Invoice Validation (Secondary Care, PbR, Pathways, SCG, etc.)

This module processes secondary care activity data at patient level in SUS or SLAM format and applies it against a large number of validation rules. Locally agreed schemas e.g. SLAM columns are auto-detected in run-time allowing flexibility in data layout. The spell level output by provider contains details of why the spell failed. The default rules-set has the following categories:

Data Quality (Poor quality, Duplicate Spell, missing fields, etc.)

Low Priority Procedures or PPwT (verifies against prior approval list)

Pathway (duplicate OPFAs, DCs within spell, contiguous spells, etc.)

PbR (PbR variation, local tariffs if provided)

Refundable Spells (e.g. Road Traffic Accident)

Specialist Activity (SSNDS 3.4, HCD validation)

Each category has permutations of a rule e.g. Low Priority Procedures runs over 100 sub-rules and Specialist Activity runs over 16,000 sub-rules.