for the table TB_NONMANAGED_COVERAGE_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_NONMANAGED_COVERAGE_TYPE. Name Nonmanaged_Coverage _Type_Id Coverage_Name Data Type smallint varchar(64) Allow Nulls False False Description Unique Key of TB_NONMANAGED_COVERAGE _TYPE Name of the Coverage (Medical, Dental, or Vision)

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Indexes
The following table describes the indexes on the table TB_NONMANAGED_COVERAGE_TYPE. Name pkc_TB_NONMANAGED_COVERAGE_TYPE_ _Nonmanaged_Coverage_Type_Id Columns Nonmanaged_Coverage_ Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_NONMANAGED_COVERAGE_TYPE. Name
FK_TB_NONMANAGED_COVERAG E_TYPE__Nonmanaged_Coverage _Type_Id__TO__TB_NONMANAGE D_COVERAGE__Nonmanaged_Co verage_Type_Id FK_TB_NONMANAGED_COVERAG E_TYPE__Nonmanaged_Coverage _Type_Id__TO__TB_NONMANAGE D_VENDOR_COVERAGE__Nonma naged_Coverage_Type_Id
Column
Foreign Table
TB_NONMANAGED_ COVERAGE
Foreign Column
TB_NONMANAGED_ VENDOR_COVERAG E
10.5.29 Table TB_NONMANAGED_PROGRAM_TYPE

The TB_NONMANAGED_PROGRAM_TYPE is a reference table to hold the names of the nonmanaged care program types (HIPP / BCCTP).
Properties
The following table describes the table level properties for the table TB_NONMANAGED_PROGRAM_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_NONMANAGED_PROGRAM_TYPE. Name Nonmanaged_Program_ Type_Id Data Type smallint Allow Nulls False Description Unique Key of TB_NONMANAGED_PROGRAM _TYPE

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Name Nonmanaged_Program_ Name
Data Type varchar(128)
Allow Nulls False
Description Name of the Non-managed care program
Indexes
The following table describes the indexes on the table TB_NONMANAGED_PROGRAM_TYPE. Name pkc_TB_NONMANAGED_PROGRAM_TYPE__ Nonmanaged_Program_Type_Id Columns Nonmanaged_Program_ Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_NONMANAGED_PROGRAM_TYPE. Name
FK_TB_NONMANAGED_PROGRA M_TYPE__Nonmanaged_Program_ Type_Id__TO__TB_BENEFICIARY_ NONMANAGED_CARE__Nonmana ged_Program_Type_Id FK_TB_NONMANAGED_PROGRA M_TYPE__Nonmanaged_Program_ Type_Id__TO__TB_INVOICE_TYPE __Nonmanaged_Program_Type_Id
Column
Foreign Table
Foreign Column
10.5.30 Table TB_NONMANAGED_VENDOR_COVERAGE

The TB_NONMANAGED_VENDOR_COVERAGE table is a join table to establish the eligibility of coverage types for Non-Managed Care Vendors.
Properties
The following table describes the table level properties for the table TB_NONMANAGED_VENDOR_COVERAGE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_NONMANAGED_VENDOR_COVERAGE.

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Name Nonmanaged_Coverage _Type_Id Vendor_Info_Id
Data Type smallint int
Description Partial Unique Key referencing the Non-managed Coverage Type Reference Table Partial Unique Key referencing the Vendor Info Table
Indexes
The following table describes the indexes on the table TB_NONMANAGED_VENDOR_COVERAGE. Name pkc_TB_NONMANAGED_VENDOR_COVERA GE___Nonmanaged_Coverage_Type_Id__Ven dor_Info_Id Columns Nonmanaged_Coverage_ Type_Id, Vendor_Info_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_NONMANAGED_VENDOR_COVERAGE. Name
FK_TB_NONMANAGED_COVERAG E_TYPE__Nonmanaged_Coverage _Type_Id__TO__TB_NONMANAGE D_VENDOR_COVERAGE__Nonma naged_Coverage_Type_Id FK_TB_VENDOR_INFO__Vendor_I nfo_Id__TO__TB_NONMANAGED_ VENDOR_COVERAGE__Nonmana ged_Vendor_Coverage_Id
Column
Foreign Table
TB_NONMANAGED_ COVERAGE_TYPE
Foreign Column
Vendor_Info_Id
TB_VENDOR_INFO
Vendor_Info_Id
10.5.31 Table TB_PAYMENT_TYPE

The TB_PAYMENT_TYPE table is a reference table responsible for holding all the various types of payment types possible.
Properties
The following table describes the table level properties for the table TB_PAYMENT_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo

