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					Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                          CHIMES                                                                                                                    Page 1
Version #1
1/7/2011


                                                                                                                                                                                                                         USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                             APPROVAL




                                                                                                                                                                                                   Date Change from
                                                                                                                                                                                                   Prev Version
  Ref
 Code   Ref Code                                                                  Field/Attribute/Function/   Requirement Description               Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                            Item/Response               "The system shall…"                   Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE               1   Web Page Incurment            Navigation           Navigation                  Allow access to this web page                       Design
                                        Bill/Payment Entry                                                    from a menu

INCUR   IBPE               2   Web Page Incurment            Navigation           Navigation                  Allow access to this web page                       Design
                                        Bill/Payment Entry                                                    as part of the incurment
                                                                                                              navigation flow
INCUR   IBPE               3   Web Page Incurment            Security             Security                    Allow only users within the same                    Design
                                        Bill/Payment Entry                                                    jurisdiction as the worker
                                                                                                              currently assigned to the case,
                                                                                                              supervisors in any counties
                                                                                                              within the same jurisdiction as
                                                                                                              the worker currently assigned to
                                                                                                              the case, or users with
                                                                                                              statewide update authority to
                                                                                                              update information.

INCUR   IBPE               4   Web Page Incurment            Filing Unit          Person Name                 Display the description                             Design      PCR 64
                                        Bill/Payment Entry                                                    '(DEEMED)' after the persons
                                                                                                              name for anyone who is a
                                                                                                              deemed individual
INCUR   IBPE               5   Web Page Incurment            Filing Unit          Person Name                 Only display deemed individuals                     Design      PCR 64
                                        Bill/Payment Entry                                                    if the deemed individuals
                                                                                                              income is greater than $0.00

INCUR   IBPE               6   Web Page Incurment            Filing Unit          Other Filing Unit           Display the filing unit for each                    Design
                                        Bill/Payment Entry                        Members                     household member that has an
                                                                                                              incurment
INCUR   IBPE               7   Web Page Incurment            Filing Unit          Other Filing Unit           Allow the user to view the first,                   Design
                                        Bill/Payment Entry                        Members                     middle, and last names of each
                                                                                                              filing unit member
INCUR   IBPE               8   Web Page Incurment            Insurance Premiums   Insurance Premiums          Allow user to view, modify, add,                    Design
                                        Bill/Payment Entry                                                    and remove insurance
                                                                                                              premiums for a person
INCUR   IBPE               9   Web Page Incurment            Insurance Premiums   Default Number of Rows      Retrieve and display the Health                     Design
                                        Bill/Payment Entry                                                    Insurance premium information
                                                                                                              for a person
INCUR   IBPE           10      Web Page Incurment            Insurance Premiums   Sort Order                  Sort chronologically by the                         Design
                                        Bill/Payment Entry                                                    Month Premium Due with the
                                                                                                              oldest date listed first
INCUR   IBPE           11      Web Page Incurment            Insurance Premiums   Default Number of Rows      Default the number of rows to                       Design
                                        Bill/Payment Entry                                                    one enterable row

INCUR   IBPE           12      Web Page Incurment            Insurance Premiums   Insurance Premiums          Protect Insurance Premium data                      Design
                                        Bill/Payment Entry                                                    from modifications if it is carried
                                                                                                              over from the previous month

INCUR   IBPE           13      Web Page Incurment            Insurance Premiums   Person Name                 Allow user to select Person                         Design
                                        Bill/Payment Entry                                                    Name from a predefined list

INCUR   IBPE           14      Web Page Incurment            Insurance Premiums   Benefit Month Entered       Benefit Month Entered is read                       Design      PCR 59
                                        Bill/Payment Entry                                                    only

INCUR   IBPE           15      Web Page Incurment            Insurance Premiums   Benefit Month Entered       Populate the Benefit Month                          Design      PCR 59
                                        Bill/Payment Entry                                                    Entered field with the given
                                                                                                              benefit month and year when a
                                                                                                              bill/payment is entered for the
                                                                                                              first time and saved
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                          CHIMES                                                                                     Page 2
Version #1
1/7/2011



REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                  Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                            Item/Response               "The system shall…"                   Comments
INCUR   IBPE               1   Web Page Incurment            Navigation           Navigation                  Allow access to this web page
                                        Bill/Payment Entry                                                    from a menu

INCUR   IBPE               2   Web Page Incurment            Navigation           Navigation                  Allow access to this web page
                                        Bill/Payment Entry                                                    as part of the incurment
                                                                                                              navigation flow
INCUR   IBPE               3   Web Page Incurment            Security             Security                    Allow only users within the same
                                        Bill/Payment Entry                                                    jurisdiction as the worker
                                                                                                              currently assigned to the case,
                                                                                                              supervisors in any counties
                                                                                                              within the same jurisdiction as
                                                                                                              the worker currently assigned to
                                                                                                              the case, or users with
                                                                                                              statewide update authority to
                                                                                                              update information.

INCUR   IBPE               4   Web Page Incurment            Filing Unit          Person Name                 Display the description
                                        Bill/Payment Entry                                                    '(DEEMED)' after the persons
                                                                                                              name for anyone who is a
                                                                                                              deemed individual
INCUR   IBPE               5   Web Page Incurment            Filing Unit          Person Name                 Only display deemed individuals
                                        Bill/Payment Entry                                                    if the deemed individuals
                                                                                                              income is greater than $0.00

INCUR   IBPE               6   Web Page Incurment            Filing Unit          Other Filing Unit           Display the filing unit for each      Person Name, Other Filing Unit Members
                                                                                                                                                    Display only first names
                                        Bill/Payment Entry                        Members                     household member that has an
                                                                                                              incurment
INCUR   IBPE               7   Web Page Incurment            Filing Unit          Other Filing Unit           Allow the user to view the first,
                                        Bill/Payment Entry                        Members                     middle, and last names of each
                                                                                                              filing unit member
INCUR   IBPE               8   Web Page Incurment            Insurance Premiums   Insurance Premiums          Allow user to view, modify, add,      Person Name, Benefit Month Entered, Month Premium
                                        Bill/Payment Entry                                                    and remove insurance                  Due, Provider, Client Responsibility.
                                                                                                                                                    Is anything required?
                                                                                                              premiums for a person
INCUR   IBPE               9   Web Page Incurment            Insurance Premiums   Default Number of Rows      Retrieve and display the Health       The client responsibility amount will be the only editable
                                                                                                                                                    item for the row
                                        Bill/Payment Entry                                                    Insurance premium information
                                                                                                              for a person
INCUR   IBPE           10      Web Page Incurment            Insurance Premiums   Sort Order                  Sort chronologically by the
                                        Bill/Payment Entry                                                    Month Premium Due with the
                                                                                                              oldest date listed first
INCUR   IBPE           11      Web Page Incurment            Insurance Premiums   Default Number of Rows      Default the number of rows to
                                        Bill/Payment Entry                                                    one enterable row

INCUR   IBPE           12      Web Page Incurment            Insurance Premiums   Insurance Premiums          Protect Insurance Premium data
                                        Bill/Payment Entry                                                    from modifications if it is carried
                                                                                                              over from the previous month

INCUR   IBPE           13      Web Page Incurment            Insurance Premiums   Person Name                 Allow user to select Person
                                        Bill/Payment Entry                                                    Name from a predefined list

INCUR   IBPE           14      Web Page Incurment            Insurance Premiums   Benefit Month Entered       Benefit Month Entered is read
                                        Bill/Payment Entry                                                    only

INCUR   IBPE           15      Web Page Incurment            Insurance Premiums   Benefit Month Entered       Populate the Benefit Month
                                        Bill/Payment Entry                                                    Entered field with the given
                                                                                                              benefit month and year when a
                                                                                                              bill/payment is entered for the
                                                                                                              first time and saved
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                       CHIMES                                                                                                                    Page 3
Version #1
1/7/2011


                                                                                                                                                                                                                      USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                          APPROVAL




                                                                                                                                                                                                Date Change from
                                                                                                                                                                                                Prev Version
  Ref
 Code   Ref Code                                                               Field/Attribute/Function/   Requirement Description               Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                            Item/Response               "The system shall…"                   Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE           16   Web Page Incurment            Insurance Premiums   Month Premium Due           Validate the health insurance                       Design
                                     Bill/Payment Entry                                                    Month Premium Due date
                                                                                                           (month/year) is greater than
                                                                                                           three months prior to the first
                                                                                                           day of the benefit currently
                                                                                                           being viewed.
INCUR   IBPE           17   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate the Client                    5/4/2007     Design
                                     Bill/Payment Entry                                                    Responsibility is numeric

INCUR   IBPE           18   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate any amount fields             5/4/2007     Design
                                     Bill/Payment Entry                                                    entered are not greater than the
                                                                                                           maximum amount allowed in the
                                                                                                           amount field
INCUR   IBPE           19   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate any amount fields have        5/4/2007     Design
                                     Bill/Payment Entry                                                    only 2 numbers after the
                                                                                                           decimal point
INCUR   IBPE           20   Web Page Incurment            Insurance Premiums   Client Responsibility       Disallow all letters and               5/4/2007     Design
                                     Bill/Payment Entry                                                    punctuation or special
                                                                                                           characters other than comma,
                                                                                                           decimal, and numbers when
                                                                                                           entering an expense amount.
INCUR   IBPE           21   Web Page Incurment            Insurance Premiums   Insurance Premiums          Require the entire row to be           5/4/2007     Design
                                     Bill/Payment Entry                                                    filled out before saving if any
                                                                                                           field within the row is entered
INCUR   IBPE           22   Web Page Incurment            Insurance Premiums   Add Rows                    Provide the ability to add             5/4/2007     Design
                                     Bill/Payment Entry                                                    Insurance Premiums rows.