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Columns
The following table describes the columns in the table TB_PAYMENT_TYPE. Name Payment_Type_Id Data Type smallint Allow Nulls False Description Unique Key of TB_PAYMENT_TYPE The method use to pay a plan , distinguished by multiple factors, including funding sources, number of months included, and type of eligibility
Payment_Type
varchar(64)
False
Indexes
The following table describes the indexes on the table TB_PAYMENT_TYPE. Name pkc_TB_PAYMENT_TYPE__Payment_Type_Id Columns Payment_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_PAYMENT_TYPE. Name
TB_PAYMENT_TYPE__Payment_T ype_Id__TO__TB_CONTRACT_PL AN_SUPPLEMENTAL_INFO__Pay ment_Type_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_PLAN_CODE _ON_PAYMENT_TYPE__Payment_ Type_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_INVOICE_TYP E__Payment_Type_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_INVOICE_DE TAILS__Payment_Type_Id
Column
Payment_Type_Id
Foreign Table
TB_CONTRACT_PLA N_SUPPLEMENTAL_I NFO TB_PLAN_CODE_ON _PAYMENT_TYPE
Foreign Column
Payment_Type_Id
Payment_Type_Id
Payment_Type_Id
Payment_Type_Id
TB_INVOICE_TYPE TB_INVOICE_DETAIL S
Payment_Type_Id
Payment_Type_Id
Payment_Type_Id
10.5.32 Table TB_PLAN_CODE_ON_PAYMENT_TYPE

The TB_PLAN_CODE_ON_PAYMENT_TYPE is a join table showing eligibility and rates for aid code groups on payment types.

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Properties
The following table describes the table level properties for the table TB_PLAN_CODE_ON_PAYMENT_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_PLAN_CODE_ON_PAYMENT_TYPE. Name Plan_Code_On_Payment _Type_Id Aid_Code_Group_Id Payment_Type_Id Rate Data Type int identity int smallint smallmoney Allow Nulls False False False False Description Unique Key of TB_PLAN_CODE_ON_PAYMENT _TYPE The Aid Code Group for a defined contract The payment type receiving this rate The rate to be paid for this aid code group on this contract
Indexes
The following table describes the indexes on the table TB_PLAN_CODE_ON_PAYMENT_TYPE. Name pkc_TB_PLAN_CODE_ON_PAYMENT_TYPE_ _Plan_Code_On_Payment_Type_Id ixn_TB_PLAN_CODE_ON_PAYMENT_TYPE__ Aid_Code_Group_Id__Payment_Type_Id Columns Plan_Code_On_Payment _Type_Id Aid_Code_Group_Id, Payment_Type_Id Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_PLAN_CODE_ON_PAYMENT_TYPE. Name
FK_TB_AID_CODE_GROUP__Aid_ Code_Group_Id__TO__TB_PLAN_ CODE_ON_PAYMENT_TYPE__Aid _Code_Group_Id FK_TB_PAYMENT_TYPE__Paymen t_Type_Id__TO__TB_PLAN_CODE _ON_PAYMENT_TYPE__Payment_ Type_Id
Column
Aid_Code_Group_Id
Foreign Table
TB_AID_CODE_GRO UP
Foreign Column
Aid_Code_Group_Id
Payment_Type_Id
TB_PAYMENT_TYPE
Payment_Type_Id

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10.5.33 Table TB_STAGING_BENEFICIARY

The TB_STAGING_BENEFICIARY table is a staging table that will only hold temporary staging data as part of the capitation data loading process.
Properties
The following table describes the table level properties for the table TB_STAGING_BENEFICIARY. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_STAGING_BENEFICIARY. Name Staging_Beneficiary_Id Client_Index_Number Meds_Renewal_Date Last_Name First_Name Middle_Initial Date_Of_Birth_St Date_Of_Death_St Death_Posted_Date_St Alien_Indicator Ethnic_Code Gender Last_Modified_Date Data Type bigint identity char(9) char(6) char(20) char(15) char(1) char(8) char(8) char(8) char(1) char(1) char(1) char(8) Allow Nulls False False False False False True True True True True True True True Description Unique Key of TB_STAGING_BENEFICIARY Representation of Client Index Number from Capitation File Representation of MEDS Renewal Date from Capitation File Representation of Last Name from Capitation File Representation of First Name from Capitation File Representation of Middle Initial from Capitation File Representation of Date of Birth from Capitation File Representation of Date of Death from Capitation File Representation of Date Death Posted from Capitation File Representation of Alien Indicator from Capitation File Representation of Ethnic Code from Capitation File Representation of Gender from Capitation File Representation of Last Modified Date from Capitation File

- 225 -
Indexes
The following table describes the indexes on the table TB_STAGING_BENEFICIARY. Note, the indexes are considered temporary as they are often dropped and re-built as a part of the bulk load process. Name pkc_TB_STAGING_BENEFICIARY__Staging_ Beneficiary_Id IXN_TB_STAGING_BENEFICIARY__Client_In dex_Number Columns Staging_Beneficiary_Id Client_Index_Number Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_STAGING_BENEFICIARY. Name
FK_TB_STAGING_BENEFICIARY__ Staging_Beneficiary_Id__TO__TB_ STAGING_MONTHLY_INFO__Stagi ng_Beneficiary_Id
Column
Staging_Beneficiary_Id
Foreign Table
TB_STAGING_MONT HLY_INFO
Foreign Column
10.5.34 Table TB_STAGING_MONTHLY_INFO

The TB_STAGING_MONTHLY_INFO table is a staging table that will only hold temporary staging data as part of the capitation data loading process.
Properties
The following table describes the table level properties for the table TB_STAGING_MONTHLY_INFO. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_STAGING_MONTHLY_INFO. Name Staging_Monthly_Info_Id Staging_Beneficiary_Id Data Type bigint identity bigint Allow Nulls False False Description Unique Key of TB_STAGING_MONTHLY_INFO Foreign Key (Non-Constraint) of Staging Monthly Info to Staging Beneficiary Table

- 226 -
Name Monthly_Offset HCP_Plan1 HCP_Status1 HCP_Aid1 HCP_Plan2 HCP_Status2 HCP_Aid2 HCP_Plan3 HCP_Status3 HCP_Aid3 HCP_Plan4 HCP_Status4 HCP_Aid4 HCP_Plan5 HCP_Status5 HCP_Aid5 Medicare_PartA Medicare_PartB Medicare_PartD
Data Type tinyint char(3) char(2) char(2) char(3) char(2) char(2) char(3) char(2) char(2) char(3) char(2) char(2) char(3) char(2) char(2) char(1) char(1) char(1)
Allow Nulls False True True True True True True True True True True True True True True True True True True
Description Offset of monthly information for a beneficiary, counted from 0 to 12 Representation of HCP Plan 1 from Capitation File Representation of HCP Status 1 from Capitation File Representation of HCP Aid 1 from Capitation File Representation of HCP Plan 2 from Capitation File Representation of HCP Status 2 from Capitation File Representation of HCP Aid 2 from Capitation File Representation of HCP Plan 3 from Capitation File Representation of HCP Status 3 from Capitation File Representation of HCP Aid 3 from Capitation File Representation of HCP Plan 4 from Capitation File Representation of HCP Status 4 from Capitation File Representation of HCP Aid 4 from Capitation File Representation of HCP Plan 5 from Capitation File Representation of HCP Status 5 from Capitation File Representation of HCP Aid 5 from Capitation File Representation of HCP Medicare Part A from Capitation File Representation of HCP Medicare Part B from Capitation File Representation of HCP Medicare Part D from Capitation File
Indexes
The following table describes the indexes on the table TB_STAGING_MONTHLY_INFO. Note, the indexes are considered temporary as they are often dropped and re-built as a part of the bulk load process. Name pkc_TB_STAGING_MONTHLY_INFO__Stagin g_Monthly_Info_Id Columns Staging_Monthly_Info_Id Unique True Clustered True

- 227 -
Name IXN_TB_STAGING_MONTHLY_INFO__Stagin g_Beneficiary_Id
Columns Staging_Beneficiary_Id Monthly_Offset
Unique False
Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_STAGING_MONTHLY_INFO. Name
FK_TB_STAGING_BENEFICIARY__ Staging_Beneficiary_Id__TO__TB_ STAGING_MONTHLY_INFO__Stagi ng_Beneficiary_Id
Column
Foreign Table
TB_STAGING_BENEF ICIARY
Foreign Column
5.
Table TB_STATUS_TYPE Properties
The TB_STATUS_TYPE table is a reference table holding the values of all possible status types.
The following table describes the table level properties for the table TB_STATUS_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_STATUS_TYPE. Name Status_Type_Id Status_Name Date_Created Date_Deleted Audit_User Managed_Care Nonmanaged_Care Data Type smallint varchar(128) datetime datetime varchar(128) bit bit Allow Nulls False False False True False False False Description Unique Key of TB_STATUS_TYPE Descriptive Phrase of a Status Creation Date of the Status For Unused Statuses, deleted date of the status type User who created the Status Type Flag to determine if status is possible for Managed Care Flag to determine if status is possible for Nonmanaged Care