INCUR   IBPE           23   Web Page Incurment            Insurance Premiums   Add Rows                    Provide the ability to enter how       5/4/2007     Design
                                     Bill/Payment Entry                                                    many Insurance Premiums rows
                                                                                                           to add.
INCUR   IBPE           24   Web Page Incurment            Insurance Premiums   Add Rows                    Default the number of rows to          5/4/2007     Design
                                     Bill/Payment Entry                                                    add to one.

INCUR   IBPE           25   Web Page Incurment            Insurance Premiums   Add Rows                    When the Add button is                 5/4/2007     Design
                                     Bill/Payment Entry                                                    pressed, the indicated # of rows
                                                                                                           to add will be displayed.
INCUR   IBPE           26   Web Page Incurment            Insurance Premiums   Remove Insurance            Provide the ability to remove          5/4/2007     Design
                                     Bill/Payment Entry                        Premiums                    Insurance Premiums rows.

INCUR   IBPE           27   Web Page Incurment            Insurance Premiums   Remove Insurance            Require an Insurance Premium           5/4/2007     Design
                                     Bill/Payment Entry                        Premiums                    row to be selected for removal
                                                                                                           when pressing the Remove
                                                                                                           button.
INCUR   IBPE           28   Web Page Incurment            Insurance Premiums   Remove Insurance            Present the user with one blank        5/4/2007     Design
                                     Bill/Payment Entry                        Premiums                    Insurance Premium row if all
                                                                                                           other Insurance Premium rows
                                                                                                           are removed.
INCUR   IBPE           29   Web Page Incurment            Medical Bills        Medical Bills               Allow user to view, modify, add,                    Design
                                     Bill/Payment Entry                                                    and remove medical bills for a
                                                                                                           person




INCUR   IBPE           30   Web Page Incurment            Medical Bills        Medical Bills               Protect Medical Bill data from                      Design
                                     Bill/Payment Entry                                                    modifications if it is carried over
                                                                                                           from the previous month
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                       CHIMES                                                                                Page 4
Version #1
1/7/2011



REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                               Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                            Item/Response               "The system shall…"                   Comments
INCUR   IBPE            1
                       16   Web Page Incurment            NavigationPremiums
                                                          Insurance            Navigation
                                                                               Month Premium Due           Allow accesshealth insurance
                                                                                                           Validate the to this web page
                                     Bill/Payment Entry                                                    from a Premium Due date
                                                                                                           Month menu
                                                                                                           (month/year) is greater than
                                                                                                           three months prior to the first
                                                                                                           day of the benefit currently
                                                                                                           being viewed.
INCUR   IBPE           17   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate the Client
                                     Bill/Payment Entry                                                    Responsibility is numeric

INCUR   IBPE           18   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate any amount fields
                                     Bill/Payment Entry                                                    entered are not greater than the
                                                                                                           maximum amount allowed in the
                                                                                                           amount field
INCUR   IBPE           19   Web Page Incurment            Insurance Premiums   Client Responsibility       Validate any amount fields have
                                     Bill/Payment Entry                                                    only 2 numbers after the
                                                                                                           decimal point
INCUR   IBPE           20   Web Page Incurment            Insurance Premiums   Client Responsibility       Disallow all letters and
                                     Bill/Payment Entry                                                    punctuation or special
                                                                                                           characters other than comma,
                                                                                                           decimal, and numbers when
                                                                                                           entering an expense amount.
INCUR   IBPE           21   Web Page Incurment            Insurance Premiums   Insurance Premiums          Require the entire row to be
                                     Bill/Payment Entry                                                    filled out before saving if any
                                                                                                           field within the row is entered
INCUR   IBPE           22   Web Page Incurment            Insurance Premiums   Add Rows                    Provide the ability to add
                                     Bill/Payment Entry                                                    Insurance Premiums rows.

INCUR   IBPE           23   Web Page Incurment            Insurance Premiums   Add Rows                    Provide the ability to enter how
                                     Bill/Payment Entry                                                    many Insurance Premiums rows
                                                                                                           to add.
INCUR   IBPE           24   Web Page Incurment            Insurance Premiums   Add Rows                    Default the number of rows to
                                     Bill/Payment Entry                                                    add to one.

INCUR   IBPE           25   Web Page Incurment            Insurance Premiums   Add Rows                    When the Add button is
                                     Bill/Payment Entry                                                    pressed, the indicated # of rows
                                                                                                           to add will be displayed.
INCUR   IBPE           26   Web Page Incurment            Insurance Premiums   Remove Insurance            Provide the ability to remove
                                     Bill/Payment Entry                        Premiums                    Insurance Premiums rows.

INCUR   IBPE           27   Web Page Incurment            Insurance Premiums   Remove Insurance            Require an Insurance Premium
                                     Bill/Payment Entry                        Premiums                    row to be selected for removal
                                                                                                           when pressing the Remove
                                                                                                           button.
INCUR   IBPE           28   Web Page Incurment            Insurance Premiums   Remove Insurance            Present the user with one blank
                                     Bill/Payment Entry                        Premiums                    Insurance Premium row if all
                                                                                                           other Insurance Premium rows
                                                                                                           are removed.
INCUR   IBPE           29   Web Page Incurment            Medical Bills        Medical Bills               Allow user to view, modify, add,      Person Name, Benefit Month Entered, Date of Service,
                                                                                                                                                 Provider, Provider Number, Client Responsibility, Not
                                     Bill/Payment Entry                                                    and remove medical bills for a
                                                                                                                                                 Covered by Medicaid indicator, Applies Only to Reduce
                                                                                                           person                                the VA-Aid & Attendence indicator.
                                                                                                                                                 Is anything required? Database is Date of Service,
                                                                                                                                                 Provider, Bill Amount


INCUR   IBPE           30   Web Page Incurment            Medical Bills        Medical Bills               Protect Medical Bill data from
                                     Bill/Payment Entry                                                    modifications if it is carried over
                                                                                                           from the previous month
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                  CHIMES                                                                                                                  Page 5
Version #1
1/7/2011


                                                                                                                                                                                                               USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                   APPROVAL




                                                                                                                                                                                         Date Change from
                                                                                                                                                                                         Prev Version
  Ref
 Code   Ref Code                                                          Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                       Item/Response               "The system shall…"                 Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE           31   Web Page Incurment            Medical Bills   Medical Bills               Bills/Payments will only be                       Design      PCR 59
                                     Bill/Payment Entry                                               applied to reduce the incurment
                                                                                                      from the benefit month entry
                                                                                                      date forward therfore,
                                                                                                      bills/payments must be entered
                                                                                                      in the earliest month that they
                                                                                                      are going to be applied

INCUR   IBPE           32   Web Page Incurment            Medical Bills   Sort Order                  Sort medical bills                                Design
                                     Bill/Payment Entry                                               chronologically by the date of
                                                                                                      service (oldest records first)
INCUR   IBPE           33   Web Page Incurment            Medical Bills   Default Number of Rows      Defautlt the number of rows to                    Design
                                     Bill/Payment Entry                                               six

INCUR   IBPE           34   Web Page Incurment            Medical Bills   Person Name                 Allow user to select Person                       Design
                                     Bill/Payment Entry                                               Name from a predefined list

INCUR   IBPE           35   Web Page Incurment            Medical Bills   Benefit Month               Benefit Month Entered is read                     Design      PCR 59
                                     Bill/Payment Entry                                               only

INCUR   IBPE           36   Web Page Incurment            Medical Bills   Benefit Month               Populate the Benefit Month                        Design      PCR 59
                                     Bill/Payment Entry                                               Entered field with the given
                                                                                                      benefit month and year when a
                                                                                                      bill/payment is entered for the
                                                                                                      first time and saved
INCUR   IBPE           37   Web Page Incurment            Medical Bills   Date of Service             Validate the date of service is                   Design
                                     Bill/Payment Entry                                               greater than three months prior
                                                                                                      to the first day of the benefit
                                                                                                      month currently being viewed
INCUR   IBPE           38   Web Page Incurment            Medical Bills   Provider                    Provide ability to search for                     Design
                                     Bill/Payment Entry                                               Providers

INCUR   IBPE           39   Web Page Incurment            Medical Bills   Provider                    Display "Provider Search" in the                  Design
                                     Bill/Payment Entry                                               provider field if no provider has
                                                                                                      been defined. If a provider has
                                                                                                      been defined the provider field
                                                                                                      will display provider name
INCUR   IBPE           40   Web Page Incurment            Medical Bills   Provider                    Display 'Non-Participating                        Design
                                     Bill/Payment Entry                                               Provider' under the providers
                                                                                                      name if provider is not found in
                                                                                                      the provider list provided by ACS

INCUR   IBPE           41   Web Page Incurment            Medical Bills   Provider                    Allow the user to view details of                 Design
                                     Bill/Payment Entry                                               a provider by clicking the
                                                                                                      provider name
INCUR   IBPE           42   Web Page Incurment            Medical Bills   Provider Number             Allow the user to enter a                         Design
                                     Bill/Payment Entry                                               provider number for a medical
                                                                                                      bill. If the provider number is
                                                                                                      valid the provider field will be
                                                                                                      populated with the appropriate
                                                                                                      value. If the provider number is
                                                                                                      not valid, an error message will
                                                                                                      be displayed
INCUR   IBPE           43   Web Page Incurment            Medical Bills   Client Responsibility       Display the word 'Carryover'                      Design
                                     Bill/Payment Entry                                               before the amount in the Client
                                                                                                      Responsibility field for any
                                                                                                      amounts that have been carried
                                                                                                      over
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                  CHIMES                                                                            Page 6
Version #1
1/7/2011



REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                          Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                       Item/Response               "The system shall…"                 Comments
INCUR   IBPE            1
                       31   Web Page Incurment            Navigation
                                                          Medical Bills   Navigation
                                                                          Medical Bills               Allow access towill only be
                                                                                                      Bills/Payments this web page
                                     Bill/Payment Entry                                               from a menu
                                                                                                      applied to reduce the incurment
                                                                                                      from the benefit month entry
                                                                                                      date forward therfore,
                                                                                                      bills/payments must be entered
                                                                                                      in the earliest month that they
                                                                                                      are going to be applied