- 228 -
Indexes
The following table describes the indexes on the table TB_STATUS_TYPE. Name pkc_TB_STATUS_TYPE__Status_Type_Id Columns Status_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_STATUS_TYPE. Name
FK_TB_STATUS_TYPE__Status_T ype_Id__TO__TB_INVOICE_STATU S__Status_Type_Id
Column
Status_Type_Id
Foreign Table
TB_INVOICE_STATU S
Foreign Column
Status_Type_Id
10.5.35 Table TB_SUPPLEMENTAL_AID_TYPE

The TB_SUPPLEMENTAL_AID_TYPE table is a reference table that enumerates all supplemental aid types.
Properties
The following table describes the table level properties for the table TB_SUPPLEMENTAL_AID_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS Dbo
Columns
The following table describes the columns in the table TB_SUPPLEMENTAL_AID_TYPE. Name Supplemental_Aid_Type _Id Supplemental_Aid_Nam e Beneficiary_Eligible_Fla g Data Type smallint varchar(64) bit Allow Nulls False False True Description Unique Key of TB_SUPPLEMENTAL_AID_TYPE Name of the Supplemental Aid TBD, related to beneficiaries being eligible for supplemental aid

- 229 -
Indexes
The following table describes the indexes on the table TB_SUPPLEMENTAL_AID_TYPE. Name pkc_TB_SUPPLEMENTAL_AID_TYPE__Suppl emental_Aid_Type_Id Columns Supplemental_Aid_Type_ Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_SUPPLEMENTAL_AID_TYPE. Name
FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_BENE_SUPPLEMENTAL_I NFO__Supplemental_Aid_Type_Id FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_CONTRACT_PLAN_SUPPL EMENTAL_INFO__Supplemental_A id_Type_Id FK_TB_SUPPLEMENTAL_AID_TYP E__Supplemental_Aid_Type_Id__T O__TB_INVOICE_TYPE__Supplem ental_Aid_Type_Id
Column
Foreign Table
TB_BENE_SUPPLEM ENTAL_INFO
Foreign Column
TB_CONTRACT_PLA N_SUPPLEMENTAL_I NFO
TB_INVOICE_TYPE
10.5.36 Table TB_VENDOR_INFO

The TB_VENDOR_INFO table holds additional vendor-specific information for vendors to be paid in the 820 invoice.
Properties
The following table describes the table level properties for the table TB_VENDOR_INFO. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_VENDOR_INFO. Name Vendor_Info_Id Data Type int identity Allow Nulls False Description Unique Key of TB_VENDOR_INFO

- 230 -
Name Address City Zip State Contract_Manager_Nam e_First Contract_Manager_Nam e_Last Contract_Manager_Phon e Other_Address Other_City Other_Zip Other_State Other_Contract_Manage r_Name_First Other_Contract_Manage r_Name_Last Other_Contract_Manage r_Phone Vendor_Code Contract_Id EIN Organization_Name Nonmanaged_Vendor_T ype
Data Type varchar(128) varchar(64) varchar(9) varchar(2) varchar(64) varchar(64) varchar(20) varchar(128) varchar(64) varchar(9) varchar(2) varchar(64) varchar(64) varchar(20) varchar(16) int varchar(9) varchar(128)
Allow Nulls False False False True True True True True True True True True True True False False True True
Description Primary Vendor Address Primary Vendor City Primary Vendor Zip Code Primary Vendor State Abbreviation Vendor Contract Manager First Name Vendor Contract Manager Last Name Vendor Contract Manager Phone Number Secondary Contact Address Secondary Contact City Secondary Contact Zip Code Secondary Contact State Secondary Contract First Name of Contract Manager Secondary Contract Last Name of Contract Manager Secondary Contract Phone Number of Contract Manager Unique alphanumeric ID assigned per contract by Accounting Division Contract to which this vendor info applies Federal Taxpayer EIN for the Vendor Name of the Vendor Organization HIPP, BCCTP and GHPP vendors may be an Insurance Company, an Insurance Carrier, an Employer, a Beneficiary Representative, or a Beneficiary HIPP, BCCTP and GHPP vendors will have a status of Active or Terminated (Represented as 1 or 0) Payment Type information for Non-managed care vendor First Name for Non-managed care vendor Last Name for Non-managed care vendor
varchar(64)
True
Nonmanaged_Vendor_St atus Payment_Type Name_First Name_Last
bit
True
varchar(64) varchar(64) varchar(64)
True True True

- 231 -
Indexes
The following table describes the indexes on the table TB_VENDOR_INFO. Name pkc_TB_VENDOR_INFO__Vender_Info_Id ixn_TB_VENDOR_INFO__Contract_Id Columns Vendor_Info_Id Contract_Id Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_VENDOR_INFO. Name
FK_TB_CONTRACT__Contract_Id_ _TO__TB_VENDOR_INFO__Contra ct_Id
Column
Contract_Id
Foreign Table
TB_CONTRACT
Foreign Column
Contract_Id
10.5.37 Table TB_VENDOR_TYPE

The TB_VENDOR_TYPE table is a reference table to hold the names of all managed care companies enrolled in managed care.
Properties
The following table describes the table level properties for the table TB_VENDOR_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_VENDOR_TYPE. Name Vendor_Type_Id EIN Vendor_Type_Name Data Type smallint varchar(9) varchar(128) Allow Nulls False True False Description Unique Key of TB_VENDOR_TYPE Federal Taxpayer EIN Managed Care Company Name

- 232 -
Indexes
The following table describes the indexes on the table TB_VENDOR_TYPE. Name pkc_TB_VENDOR_TYPE__Vendor_Type_Id Columns Vendor_Type_Id Unique True Clustered True
Foreign Keys
The following table describes the foreign keys on the table TB_VENDOR_TYPE. Name
FK_TB_VENDOR_TYPE__Vendor_ Type_Id__TO__TB_HEALTH_CARE _PLAN_TYPE__Vendor_Type_Id
Column
Vendor_Type_Id
Foreign Table
Foreign Column
Vendor_Type_Id
10.5.38 Table TB_WAIVER_TYPE

The TB_WAIVER_TYPE is a reference table to hold waiver information and how they relate to health care plans.
Properties
The following table describes the table level properties for the table TB_WAIVER_TYPE. Property Collation Schema Value SQL_Latin1_General_CP1_CI_AS dbo
Columns
The following table describes the columns in the table TB_WAIVER_TYPE. Name Waiver_Type_Id Waiver_Name Data Type int identity varchar(128) Allow Nulls False False Description Unique Key of TB_WAIVER_TYPE Name of the Waiver Program

- 233 -
Name
Data Type
Allow Nulls
Description Number of the waiver. Waiver Number = Standard 1915(b) Waiver coding system: a) State Code; b) Two-digit waiver number; c) R+Two-digit waiver renewal number (changes upon renewal, approx. 2 years); and d) Two-digit consecutive waiver year (changes each July). Waiver Effective Date Waiver Effective Termination Date The percentage of the population covered under a State's waiver program. This percentage is annually recalculated by FAU. The Health Care Plan to which this Waiver applies
Waiver_Number
varchar(32)
False
Effective_Date_From Effective_Date_To Waiver_Percentage Health_Care_Plan_Type_ Id
date date decimal(6,3)
False True False
smallint
False
Indexes
The following table describes the indexes on the table TB_WAIVER_TYPE. Name pkc_TB_WAIVER_TYPE__Waiver_Type_Id ixn_TB_WAIVER_TYPE__Health_Care_Plan_T ype_Id Columns Waiver_Type_Id Health_Care_Plan_Type_ Id Unique True False Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_WAIVER_TYPE. Name
FK_TB_HEALTH_CARE_PLAN_TY PE__Health_Care_Plan_Type_Id__ TO__TB_WAIVER_TYPE__Health_ Care_Plan_Type_Id
Column
Foreign Table
Foreign Column
10.5.39 Table TB_WARRANT

The TB_WARRANT table holds warrant information from the CD102 file.
Properties
The following table describes the table level properties for the table TB_WARRANT.

- 234 -
Columns
The following table describes the columns in the table TB_WARRANT. Name Warrant_Id Claim_Schedule_Numbe r Warrant_Number_Begin Warrant_Number_End Warrant_Date Warrant_Amount Data Type int identity varchar(20) bigint bigint date money Allow Nulls False False False False False False Description Unique Key of TB_WARRANT Claim Schedule Number assigned to the invoice from accounting (from CD102) Beginning Warrant Number assigned to claim schedule End Warrant Number assigned to claim schedule The Date of the Warrant The Total Amount on the Warrant
Indexes
The following table describes the indexes on the table TB_WARRANT. Name pkc_TB_WARRANT__Warrant_Id ixn_TB_WARRANT__Claim_Schedule_Numbe r Columns Warrant_Id Claim_Schedule_Number Unique True True Clustered True False
Foreign Keys
The following table describes the foreign keys on the table TB_WARRANT. Name
FK_TB_WARRANT__Warrant_Id__ TO__TB_INVOICE__Warrant_Id
Column
Warrant_Id
Foreign Table
TB_INVOICE
Foreign Column
Warrant_Id