INCUR   IBPE           32   Web Page Incurment            Medical Bills   Sort Order                  Sort medical bills
                                     Bill/Payment Entry                                               chronologically by the date of
                                                                                                      service (oldest records first)
INCUR   IBPE           33   Web Page Incurment            Medical Bills   Default Number of Rows      Defautlt the number of rows to
                                     Bill/Payment Entry                                               six

INCUR   IBPE           34   Web Page Incurment            Medical Bills   Person Name                 Allow user to select Person
                                     Bill/Payment Entry                                               Name from a predefined list

INCUR   IBPE           35   Web Page Incurment            Medical Bills   Benefit Month               Benefit Month Entered is read
                                     Bill/Payment Entry                                               only

INCUR   IBPE           36   Web Page Incurment            Medical Bills   Benefit Month               Populate the Benefit Month
                                     Bill/Payment Entry                                               Entered field with the given
                                                                                                      benefit month and year when a
                                                                                                      bill/payment is entered for the
                                                                                                      first time and saved
INCUR   IBPE           37   Web Page Incurment            Medical Bills   Date of Service             Validate the date of service is
                                     Bill/Payment Entry                                               greater than three months prior
                                                                                                      to the first day of the benefit
                                                                                                      month currently being viewed
INCUR   IBPE           38   Web Page Incurment            Medical Bills   Provider                    Provide ability to search for
                                     Bill/Payment Entry                                               Providers

INCUR   IBPE           39   Web Page Incurment            Medical Bills   Provider                    Display "Provider Search" in the
                                     Bill/Payment Entry                                               provider field if no provider has
                                                                                                      been defined. If a provider has
                                                                                                      been defined the provider field
                                                                                                      will display provider name
INCUR   IBPE           40   Web Page Incurment            Medical Bills   Provider                    Display 'Non-Participating
                                     Bill/Payment Entry                                               Provider' under the providers
                                                                                                      name if provider is not found in
                                                                                                      the provider list provided by ACS

INCUR   IBPE           41   Web Page Incurment            Medical Bills   Provider                    Allow the user to view details of
                                     Bill/Payment Entry                                               a provider by clicking the
                                                                                                      provider name
INCUR   IBPE           42   Web Page Incurment            Medical Bills   Provider Number             Allow the user to enter a           When should the provider name be displayed? When
                                     Bill/Payment Entry                                               provider number for a medical       the Save button is pressed or when the user presses
                                                                                                                                          the provider search link or should there be another
                                                                                                      bill. If the provider number is     button?
                                                                                                      valid the provider field will be
                                                                                                      populated with the appropriate
                                                                                                      value. If the provider number is
                                                                                                      not valid, an error message will
                                                                                                      be displayed
INCUR   IBPE           43   Web Page Incurment            Medical Bills   Client Responsibility       Display the word 'Carryover'
                                     Bill/Payment Entry                                               before the amount in the Client
                                                                                                      Responsibility field for any
                                                                                                      amounts that have been carried
                                                                                                      over
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                                                                                                  Page 7
Version #1
1/7/2011


                                                                                                                                                                                                                        USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                            APPROVAL




                                                                                                                                                                                                  Date Change from
                                                                                                                                                                                                  Prev Version
  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                 Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE           44   Web Page Incurment            Medical Bills            Client Responsibility       Validate all amount fields are       5/4/2007     Design
                                     Bill/Payment Entry                                                        numeric.

INCUR   IBPE           45   Web Page Incurment            Medical Bills            Client Responsibility       Validate any amount fields           5/4/2007     Design
                                     Bill/Payment Entry                                                        entered are not greater than the
                                                                                                               maximum amount allowed in the
                                                                                                               amount field
INCUR   IBPE           46   Web Page Incurment            Medical Bills            Client Responsibility       Validate any amount fields have      5/4/2007     Design
                                     Bill/Payment Entry                                                        only 2 numbers after the
                                                                                                               decimal point
INCUR   IBPE           47   Web Page Incurment            Medical Bills            Client Responsibility       Disallow all letters and             5/4/2007     Design
                                     Bill/Payment Entry                                                        punctuation or special
                                                                                                               characters other than comma,
                                                                                                               decimal, and numbers when
                                                                                                               entering an expense amount.
INCUR   IBPE           48   Web Page Incurment            Medical Bills            VA Aid and Attendence       Display description after                         Design      PCR 66
                                     Bill/Payment Entry                                                        Heading for VA Aid and
                                                                                                               Attendence
INCUR   IBPE           49   Web Page Incurment            Medical Bills            VA Aid and Attendence       Only display VA description and                   Design      PCR 66
                                     Bill/Payment Entry                                                        VA Aid & Attendance column if a
                                                                                                               person on the case for the given
                                                                                                               benefit month has a VA Aid &
                                                                                                               Attendance income
INCUR   IBPE           50   Web Page Incurment            Medical Bills            Potential Duplicate Bills   Display a warning message if a                    Design
                                     Bill/Payment Entry                                                        medical bill is potentially a
                                                                                                               duplicate of another bill when
                                                                                                               saving. A duplicate bill would
                                                                                                               match person name, date of
                                                                                                               service, client responsibility
                                                                                                               amount, and provider
INCUR   IBPE           51   Web Page Incurment            Medical Bills            Medical Bills               Require the entire row to be         5/4/2007     Design
                                     Bill/Payment Entry                                                        filled out before saving if any
                                                                                                               field within the row is entered
INCUR   IBPE           52   Web Page Incurment            Medical Bills            Add Rows                    Provide the ability to add           5/4/2007     Design
                                     Bill/Payment Entry                                                        Medical Bills rows.

INCUR   IBPE           53   Web Page Incurment            Medical Bills            Add Rows                    Provide the ability to enter how     5/4/2007     Design
                                     Bill/Payment Entry                                                        many Medical Bills rows to add.

INCUR   IBPE           54   Web Page Incurment            Medical Bills            Add Rows                    Default the number of rows to        5/4/2007     Design
                                     Bill/Payment Entry                                                        add to one.

INCUR   IBPE           55   Web Page Incurment            Medical Bills            Add Rows                    When the Add button is               5/4/2007     Design
                                     Bill/Payment Entry                                                        pressed, the indicated # of rows
                                                                                                               to add will be displayed.
INCUR   IBPE           56   Web Page Incurment            Medical Bills            Remove Medical Bills        Provide the ability to remove        5/4/2007     Design
                                     Bill/Payment Entry                                                        Medical Bills rows.

INCUR   IBPE           57   Web Page Incurment            Medical Bills            Remove Medical Bills        Require a Medical Bill row to be     5/4/2007     Design
                                     Bill/Payment Entry                                                        selected for removal when
                                                                                                               pressing the Remove button.
INCUR   IBPE           58   Web Page Incurment            Medical Bills            Remove Medical Bills        Present the user with one blank      5/4/2007     Design
                                     Bill/Payment Entry                                                        Medical Bill row if all other
                                                                                                               Medical Bill rows are removed.

INCUR   IBPE           59   Web Page Incurment            Current Payment on Old   Current Payment on Old      Allow user to view, modify, add,                  Design
                                     Bill/Payment Entry   Medical Bills            Medical Bills               and remove current payments
                                                                                                               on old medical bills for a person
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                                                                Page 8
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                 Comments
INCUR   IBPE            1
                       44   Web Page Incurment            Navigation
                                                          Medical Bills            Navigation
                                                                                   Client Responsibility       Allow access to this fieldspage
                                                                                                               Validate all amount web are
                                     Bill/Payment Entry                                                        from a menu
                                                                                                               numeric.

INCUR   IBPE           45   Web Page Incurment            Medical Bills            Client Responsibility       Validate any amount fields
                                     Bill/Payment Entry                                                        entered are not greater than the
                                                                                                               maximum amount allowed in the
                                                                                                               amount field
INCUR   IBPE           46   Web Page Incurment            Medical Bills            Client Responsibility       Validate any amount fields have
                                     Bill/Payment Entry                                                        only 2 numbers after the
                                                                                                               decimal point
INCUR   IBPE           47   Web Page Incurment            Medical Bills            Client Responsibility       Disallow all letters and
                                     Bill/Payment Entry                                                        punctuation or special
                                                                                                               characters other than comma,
                                                                                                               decimal, and numbers when
                                                                                                               entering an expense amount.
INCUR   IBPE           48   Web Page Incurment            Medical Bills            VA Aid and Attendence       Display description after           Description: If the 'Applies Only to VA Aid &
                                                                                                                                                   Attendence' checkbox is checked, the bill will only be
                                     Bill/Payment Entry                                                        Heading for VA Aid and
                                                                                                                                                   used to offset the Aid & Attendence amount and will not
                                                                                                               Attendence                          be used to meet the incurment
INCUR   IBPE           49   Web Page Incurment            Medical Bills            VA Aid and Attendence       Only display VA description and
                                     Bill/Payment Entry                                                        VA Aid & Attendance column if a
                                                                                                               person on the case for the given
                                                                                                               benefit month has a VA Aid &
                                                                                                               Attendance income
INCUR   IBPE           50   Web Page Incurment            Medical Bills            Potential Duplicate Bills   Display a warning message if a
                                     Bill/Payment Entry                                                        medical bill is potentially a
                                                                                                               duplicate of another bill when
                                                                                                               saving. A duplicate bill would
                                                                                                               match person name, date of
                                                                                                               service, client responsibility
                                                                                                               amount, and provider
INCUR   IBPE           51   Web Page Incurment            Medical Bills            Medical Bills               Require the entire row to be
                                     Bill/Payment Entry                                                        filled out before saving if any
                                                                                                               field within the row is entered
INCUR   IBPE           52   Web Page Incurment            Medical Bills            Add Rows                    Provide the ability to add
                                     Bill/Payment Entry                                                        Medical Bills rows.