- 235 -
10.6 User Permissions

The following subsections describe the different usage scenarios and associated user permissions required to successfully implement the 820 Phase 2 database design.
10.6.1
Extraction / Transformation / Loading (ETL)
The following permissions are required in order to execute either SQL XML Bulk Load or SQL Server Integration Services: CONNECT ALTER o For each schema associated with a table associated with ETL CREATE TABLE o For each table associated with ETL INSERT o For each table associated with ETL UPDATE o For each table associated with ETL SELECT o For each table associated with ETL
10.6.2
Business Processing
The following permissions are required in order to conduct regular system business processing: CONNECT EXECUTE o On each stored procedure used in the database
10.6.3
Reporting
The following permissions are required in order to conduct regular system business processing: CONNECT EXECUTE o On each stored procedure used in reporting

- 236 -
Appendix B Process Model

- 237 -
Comment # 1
Reviewer Initials WL
Design Specifications Issues/Concerns Page Section Will file layouts for input files be included so that we know what data is being brought into the system? Will there be back-ups of input files and if so, how long do they need to be retained? The may be instances where data in the database may need to be recreated from the input files, so they should be retained for an appropriate time period.
Resolution (to be completed by Vendor) The details for the input files are containted in Use cases 1.1 & 3.1
State Response
Okay All MMCD, CMS64, CD102 Files will be locally stored for 36 months, will be locally archived in archive files for 72 months, then will be stored on appropriate backup medium beyond 72 months.
WL
3 4
WL WL 46 9
Okay Will there be front-end edits run against the input files to determine if Front End Edits will be testing for validity of input files. Missing fields fields are missing or invalid or files are duplicate files? will be reported as a front end error. Empty fields will be reported as a processing error. Because files can be re-dropped to re-process entries, duplicate files are ignored by the system, but will enter processing. Okay Will there be an error table for the error conditions? Error conditions are incorporated in code. Error code table will be added to M&A plan. Okay- add to M&A plan The data fields in the data dictionary follow SQL Data Types and do Shouldn't size, valid values, field formats (e.g. date format is MMDDYYYY), and calculations (if a field is calculated) be included in include size when appropriate. For a detailed description of SQL Data Types, information can be found on the MSDN web site at the data dictionary? http://msdn.microsoft.com/en-us/library/ms187752(SQL.90).aspx. Okay In the Level 1 Context Diagram and the Level 2 Context Diagram the Change from Vendor to Payment Recipient will be made. word "Vendor" should be changed to something more descriptive such as "Health Plan" or "Payment Recipient" "It will provide calculations on a beneficiary level." Descriptions throughout the design specifications mention calculations. Where are the actual calculations stored? They need to be documented somehow so that they can be reviewed at a later date if nec All calculations are performed at runtime so the calculations are not saved anywhere. However, results of calculation are saved in tb_invoice, tb_invoice_detail tables. Calculation of each invoice and storage of calculation results have been covered in InvoiceManagement.doc.
WL
131
Appendix A
AS
8&9
2.1 & 2.2
Okay
AS
14 et al
4.1
Okay
Various descriptions mention archiving and files that will be archived. The process of retrieving archived files will be adressed in the Where exactly will archived files be stored and for how long? What is Maintainence and Administration plan. Archive process needs to be the process for retrieving an archived file or document? Page 24 has defined by DHCS. another callout to the "predetermined archiv 3 AS 21, 24 5.1.1 When invoices don't match, an error will be reported as status on the Exception: Invoices Do Not Match - exceptions are reported to the system administrator. Who is the system administrator and is this the invoice. The Capitation Unit will be able to see the error on the user interface on the Invoice screen. person(s) that the Capitation Unit wants to perform the review? 4 AS 24 5.2.1 User Platform - Vendor should clarify the minimum version of Adobe Updated document to include refrence to Information Technology Reader and Microsoft Office that is compatible with CapMan as has Hardware and Software Standards and supported software versions. been done with Internet Explorer 6.0+. Actually, the minimum version required for all software applications should be cons 5 AS 108 10.1.4 Analyst Platform - non-standard software is required. What will be done if the non-standard software is not approved? 6 7 AS AS 107 26 10.1.3 More details on the SFTP interface are needed. 5.4 Okay From the list of approved software (Information Technology Hardware and Software Standards), SpecBuilder is the only software product that is not a listed standard. However, TR 0616 mandates the use of SpecBuilder. Okay The details for the SFTP interface are containted in Use case 1.1 Okay Okay- add to M&A plan Okay
AS
28, 112, 129
5.4.1 and 10.4.1
The details for the SFTP interface are contained in Use case 1.1. Page 28 states "All 820 files are sent to the SFTP interface where they are then forwarded to the corresponding recipients." Are the files The scope of responsibility of the 820 Phase 2 system ends with the delivery of the 820 EDI transactions to the SFTP server. actually forwarded or simply put on the SFTP server in a repository for pickup? It would seem from page 112 that Pla Okay Microsoft's Membership Providers will be used to handle user Where in the design specifications does it outline the levels of user access? There are various points in the document that describe that access. users need appropriate roles and rights, for example to run reports, but I couldn't find anything that outlined the Okay Is BizTalk Server 2009 supported by ITSD. Version 2004 and 2006 had been used in the past but need to confirm they will support the latest Microsoft version. ITSD policy requires password changes on a routine basis (every 90 days, I think). How are password changes on the SFTP services going to be coordinated with outside groups (e.g. MEDS interface partner, etc.) that need to write to these accounts? BizTalk 2009 server is supported by ITSD. Okay The SFTP account for the MEDS interface will be set to not expire, following ITSD's practice of system to system communication. The Maintenance and Administration Plan (TR-0628) will address password changes. Okay The Security Section does not provide a detailed look at the threat model for the system and how each threat is being addressed. For example, the security section is missing a discussion of the use of HTTPS protocol within the different environments. The use and details of methods used to encrypt the network communications (certificates, authorities, etc.) is needed. THe 820 Phase 2 application is located behind the DMZ in the DHCS intranet and not exposed to the extranet. Users are authenticated against the DHCS intranet active directory and are required to be listed on the LDAP server. Since the application is behind the firewall HTTPS is not required. Okay The security section is missing a discussion on the security accounts The SQL server security is dictated by DHCS ITSD standards. SQL for the servers (impersonation policy, SQL login accounts, database server accounts are allocated and assigned by ITSD to projects. roles, security protocol betweeen servers such as IPSEC etc.) How are these security assets protected? What are the ITSD policies that need to be met? Who will be responsible for changing server security credetials? etc.?
AS
98,189
9.22.1 and 10.6
10
CC
62
10.1.1
11
CC
10.4
12
CC
10.4
13
CC
10.4 The Use Case - Design Specification Traceablity Matrix does not have sufficient detail to be support traceablity back to specific requirements (functional and technical) The design specification is based of the requirements document, so the traceability should reflect that. Each sub-section in the Business Object section also traces what sections were used in the Requirements document.
Okay
14
CC
Okay
In diagrams, the component 'User Interface' does not make sense. A Since a majority of system workflow is centered around the user user interface is a design concept rather than a system component. interface, Trinity Technology Group recomends leaving the 'User Interface' in the context diagram. In discussions, it was indicated that component was actually CAPMAN. The diagrams should represent that for clarity. 15 CC 8 2.2 Okay
The document is lacking in details on Error and Exception Handling. Exceptions based on the use cases have been incorporated into A document detailing design to this level should include a discussion section 6. Add exception conditions to M&A plan on the specifics of this important topic. Details are needed on the methods, mechanisms and processes used to perform exception handling at every level of the application (BIZTALK, ASP.NET, SQL SERVER, etc.) A list of all error messages should be included as an appendix and should include details on what each message means and how to diagnose or correct the errors. 16 CC The document is lacking in details on auditing and logging procsses. Details are needed on the frequency and format of logs. Details on the format and content of each log should be provided. 17 CC The document is lacking in details on the standards compliances required and how the system will meet these standards. For example, there is no discussion on coding standards/guidelines/conventions, code comment policy, module development standards, use of object oriented programming standards, design patterns, etc. More detail is needed to enable proper validation of the source code and conformance checking can be completed. The 820 Phase 2 application must adhere to the publised ITSD coding standards. The standards documents are: WAA Addendum for WCF and WWF.doc, ITSD BizTalk Application Standards DRAFT.doc, Database Coding Standard and Guideline.doc, and CDHS Web Application Architecture V5.doc. Log details will be provided in the Maintenance and Administration Plan Okay- add to M&A plan Okay- add to M&A plan
18
CC
Okay
It is noted within Section 9 in numerous places that "the page is ADA Updated the document to include the Watch Fire Web XM tool that compliant and conforms to the ADA standards". There is no design ITSD uses to check web sites for ADA compliance. URL: http://dhssaccots03/WatchfireWebXm/FolderExplorer.aspx?fid=54 considerations mentioned or details on how "ADA standards" are met. ADA compliance and assessiblity standards are a very complex subject involving levels of sccessiblity being met by any application. No system is simply ADA compliant - there are agreed upon levels of assessiblity that a system will meet. More detail on the standards being met and the processes used to conform to those standards are needed. 19 CC 9 The document is lacking in detail on the patterns and practices to be used when constructing the system. The section does mention use of the Microsoft Entity Framework for the Data Objects but there is limited design for the solution architecture in general. I would expect to see a section detailing how the solution will be structured - files and folders, projects and solutions, details on tiers and separation of functionality (business rules, edits, logging, exception handling, etc.), module cohesion/coupling, module reuse, data persistence, object oriented programming usage, design patterns, Microsoft Patterns and Practices, etc. 19 20 21 CC CC CC 38 7 10.2 6 Still not clear on the use/requirement for Microsoft InfoPath 2007 on the BizTalk servers. No discussion provided. Issues with Section 6 and level of detail have been communicated and are being worked by vendor. Microsoft InfoPath 2007 is a prerequisite for BizTalk installation. Okay Details have been added to section 6. Okay Section six indicates that the appliaction is designed and developed utlizing Object Oriented Deisgn methodologies, the section has also been updated to include greater detail regarding the design of the objects. The M&A plan will include a tree structure for the source code file management. Okay
Okay- add to M&A plan
22
GR
23,24
5.2.1
System enters an exception state if invoice information is incomplete for unpaid invoices in the 820 Phase 2 system. The exception is reported to the system administrator and the orchestration instance is suspended awaiting further review. Diagram shows intervention required. How is the intervention going to be handled? Is there a user interface? If the number of warrants associated with the Claim Schedule Number does not equal the number of unique vendor codes for the all invoices within the Claim Schedule, then system updates the status of all invoices to CD102 Payment Error. System generates the following payment error notification for each invoice with status of CD102 Payment Error:CD102 Payment Error Number of Warrants [##] on CD102 for Claim Schedule Number [##] is not equal to Number of Vendors [##] for the Claim Schedule in System. User must enter a payment error adjustment. How is a payment error adjustment going to help if the dollar amount is correct? How can the number of warrants be synced up with the number of unique vendor codes?
When invoices don't match, an error will be reported as status on the invoice. The Capitation Unit will be able to see the error on the user interface on the Invoice screen. Add exception conditions to M&A plan Okay- add to M&A plan When entered, this adjustment balances the warrant amount to the invoice amount and generates a new invoice to make up for the difference (the amount that was either overpaid or underpaid). The range of warrants coming in on the CD102 file with the schedule number will be matched with the schedule number from the CMS64 file. The CMS64 file will then contain the vendor codes.
23
GR
31
6.1.1.1 If an 820 transaction does not pass SNIP validations, system halts processing of the transaction and posts SNIP Error Report. System logs an error for System Administrator. How will these errors be resolved? Is there a UI? This section is also numbered in correctly in document (1.1.1.1) Since the 820 system creates the EDI file, this will mean that there is an application error that needs to be resolved. The BizTalk orchestartion that creates the EDI file will then have to be restarted (by an administrator).
24
GR
57
6.5.1.1
25
GR
The documents list several automated processes that are halted due Biztalk allows a process to restart through its administration tool. No to an error occuring. How are these processes re-started? Is there cleanup has to happen after an error. sometype of cleanup that is going to need to occur before restart of a process?