INCUR   IBPE           53   Web Page Incurment            Medical Bills            Add Rows                    Provide the ability to enter how
                                     Bill/Payment Entry                                                        many Medical Bills rows to add.

INCUR   IBPE           54   Web Page Incurment            Medical Bills            Add Rows                    Default the number of rows to
                                     Bill/Payment Entry                                                        add to one.

INCUR   IBPE           55   Web Page Incurment            Medical Bills            Add Rows                    When the Add button is
                                     Bill/Payment Entry                                                        pressed, the indicated # of rows
                                                                                                               to add will be displayed.
INCUR   IBPE           56   Web Page Incurment            Medical Bills            Remove Medical Bills        Provide the ability to remove
                                     Bill/Payment Entry                                                        Medical Bills rows.

INCUR   IBPE           57   Web Page Incurment            Medical Bills            Remove Medical Bills        Require a Medical Bill row to be
                                     Bill/Payment Entry                                                        selected for removal when
                                                                                                               pressing the Remove button.
INCUR   IBPE           58   Web Page Incurment            Medical Bills            Remove Medical Bills        Present the user with one blank
                                     Bill/Payment Entry                                                        Medical Bill row if all other
                                                                                                               Medical Bill rows are removed.

INCUR   IBPE           59   Web Page Incurment            Current Payment on Old   Current Payment on Old      Allow user to view, modify, add,    Person Name, Benefit Month Entered, Date of
                                     Bill/Payment Entry   Medical Bills            Medical Bills               and remove current payments         Payment, Provider, Provider Number, Date of Service,
                                                                                                                                                   Client Responsibility.
                                                                                                               on old medical bills for a person   Is anything required?
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                                                                                                    Page 9
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                                                                                                                                                                                                                          USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                              APPROVAL




                                                                                                                                                                                                    Date Change from
                                                                                                                                                                                                    Prev Version
  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description               Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                   Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE           60   Web Page Incurment            Current Payment on Old   Current Payment on Old      Protect Current Payment on Old                      Design
                                     Bill/Payment Entry   Medical Bills            Medical Bills               Medical Bill data from
                                                                                                               modifications if it is carried over
                                                                                                               from the previous month
INCUR   IBPE           61   Web Page Incurment            Current Payment on Old   Sort Order                  Sort current payments on old                        Design
                                     Bill/Payment Entry   Medical Bills                                        medical bills chronologically by
                                                                                                               date of payment (oldest records
                                                                                                               first)
INCUR   IBPE           62   Web Page Incurment            Current Payment on Old   Default Number of Rows      Default the number of rows to                       Design
                                     Bill/Payment Entry   Medical Bills                                        two

INCUR   IBPE           63   Web Page Incurment            Current Payment on Old   Person Name                 Allow the user to select a                          Design
                                     Bill/Payment Entry   Medical Bills                                        persons name from a predefined
                                                                                                               list
INCUR   IBPE           64   Web Page Incurment            Current Payment on Old   Benefit Month               Benefit Month Entered is read                       Design      PCR 59
                                     Bill/Payment Entry   Medical Bills                                        only

INCUR   IBPE           65   Web Page Incurment            Current Payment on Old   Benefit Month               Populate the Benefit Month                          Design      PCR 59
                                     Bill/Payment Entry   Medical Bills                                        Entered field with the given
                                                                                                               benefit month and year when a
                                                                                                               bill/payment is entered for the
                                                                                                               first time and saved
INCUR   IBPE           66   Web Page Incurment            Current Payment on Old   Provider                    Provide ability to search for                       Design
                                     Bill/Payment Entry   Medical Bills                                        Providers

INCUR   IBPE           67   Web Page Incurment            Current Payment on Old   Provider                    Display "Provider Search" in the                    Design
                                     Bill/Payment Entry   Medical Bills                                        provider field if no provider has
                                                                                                               been defined. If a provider has
                                                                                                               been defined the provider field
                                                                                                               will display provider name
INCUR   IBPE           68   Web Page Incurment            Current Payment on Old   Provider                    Display 'Non-Participating                          Design
                                     Bill/Payment Entry   Medical Bills                                        Provider' under the providers
                                                                                                               name if provider is not found in
                                                                                                               the provider list provided by ACS

INCUR   IBPE           69   Web Page Incurment            Current Payment on Old   Provider                    Allow the user to view details of                   Design
                                     Bill/Payment Entry   Medical Bills                                        a provider by clicking the
                                                                                                               provider name
INCUR   IBPE           70   Web Page Incurment            Current Payment on Old   Provider Number             Provider and Provider Number
                                     Bill/Payment Entry   Medical Bills                                        fields are read only if a valid
                                                                                                               provider has been selected
INCUR   IBPE           71   Web Page Incurment            Current Payment on Old   Provider Number             Allow the user to enter a                           Design
                                     Bill/Payment Entry   Medical Bills                                        provider number for a medical
                                                                                                               bill. If the provider number is
                                                                                                               valid the provider field will be
                                                                                                               populated with the appropriate
                                                                                                               value. If the provider number is
                                                                                                               not valid, an error message will
                                                                                                               be displayed
INCUR   IBPE           72   Web Page Incurment            Current Payment on Old   Date of Service             Validate the date of service is at                  Design
                                     Bill/Payment Entry   Medical Bills                                        least three months prior to the
                                                                                                               first day of the benefit currently
                                                                                                               being viewed
INCUR   IBPE           73   Web Page Incurment            Current Payment on Old   Client Responsibility       Display the word 'Carryover'                        Design
                                     Bill/Payment Entry   Medical Bills                                        before the amount in the Client
                                                                                                               Responsibility field for any
                                                                                                               amounts that have been carried
                                                                                                               over
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                                                              Page 10
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                   Comments
INCUR   IBPE            1
                       60   Web Page Incurment            Navigation
                                                          Current Payment on Old   Navigation
                                                                                   Current Payment on Old      Allow access to Payment page
                                                                                                               Protect Current this web on Old
                                     Bill/Payment Entry   Medical Bills            Medical Bills               from a menudata from
                                                                                                               Medical Bill
                                                                                                               modifications if it is carried over
                                                                                                               from the previous month
INCUR   IBPE           61   Web Page Incurment            Current Payment on Old   Sort Order                  Sort current payments on old
                                     Bill/Payment Entry   Medical Bills                                        medical bills chronologically by
                                                                                                               date of payment (oldest records
                                                                                                               first)
INCUR   IBPE           62   Web Page Incurment            Current Payment on Old   Default Number of Rows      Default the number of rows to
                                     Bill/Payment Entry   Medical Bills                                        two

INCUR   IBPE           63   Web Page Incurment            Current Payment on Old   Person Name                 Allow the user to select a
                                     Bill/Payment Entry   Medical Bills                                        persons name from a predefined
                                                                                                               list
INCUR   IBPE           64   Web Page Incurment            Current Payment on Old   Benefit Month               Benefit Month Entered is read
                                     Bill/Payment Entry   Medical Bills                                        only

INCUR   IBPE           65   Web Page Incurment            Current Payment on Old   Benefit Month               Populate the Benefit Month
                                     Bill/Payment Entry   Medical Bills                                        Entered field with the given
                                                                                                               benefit month and year when a
                                                                                                               bill/payment is entered for the
                                                                                                               first time and saved
INCUR   IBPE           66   Web Page Incurment            Current Payment on Old   Provider                    Provide ability to search for
                                     Bill/Payment Entry   Medical Bills                                        Providers

INCUR   IBPE           67   Web Page Incurment            Current Payment on Old   Provider                    Display "Provider Search" in the
                                     Bill/Payment Entry   Medical Bills                                        provider field if no provider has
                                                                                                               been defined. If a provider has
                                                                                                               been defined the provider field
                                                                                                               will display provider name
INCUR   IBPE           68   Web Page Incurment            Current Payment on Old   Provider                    Display 'Non-Participating
                                     Bill/Payment Entry   Medical Bills                                        Provider' under the providers
                                                                                                               name if provider is not found in
                                                                                                               the provider list provided by ACS

INCUR   IBPE           69   Web Page Incurment            Current Payment on Old   Provider                    Allow the user to view details of
                                     Bill/Payment Entry   Medical Bills                                        a provider by clicking the
                                                                                                               provider name
INCUR   IBPE           70   Web Page Incurment            Current Payment on Old   Provider Number             Provider and Provider Number
                                     Bill/Payment Entry   Medical Bills                                        fields are read only if a valid
                                                                                                               provider has been selected
INCUR   IBPE           71   Web Page Incurment            Current Payment on Old   Provider Number             Allow the user to enter a             When should the provider name be displayed? When
                                     Bill/Payment Entry   Medical Bills                                        provider number for a medical         the Save button is pressed or when the user presses
                                                                                                                                                     the provider search link or should there be another
                                                                                                               bill. If the provider number is       button?
                                                                                                               valid the provider field will be
                                                                                                               populated with the appropriate
                                                                                                               value. If the provider number is
                                                                                                               not valid, an error message will
                                                                                                               be displayed
INCUR   IBPE           72   Web Page Incurment            Current Payment on Old   Date of Service             Validate the date of service is at
                                     Bill/Payment Entry   Medical Bills                                        least three months prior to the
                                                                                                               first day of the benefit currently
                                                                                                               being viewed
INCUR   IBPE           73   Web Page Incurment            Current Payment on Old   Client Responsibility       Display the word 'Carryover'
                                     Bill/Payment Entry   Medical Bills                                        before the amount in the Client
                                                                                                               Responsibility field for any
                                                                                                               amounts that have been carried
                                                                                                               over
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                                                                                                 Page 11
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1/7/2011


                                                                                                                                                                                                                       USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                           APPROVAL




                                                                                                                                                                                                 Date Change from
                                                                                                                                                                                                 Prev Version
  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description            Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IBPE           74   Web Page Incurment            Current Payment on Old   Client Responsibility       Validate all amount fields are      5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        numeric.