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820 Phase 2 Design Specifications

California Department of Health Care Services 820 Phase 2

Document Id: Version: 1.3 Date: December 9, 2009

Project Identifier: 820 Phase 2 DHCS Project Manager: Curtis Milberger

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

10-20-2009 11-09-2009 12-09-2009

1.1 1.2 1.3

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

2 System Context Diagram

2.1 Level 1 Context Diagram

Level 1 Context Diagram

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

2.2 Level 2 Context Diagram

Capitation File SCO

Accounting CMS64 Payment Beneficiaries Contracts Invoices

Remittance Generation User Interface

820 Remittance Advice

Contract/Invoices Beneficiaries/Invoices Reports

Managed Care User

Non-Managed Care User

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

3 820 System Activity Diagram

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

Shape Receive Capitation File

Load into Staging Tables

Approve Invoices Wait for Payments

Receive CMS64 File

Receive CD102 File

Match Invoices To Payment

Create Payment Remittance Advice

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

4.1 Component Diagram

California Department of Health Care Services, 820 Phase 2 System, 2009

820 Phase 2 Design Specifications

user interface NonManagedCareUI

user interface ManagedCareUI

orchestration ProcessPayment business layer ReportMgmt

business layer ContractMgmt

business layer InvoiceMgmt

business layer CapitationMgmt

business layer BeneficiaryMgmt

business layer PaymentMgmt