INCUR   IBPE           75   Web Page Incurment            Current Payment on Old   Client Responsibility       Validate any amount fields          5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        entered are not greater than the
                                                                                                               maximum amount allowed in the
                                                                                                               amount field
INCUR   IBPE           76   Web Page Incurment            Current Payment on Old   Client Responsibility       Validate any amount fields have     5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        only 2 numbers after the
                                                                                                               decimal point
INCUR   IBPE           77   Web Page Incurment            Current Payment on Old   Client Responsibility       Disallow all letters and            5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        punctuation or special
                                                                                                               characters other than comma,
                                                                                                               decimal, and numbers when
                                                                                                               entering an expense amount.
INCUR   IBPE           78   Web Page Incurment            Current Payment on Old   Potential Duplicate Bills   Display a warning message if a                   Design
                                     Bill/Payment Entry   Medical Bills                                        medical bill is potentially a
                                                                                                               duplicate of another bill when
                                                                                                               saving. A duplicate bill would
                                                                                                               match person name, date of
                                                                                                               service, client responsibility
                                                                                                               amount, and provider
INCUR   IBPE           79   Web Page Incurment            Current Payment on Old   Current Payment on Old      Require the entire row to be        5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills            Medical Bills               filled out before saving if any
                                                                                                               field within the row is entered
INCUR   IBPE           80   Web Page Incurment            Current Payment on Old   Add Rows                    Provide the ability to add          5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        Current Payment on Old
                                                                                                               Medical Bills rows.
INCUR   IBPE           81   Web Page Incurment            Current Payment on Old   Add Rows                    Provide the ability to enter how    5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        many Current Payment on Old
                                                                                                               Medical Bills rows to add.
INCUR   IBPE           82   Web Page Incurment            Current Payment on Old   Add Rows                    Default the number of rows to       5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        add to one.

INCUR   IBPE           83   Web Page Incurment            Current Payment on Old   Add Rows                    When the Add button is              5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills                                        pressed, the indicated # of rows
                                                                                                               to add will be displayed.
INCUR   IBPE           84   Web Page Incurment            Current Payment on Old   Remove Current              Provide the ability to remove       5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Current Payment on Old
                                                                                   Bills                       Medical Bills rows.
INCUR   IBPE           85   Web Page Incurment            Current Payment on Old   Remove Current              Require a Current Payment on        5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Old Medical Bill row to be
                                                                                   Bills                       selected for removal when
                                                                                                               pressing the Remove button.
INCUR   IBPE           86   Web Page Incurment            Current Payment on Old   Remove Current              Present the user with one blank     5/4/2007     Design
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Current Payment on Old
                                                                                   Bills                       Medical Bill row if all other
                                                                                                               Current Payment on Old
                                                                                                               Medical Bill rows are removed.
Filename: CHIMES Requirements - Incurment Bill Entry Payment                                                           CHIMES                                Page 12
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                                Item/Response               "The system shall…"                Comments
INCUR   IBPE            1
                       74   Web Page Incurment            Navigation
                                                          Current Payment on Old   Navigation
                                                                                   Client Responsibility       Allow access to this fieldspage
                                                                                                               Validate all amount web are
                                     Bill/Payment Entry   Medical Bills                                        from a menu
                                                                                                               numeric.

INCUR   IBPE           75   Web Page Incurment            Current Payment on Old   Client Responsibility       Validate any amount fields
                                     Bill/Payment Entry   Medical Bills                                        entered are not greater than the
                                                                                                               maximum amount allowed in the
                                                                                                               amount field
INCUR   IBPE           76   Web Page Incurment            Current Payment on Old   Client Responsibility       Validate any amount fields have
                                     Bill/Payment Entry   Medical Bills                                        only 2 numbers after the
                                                                                                               decimal point
INCUR   IBPE           77   Web Page Incurment            Current Payment on Old   Client Responsibility       Disallow all letters and
                                     Bill/Payment Entry   Medical Bills                                        punctuation or special
                                                                                                               characters other than comma,
                                                                                                               decimal, and numbers when
                                                                                                               entering an expense amount.
INCUR   IBPE           78   Web Page Incurment            Current Payment on Old   Potential Duplicate Bills   Display a warning message if a
                                     Bill/Payment Entry   Medical Bills                                        medical bill is potentially a
                                                                                                               duplicate of another bill when
                                                                                                               saving. A duplicate bill would
                                                                                                               match person name, date of
                                                                                                               service, client responsibility
                                                                                                               amount, and provider
INCUR   IBPE           79   Web Page Incurment            Current Payment on Old   Current Payment on Old      Require the entire row to be
                                     Bill/Payment Entry   Medical Bills            Medical Bills               filled out before saving if any
                                                                                                               field within the row is entered
INCUR   IBPE           80   Web Page Incurment            Current Payment on Old   Add Rows                    Provide the ability to add
                                     Bill/Payment Entry   Medical Bills                                        Current Payment on Old
                                                                                                               Medical Bills rows.
INCUR   IBPE           81   Web Page Incurment            Current Payment on Old   Add Rows                    Provide the ability to enter how
                                     Bill/Payment Entry   Medical Bills                                        many Current Payment on Old
                                                                                                               Medical Bills rows to add.
INCUR   IBPE           82   Web Page Incurment            Current Payment on Old   Add Rows                    Default the number of rows to
                                     Bill/Payment Entry   Medical Bills                                        add to one.

INCUR   IBPE           83   Web Page Incurment            Current Payment on Old   Add Rows                    When the Add button is
                                     Bill/Payment Entry   Medical Bills                                        pressed, the indicated # of rows
                                                                                                               to add will be displayed.
INCUR   IBPE           84   Web Page Incurment            Current Payment on Old   Remove Current              Provide the ability to remove
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Current Payment on Old
                                                                                   Bills                       Medical Bills rows.
INCUR   IBPE           85   Web Page Incurment            Current Payment on Old   Remove Current              Require a Current Payment on
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Old Medical Bill row to be
                                                                                   Bills                       selected for removal when
                                                                                                               pressing the Remove button.
INCUR   IBPE           86   Web Page Incurment            Current Payment on Old   Remove Current              Present the user with one blank
                                     Bill/Payment Entry   Medical Bills            Payment on Old Medical      Current Payment on Old
                                                                                   Bills                       Medical Bill row if all other
                                                                                                               Current Payment on Old
                                                                                                               Medical Bill rows are removed.
Filename: CHIMES Requirements - Incurment Detail                                                                     CHIMES                                                                                                                     Page 13
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                                                                                                                                                                                                                         USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                             APPROVAL




                                                                                                                                                                                                   Date Change from
                                                                                                                                                                                                   Prev Version
  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.      Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                             Item/Response               "The system shall…"                 Introduced   Introduced   Source    Removed                        Approved Approving User
INCUR                          Web Page Incurment Details                                                      auto populate the cash option                                 RAL #71
                                                                                                               as an expense once fiscal
                                                                                                               authorized the payment on the
                                                                                                               medical expense section.
INCUR                          Web Page Incurment Details                                                      Generate a one-day                                            RAL #70
                                                                                                               authorization letter to
                                                                                                               appropriate provider(s) when
                                                                                                               the client's incurment is met on
                                                                                                               that day.
INCUR   IDTL               1   Web Page Incurment Details   Navigation             Navigation                  Allow access to this web page                     Design
                                                                                                               as part of the incurment
                                                                                                               navigation flow
INCUR   IDTL               2   Web Page Incurment Details   Security               Security                    Allow only users with the same                    Design
                                                                                                               jurisdiction as the worker
                                                                                                               currently assigned to the case,
                                                                                                               supervisors in any counties with
                                                                                                               the same jurisdiction as the as
                                                                                                               the worker currently assigned to
                                                                                                               the case, or with statewide
                                                                                                               update authority will be allowed
                                                                                                               to update information

INCUR   IDTL               3   Web Page Incurment Details   Worker Determination   Incurment Summary           Display a summary of incurment                    Design
                                                                                                               information for each person for
                                                                                                               a filing unit

INCUR   IDTL               4   Web Page Incurment Details   Worker Determination   Previous Worker             Display the previous worker                       Design
                                                                                   Determination               determination information for
                                                                                                               any filing unit member that has
                                                                                                               an incurment determination that
                                                                                                               has been finalized for the
                                                                                                               current benefit month
INCUR   IDTL               5   Web Page Incurment Details   Worker Determination   Person                      Allow the user to view the first,                 Design
                                                                                                               middle, and last names of each
                                                                                                               filing unit member
INCUR   IDTL               6   Web Page Incurment Details   Worker Determination   Person                      Display the description                           Design      PCR 64
                                                                                                               '(DEEMED)' after the persons
                                                                                                               name for anyone who is a
                                                                                                               deemed individual
INCUR   IDTL               7   Web Page Incurment Details   Worker Determination   Person                      Only display deemed individuals                   Design      PCR 64
                                                                                                               if the deemed individuals
                                                                                                               income is greater than $0.00

INCUR   IDTL               8   Web Page Incurment Details   Worker Determination   Other Filing Unit           Display the filing unit for each                  Design
                                                                                   Members                     household member that has an
                                                                                                               incurment
INCUR   IDTL               9   Web Page Incurment Details   Worker Determination   Incurment Amount            Determine incurment amount                        Design      PCR 66
                                                                                   Remaining                   remaining by subtracting any
                                                                                                               carryover amounts, current
                                                                                                               month bills except those marked
                                                                                                               as applying to VA Aid &
                                                                                                               Attendence only, insurance
                                                                                                               premiums, and current
                                                                                                               payments on past medical bills,
                                                                                                               all of which are remaining after
                                                                                                               they have been applied to
                                                                                                               reduce to the VA Aid &
                                                                                                               Attendence amount from the
                                                                                                               incurment amount
Filename: CHIMES Requirements - Incurment Detail                                                                     CHIMES                                                                          Page 14
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                   Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                             Item/Response               "The system shall…"                 Comments
INCUR                          Web Page Incurment Details                                                      auto populate the cash option
                                                                                                               as an expense once fiscal
                                                                                                               authorized the payment on the
                                                                                                               medical expense section.
INCUR                          Web Page Incurment Details                                                      Generate a one-day
                                                                                                               authorization letter to
                                                                                                               appropriate provider(s) when
                                                                                                               the client's incurment is met on
                                                                                                               that day.
INCUR   IDTL               1   Web Page Incurment Details   Navigation             Navigation                  Allow access to this web page
                                                                                                               as part of the incurment
                                                                                                               navigation flow
INCUR   IDTL               2   Web Page Incurment Details   Security               Security                    Allow only users with the same
                                                                                                               jurisdiction as the worker
                                                                                                               currently assigned to the case,
                                                                                                               supervisors in any counties with
                                                                                                               the same jurisdiction as the as
                                                                                                               the worker currently assigned to
                                                                                                               the case, or with statewide
                                                                                                               update authority will be allowed
                                                                                                               to update information

INCUR   IDTL               3   Web Page Incurment Details   Worker Determination   Incurment Summary           Display a summary of incurment      Person, Filing Unit Members, Incurment Amount,
                                                                                                                                                   Incurment Amount Remaining, VA Aid & Attendence
                                                                                                               information for each person for
                                                                                                                                                   Amount, VA Aid & Attendence Offset Amount
                                                                                                               a filing unit                       Remaining, System Determination, Worker
                                                                                                                                                   Determination, Benefit Status
INCUR   IDTL               4   Web Page Incurment Details   Worker Determination   Previous Worker             Display the previous worker
                                                                                   Determination               determination information for
                                                                                                               any filing unit member that has
                                                                                                               an incurment determination that
                                                                                                               has been finalized for the
                                                                                                               current benefit month
INCUR   IDTL               5   Web Page Incurment Details   Worker Determination   Person                      Allow the user to view the first,
                                                                                                               middle, and last names of each
                                                                                                               filing unit member
INCUR   IDTL               6   Web Page Incurment Details   Worker Determination   Person                      Display the description
                                                                                                               '(DEEMED)' after the persons
                                                                                                               name for anyone who is a
                                                                                                               deemed individual
INCUR   IDTL               7   Web Page Incurment Details   Worker Determination   Person                      Only display deemed individuals
                                                                                                               if the deemed individuals
                                                                                                               income is greater than $0.00

INCUR   IDTL               8   Web Page Incurment Details   Worker Determination   Other Filing Unit           Display the filing unit for each    Person Name, Other Filing Unit Members
                                                                                   Members                     household member that has an        Display only first names

                                                                                                               incurment
INCUR   IDTL               9   Web Page Incurment Details   Worker Determination   Incurment Amount            Determine incurment amount          See the order the bill payments are applied in
                                                                                   Remaining                   remaining by subtracting any        requirement description #

                                                                                                               carryover amounts, current
                                                                                                               month bills except those marked
                                                                                                               as applying to VA Aid &
                                                                                                               Attendence only, insurance
                                                                                                               premiums, and current
                                                                                                               payments on past medical bills,
                                                                                                               all of which are remaining after
                                                                                                               they have been applied to
                                                                                                               reduce to the VA Aid &
                                                                                                               Attendence amount from the
                                                                                                               incurment amount
Filename: CHIMES Requirements - Incurment Detail                                                                  CHIMES                                                                                                                      Page 15
Version #1
1/7/2011


                                                                                                                                                                                                                       USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                           APPROVAL




                                                                                                                                                                                                 Date Change from
                                                                                                                                                                                                 Prev Version
  Ref
 Code   Ref Code                                                                Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.       Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                             Item/Response               "The system shall…"                 Introduced   Introduced   Source     Removed                        Approved Approving User
INCUR   IDTL           10   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   Only display VA Aid &                                 Design      PCR 66
                                                                                                        Attendence Amount field if
                                                                                                        someone on the case has VA
                                                                                                        Aid & Attendence income
                                                                                                        greater than $0.00
INCUR   IDTL           11   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   Only display VA Aid &                                 Design      PCR 66
                                                                                Offset Amount Remaining Attendence Offset Amount
                                                                                                        Remaining field if someone on
                                                                                                        the case has VA Aid &
                                                                                                        Attendence income greater than
                                                                                                        $0.00
INCUR   IDTL           12   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   Determine VA Aid & Attendence                         Design      PCR 66
                                                                                Offset Amount Remaining Offset Amount Remaining by
                                                                                                        subtracting any carryover
                                                                                                        amounts, current month bills,
                                                                                                        insurance premiums, current
                                                                                                        payments on past medical bills,
                                                                                                        all of which were incurred by the
                                                                                                        person with the VA Aid &
                                                                                                        Attendence from the VA Aid &
                                                                                                        Attendence amount

INCUR   IDTL           13   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Met" in the                    Design
                                                                                                            system determination field if the
                                                                                                            incurment amount remaining
                                                                                                            and VA Aid & Attendence offset
                                                                                                            amount remaining are zero and
                                                                                                            no worker incurment
                                                                                                            determinations have been
                                                                                                            finalized

INCUR   IDTL           14   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Met" in the                    Design
                                                                                                            system determination field if the
                                                                                                            last finalized worker incurment
                                                                                                            determination was Cash Option
                                                                                                            or Incurment Met
INCUR   IDTL           15   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Not Met" in                    Design
                                                                                                            the system determination field if
                                                                                                            either the incurment amount
                                                                                                            remaining or VA Aid &
                                                                                                            Attendence offset amount
                                                                                                            remaining are greater than zero
                                                                                                            and no worker incurment
                                                                                                            determinations have been
                                                                                                            finalized
INCUR   IDTL           16   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Not Met" in                    Design
                                                                                                            the system determination field if
                                                                                                            the last finalized worker
                                                                                                            incurment determination was
                                                                                                            Incurment Not Met.
INCUR   IDTL           17   Web Page Incurment Details   Worker Determination   System Determination        Display "Decline" in the system                   Design
                                                                                                            determination field if the last
                                                                                                            finalized worker incurment
                                                                                                            determination for the benefit
                                                                                                            month was Decline
INCUR   IDTL           18   Web Page Incurment Details   Worker Determination   Worker Determination        Allow the user to select a                        Design      Document
                                                                                                            Worker Determination from a
                                                                                                            predefined list of incurment
                                                                                                            determinations for each person
                                                                                                            with an incurment
Filename: CHIMES Requirements - Incurment Detail                                                                  CHIMES                                                            Page 16
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                             Item/Response               "The system shall…"                 Comments
INCUR   IDTL           10   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   auto populate the cash option
                                                                                                        Only display VA Aid &
                                                                                                        as an expense once field if
                                                                                                        Attendence Amount fiscal
                                                                                                        someone on the case has the
                                                                                                        authorized the payment onVA
                                                                                                        medical expense section.
                                                                                                        Aid & Attendence income
                                                                                                        greater than $0.00
INCUR   IDTL           11   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   Only display VA Aid &
                                                                                Offset Amount Remaining Attendence Offset Amount
                                                                                                        Remaining field if someone on
                                                                                                        the case has VA Aid &
                                                                                                        Attendence income greater than
                                                                                                        $0.00
INCUR   IDTL           12   Web Page Incurment Details   Worker Determination   VA Aid & Attendenance   Determine VA Aid & Attendence
                                                                                Offset Amount Remaining Offset Amount Remaining by
                                                                                                        subtracting any carryover
                                                                                                        amounts, current month bills,
                                                                                                        insurance premiums, current
                                                                                                        payments on past medical bills,
                                                                                                        all of which were incurred by the
                                                                                                        person with the VA Aid &
                                                                                                        Attendence from the VA Aid &
                                                                                                        Attendence amount

INCUR   IDTL           13   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Met" in the
                                                                                                            system determination field if the
                                                                                                            incurment amount remaining
                                                                                                            and VA Aid & Attendence offset
                                                                                                            amount remaining are zero and
                                                                                                            no worker incurment
                                                                                                            determinations have been
                                                                                                            finalized

INCUR   IDTL           14   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Met" in the
                                                                                                            system determination field if the
                                                                                                            last finalized worker incurment
                                                                                                            determination was Cash Option
                                                                                                            or Incurment Met
INCUR   IDTL           15   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Not Met" in
                                                                                                            the system determination field if
                                                                                                            either the incurment amount
                                                                                                            remaining or VA Aid &
                                                                                                            Attendence offset amount
                                                                                                            remaining are greater than zero
                                                                                                            and no worker incurment
                                                                                                            determinations have been
                                                                                                            finalized
INCUR   IDTL           16   Web Page Incurment Details   Worker Determination   System Determination        Display "Incurment Not Met" in
                                                                                                            the system determination field if
                                                                                                            the last finalized worker
                                                                                                            incurment determination was
                                                                                                            Incurment Not Met.
INCUR   IDTL           17   Web Page Incurment Details   Worker Determination   System Determination        Display "Decline" in the system
                                                                                                            determination field if the last
                                                                                                            finalized worker incurment
                                                                                                            determination for the benefit
                                                                                                            month was Decline
INCUR   IDTL           18   Web Page Incurment Details   Worker Determination   Worker Determination        Allow the user to select a          See Worker Determination document
                                                                                                            Worker Determination from a
                                                                                                            predefined list of incurment
                                                                                                            determinations for each person
                                                                                                            with an incurment
Filename: CHIMES Requirements - Incurment Detail                                                                  CHIMES                                                                                                                      Page 17
Version #1
1/7/2011


                                                                                                                                                                                                                       USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                           APPROVAL




                                                                                                                                                                                                 Date Change from
                                                                                                                                                                                                 Prev Version
  Ref
 Code   Ref Code                                                                Field/Attribute/Function/   Requirement Description               Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                             Item/Response               "The system shall…"                   Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IDTL           19   Web Page Incurment Details   Worker Determination   Worker Determination        Default worker determination to                     Design
                                                                                                            match the system determination
                                                                                                            if no worker incurment
                                                                                                            determination has been finalized

INCUR   IDTL           20   Web Page Incurment Details   Worker Determination   Worker Determination        Default worker determination to                     Design
                                                                                                            "No Determination" if a worker
                                                                                                            incurment determination has
                                                                                                            been finalized

INCUR   IDTL           21   Web Page Incurment Details   Worker Determination   Worker Determination        Provide the ability to select the                   Design
                                                                                                            Cash Option for incurment cases

INCUR   IDTL           22   Web Page Incurment Details   Worker Determination   Worker Determination        Remove Cash Option from the                         Design      PCR 66
                                                                                                            worker determination selection
                                                                                                            list if anyone on the case has
                                                                                                            VA Aid & Attendence income for
                                                                                                            the benefit month
INCUR   IDTL           23   Web Page Incurment Details   Worker Determination   Benefit Status              Only show the benefit status for                    Design
                                                                                                            the previous determinations
INCUR   IDTL           24   Web Page Incurment Details   Incurment Detail       Incurment Detail            Display how bills, payments,                        Design
                                                                                                            and cash options apply to each
                                                                                                            person's incurment


INCUR   IDTL           25   Web Page Incurment Details   Incurment Detail       Incurment Detail            Display incurment details                           Design
                                                                                                            initially if a worker determination
                                                                                                            has been finalized. Otherwise,
                                                                                                            incurment details will be hidden
                                                                                                            until toggled by the user.


INCUR   IDTL           26   Web Page Incurment Details   Incurment Detail       Incurment Detail            If someone chooses cash option                      Design      PCR 66
                                                                                                            then their bills for the current
                                                                                                            month cannot be used to meet
                                                                                                            anyone elses incurment

INCUR   IDTL           27   Web Page Incurment Details   Incurment Detail       Incurment Detail            Only bills/payments for a person                    Design
                                                                                                            in the same filing unit as the
                                                                                                            individual and the individuals
                                                                                                            bills/payments can be used to
                                                                                                            reduce the incurment amount

INCUR   IDTL           28   Web Page Incurment Details   Incurment Detail       Incurment Detail            If the worker incurment                             Design
                                                                                                            determination is Cash Option
                                                                                                            the cash option amount applies
                                                                                                            to everyones incurment amount
                                                                                                            on the case that has selected
                                                                                                            Cash Option as the worker
                                                                                                            incurment determination

INCUR   IDTL           29   Web Page Incurment Details   Incurment Detail       Incurment Detail            A deemed individuals bills will                     Design
                                                                                                            carryover into the next month if
                                                                                                            the individual continues to be
                                                                                                            deemed in the next month
Filename: CHIMES Requirements - Incurment Detail                                                                  CHIMES                                                                                 Page 18
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1/7/2011



REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                             Item/Response               "The system shall…"                   Comments
INCUR   IDTL           19   Web Page Incurment Details   Worker Determination   Worker Determination        auto populate the cash optionto
                                                                                                            Default worker determination
                                                                                                            as an expense once fiscal
                                                                                                            match the system determination
                                                                                                            authorized the payment on the
                                                                                                            if no worker incurment
                                                                                                            medical expense section.
                                                                                                            determination has been finalized

INCUR   IDTL           20   Web Page Incurment Details   Worker Determination   Worker Determination        Default worker determination to
                                                                                                            "No Determination" if a worker
                                                                                                            incurment determination has
                                                                                                            been finalized

INCUR   IDTL           21   Web Page Incurment Details   Worker Determination   Worker Determination        Provide the ability to select the
                                                                                                            Cash Option for incurment cases

INCUR   IDTL           22   Web Page Incurment Details   Worker Determination   Worker Determination        Remove Cash Option from the
                                                                                                            worker determination selection
                                                                                                            list if anyone on the case has
                                                                                                            VA Aid & Attendence income for
                                                                                                            the benefit month
INCUR   IDTL           23   Web Page Incurment Details   Worker Determination   Benefit Status              Only show the benefit status for
                                                                                                            the previous determinations
INCUR   IDTL           24   Web Page Incurment Details   Incurment Detail       Incurment Detail            Display how bills, payments,          Person Name, Date of Service/Payment, Provider,
                                                                                                            and cash options apply to each        Client Responsibility, Amount Applied to VA Aid &
                                                                                                                                                  Attendence, Amount Applied to Incurment, Amount
                                                                                                            person's incurment                    Eligible for Medicaid Payment, Not Covered by
                                                                                                                                                  Medicaid, Applies Only to Reduce VA Aid & Attendence


INCUR   IDTL           25   Web Page Incurment Details   Incurment Detail       Incurment Detail            Display incurment details
                                                                                                            initially if a worker determination
                                                                                                            has been finalized. Otherwise,
                                                                                                            incurment details will be hidden
                                                                                                            until toggled by the user.


INCUR   IDTL           26   Web Page Incurment Details   Incurment Detail       Incurment Detail            If someone chooses cash option
                                                                                                            then their bills for the current
                                                                                                            month cannot be used to meet
                                                                                                            anyone elses incurment

INCUR   IDTL           27   Web Page Incurment Details   Incurment Detail       Incurment Detail            Only bills/payments for a person
                                                                                                            in the same filing unit as the
                                                                                                            individual and the individuals
                                                                                                            bills/payments can be used to
                                                                                                            reduce the incurment amount

INCUR   IDTL           28   Web Page Incurment Details   Incurment Detail       Incurment Detail            If the worker incurment
                                                                                                            determination is Cash Option
                                                                                                            the cash option amount applies
                                                                                                            to everyones incurment amount
                                                                                                            on the case that has selected
                                                                                                            Cash Option as the worker
                                                                                                            incurment determination

INCUR   IDTL           29   Web Page Incurment Details   Incurment Detail       Incurment Detail            A deemed individuals bills will
                                                                                                            carryover into the next month if
                                                                                                            the individual continues to be
                                                                                                            deemed in the next month
Filename: CHIMES Requirements - Incurment Detail                                                              CHIMES                                                                                                                    Page 19
Version #1
1/7/2011


                                                                                                                                                                                                                 USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                     APPROVAL




                                                                                                                                                                                           Date Change from
                                                                                                                                                                                           Prev Version
  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                         Item/Response               "The system shall…"                 Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IDTL           30   Web Page Incurment Details   Incurment Detail   Incurment Detail            Allow bills/payments with a date                  Design
                                                                                                        of service up to 3 months prior
                                                                                                        to the benefit month being
                                                                                                        worked and still having
                                                                                                        remaining amounts that have
                                                                                                        not been covered by medicaid to
                                                                                                        be used to reduce the incurment
                                                                                                        amounts
INCUR   IDTL           31   Web Page Incurment Details   Incurment Detail   Incurment Detail            Disallow bills/payments to be                     Design      PCR 59
                                                                                                        applied to reducing the
                                                                                                        incurment amount if the benefit
                                                                                                        month entry date for the
                                                                                                        bill/payment is after the benefit
                                                                                                        month being worked
INCUR   IDTL           32   Web Page Incurment Details   Incurment Detail   Incurment Detail            If a person has a VA Aid &                        Design      PCR 66
                                                                                                        Attendence amount that amount
                                                                                                        will be reduced first using the
                                                                                                        persons bills/payments before
                                                                                                        being applied to the incurment
                                                                                                        amount

INCUR   IDTL           33   Web Page Incurment Details   Incurment Detail   Incurment Detail            Another person's bills/payments                   Design      PCR 66
                                                                                                        can be applied toward an
                                                                                                        individuals incurment amount if
                                                                                                        the individual has a VA Aid &
                                                                                                        Attendence amount

INCUR   IDTL           34   Web Page Incurment Details   Incurment Detail   Incurment Detail            A persons VA Aid & Attendecne                     Design      PCR 66
                                                                                                        amount can only be reduced by
                                                                                                        the persons bills/payments and
                                                                                                        not by other filing unit members
                                                                                                        bills/payments

INCUR   IDTL           35   Web Page Incurment Details   Incurment Detail   Incurment Detail            Apply bills/payments to                           Design
                                                                                                        individual incurments
                                                                                                        chronologically, oldest first,
                                                                                                        based on premium due month,
                                                                                                        date of service, or the date of
                                                                                                        payment
INCUR   IDTL           36   Web Page Incurment Details   Incurment Detail   Incurment Detail            Apply bills/payments to                           Design
                                                                                                        individual incurments with
                                                                                                        premium due month, date of
                                                                                                        service, or the date of payment
                                                                                                        that are the same in the
                                                                                                        following order: 1.
                                                                                                        Bills/Payments that have a date
                                                                                                        of service/payment from a prior
                                                                                                        month. 2. Current month health
                                                                                                        insurance premiums. 3. Current
                                                                                                        payment on past medical bills.
                                                                                                        4. Current month bills not
                                                                                                        covered by medicaid. 5. Current
                                                                                                        month bills that are potentially
                                                                                                        covered by medicaid.
Filename: CHIMES Requirements - Incurment Detail                                                              CHIMES                                                                                Page 20
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                         Item/Response               "The system shall…"                 Comments
INCUR   IDTL           30   Web Page Incurment Details   Incurment Detail   Incurment Detail            auto populate the cash option
                                                                                                        Allow bills/payments with a date    Carryover
                                                                                                        of an expense 3 months
                                                                                                        as service up toonce fiscalprior
                                                                                                        authorized the payment on the
                                                                                                        to the benefit month being
                                                                                                        medical and still having
                                                                                                        worked expense section.
                                                                                                        remaining amounts that have
                                                                                                        not been covered by medicaid to
                                                                                                        be used to reduce the incurment
                                                                                                        amounts
INCUR   IDTL           31   Web Page Incurment Details   Incurment Detail   Incurment Detail            Disallow bills/payments to be       Bills/payments must be entered in the earliest month
                                                                                                                                            that they are to be applied to reducing the incurment
                                                                                                        applied to reducing the
                                                                                                                                            amount
                                                                                                        incurment amount if the benefit
                                                                                                        month entry date for the
                                                                                                        bill/payment is after the benefit
                                                                                                        month being worked
INCUR   IDTL           32   Web Page Incurment Details   Incurment Detail   Incurment Detail            If a person has a VA Aid &
                                                                                                        Attendence amount that amount
                                                                                                        will be reduced first using the
                                                                                                        persons bills/payments before
                                                                                                        being applied to the incurment
                                                                                                        amount

INCUR   IDTL           33   Web Page Incurment Details   Incurment Detail   Incurment Detail            Another person's bills/payments
                                                                                                        can be applied toward an
                                                                                                        individuals incurment amount if
                                                                                                        the individual has a VA Aid &
                                                                                                        Attendence amount

INCUR   IDTL           34   Web Page Incurment Details   Incurment Detail   Incurment Detail            A persons VA Aid & Attendecne
                                                                                                        amount can only be reduced by
                                                                                                        the persons bills/payments and
                                                                                                        not by other filing unit members
                                                                                                        bills/payments

INCUR   IDTL           35   Web Page Incurment Details   Incurment Detail   Incurment Detail            Apply bills/payments to
                                                                                                        individual incurments
                                                                                                        chronologically, oldest first,
                                                                                                        based on premium due month,
                                                                                                        date of service, or the date of
                                                                                                        payment
INCUR   IDTL           36   Web Page Incurment Details   Incurment Detail   Incurment Detail            Apply bills/payments to             This order applies to VA Aid & Attendence amounts as
                                                                                                        individual incurments with          well.

                                                                                                        premium due month, date of
                                                                                                        service, or the date of payment
                                                                                                        that are the same in the
                                                                                                        following order: 1.
                                                                                                        Bills/Payments that have a date
                                                                                                        of service/payment from a prior
                                                                                                        month. 2. Current month health
                                                                                                        insurance premiums. 3. Current
                                                                                                        payment on past medical bills.
                                                                                                        4. Current month bills not
                                                                                                        covered by medicaid. 5. Current
                                                                                                        month bills that are potentially
                                                                                                        covered by medicaid.
Filename: CHIMES Requirements - Incurment Detail                                                              CHIMES                                                                                                                     Page 21
Version #1
1/7/2011


                                                                                                                                                                                                                  USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                      APPROVAL




                                                                                                                                                                                            Date Change from
                                                                                                                                                                                            Prev Version
  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description              Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                         Item/Response               "The system shall…"                  Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IDTL           37   Web Page Incurment Details   Incurment Detail   Incurment Detail            Apply bills/payments to                            Design      PCR 64
                                                                                                        individual incurments with
                                                                                                        premium due month, date of
                                                                                                        service, or the date of payment
                                                                                                        that are the same AND are are
                                                                                                        in similar categories (Insurance
                                                                                                        Premiums, Medical Bills,
                                                                                                        Current Payment on Old
                                                                                                        Medical Bills) in the following
                                                                                                        order: 1. Deemed individuals
                                                                                                        bills. 2. Bills for someone in the
                                                                                                        filing unit with no coverage
                                                                                                        group for the current month. 3.
                                                                                                        Bills for people who have
                                                                                                        declined coverage for the
                                                                                                        current month. 4. Bills for
                                                                                                        people with the highest
                                                                                                        incurment. 5. If two or more
                                                                                                        bills have the same date of
                                                                                                        service and both fit one of the
                                                                                                        above descriptions, the bills will
                                                                                                        be randomly sorted and then
                                                                                                        applied to the incurment.
INCUR   IDTL           38   Web Page Incurment Details   Incurment Detail   Incurment Detail            When the information is saved                      Design
                                                                                                        the sort order that the
                                                                                                        bills/payments were applied to a
                                                                                                        persons incurment reduction
                                                                                                        must be saved
INCUR   IDTL           39   Web Page Incurment Details   Incurment Detail   Incurment Detail            Bold the bill/payment that has                     Design
                                                                                                        potentially met the incurment
INCUR   IDTL           40   Web Page Incurment Details   Incurment Detail   Display Order               Display the bills/payments in the                  Design
                                                                                                        order that they were used to
                                                                                                        reduce the incurment and VA
                                                                                                        Aid and Attendence amounts for
                                                                                                        each individual
INCUR   IDTL           41   Web Page Incurment Details   Incurment Detail   Description                 Display description below each                     Design
                                                                                                        persons detail bill/payment
                                                                                                        applied data stating what the
                                                                                                        bolded row represents

INCUR   IDTL           42   Web Page Incurment Details   Incurment Detail   Description                 Display description below each                     Design      PCR 66
                                                                                                        persons detail bill/payment
                                                                                                        applied data stating what the VA
                                                                                                        Aid & Attendence indicator is
                                                                                                        used for if someone on the case
                                                                                                        has VA Aid & Attendence income

INCUR   IDTL           43   Web Page Incurment Details   Incurment Detail   Reset Button                Hide the incurment details when                    Design
                                                                                                        the reset button is pressed
Filename: CHIMES Requirements - Incurment Detail                                                              CHIMES                                                                                   Page 22
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                         Item/Response               "The system shall…"                  Comments
INCUR   IDTL           37   Web Page Incurment Details   Incurment Detail   Incurment Detail            auto populate the cash option
                                                                                                        Apply bills/payments to              This order applies to VA Aid & Attendence amounts as
                                                                                                        as an expense once fiscal
                                                                                                        individual incurments with           well.
                                                                                                        authorized the payment on the
                                                                                                        premium due month, date of
                                                                                                        medical expense section.
                                                                                                        service, or the date of payment
                                                                                                        that are the same AND are are
                                                                                                        in similar categories (Insurance
                                                                                                        Premiums, Medical Bills,
                                                                                                        Current Payment on Old
                                                                                                        Medical Bills) in the following
                                                                                                        order: 1. Deemed individuals
                                                                                                        bills. 2. Bills for someone in the
                                                                                                        filing unit with no coverage
                                                                                                        group for the current month. 3.
                                                                                                        Bills for people who have
                                                                                                        declined coverage for the
                                                                                                        current month. 4. Bills for
                                                                                                        people with the highest
                                                                                                        incurment. 5. If two or more
                                                                                                        bills have the same date of
                                                                                                        service and both fit one of the
                                                                                                        above descriptions, the bills will
                                                                                                        be randomly sorted and then
                                                                                                        applied to the incurment.
INCUR   IDTL           38   Web Page Incurment Details   Incurment Detail   Incurment Detail            When the information is saved
                                                                                                        the sort order that the
                                                                                                        bills/payments were applied to a
                                                                                                        persons incurment reduction
                                                                                                        must be saved
INCUR   IDTL           39   Web Page Incurment Details   Incurment Detail   Incurment Detail            Bold the bill/payment that has
                                                                                                        potentially met the incurment
INCUR   IDTL           40   Web Page Incurment Details   Incurment Detail   Display Order               Display the bills/payments in the
                                                                                                        order that they were used to
                                                                                                        reduce the incurment and VA
                                                                                                        Aid and Attendence amounts for
                                                                                                        each individual
INCUR   IDTL           41   Web Page Incurment Details   Incurment Detail   Description                 Display description below each       Description: The incurment potentially has been met by
                                                                                                        persons detail bill/payment          the item shown in bold

                                                                                                        applied data stating what the
                                                                                                        bolded row represents

INCUR   IDTL           42   Web Page Incurment Details   Incurment Detail   Description                 Display description below each       Description: When the 'Applies only to VA Aid &
                                                                                                                                             Attendence' checkbox is checked, the bill could only be
                                                                                                        persons detail bill/payment
                                                                                                                                             used to offset the Aid & Attendence amount and cannot
                                                                                                        applied data stating what the VA     be used to meet the incurment
                                                                                                        Aid & Attendence indicator is
                                                                                                        used for if someone on the case
                                                                                                        has VA Aid & Attendence income

INCUR   IDTL           43   Web Page Incurment Details   Incurment Detail   Reset Button                Hide the incurment details when
                                                                                                        the reset button is pressed
Filename: CHIMES Requirements - Incurment Summary                                                              CHIMES                                                                                                                    Page 23
Version #1
1/7/2011


                                                                                                                                                                                                                  USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                      APPROVAL




                                                                                                                                                                                            Date Change from
                                                                                                                                                                                            Prev Version
  Ref
 Code   Ref Code                                                             Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                       Item/Response               "The system shall…"                 Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   ISUM               1   Web Page Incurment        Navigation          Navigation                  Allow access to this web page                     Design
                                        Summary                                                          as part of the incurment
                                                                                                         navigation flow
INCUR   ISUM               2   Web Page Incurment        Security            Security                    Allow only users with the same                    Design
                                        Summary                                                          jurisdiction as the worker
                                                                                                         currently assigned to the case,
                                                                                                         supervisors in any counties with
                                                                                                         the same jurisdiction as the as
                                                                                                         the worker currently assigned to
                                                                                                         the case, or with statewide
                                                                                                         update authority will be allowed
                                                                                                         to update information

INCUR   ISUM               3   Web Page Incurment        Incurment Summary   Incurment Summary           Display the most recent                           Design
                                        Summary                                                          incurment summary information
                                                                                                         for the benefit month for each
                                                                                                         person with an incurment amount

INCUR   ISUM               4   Web Page Incurment        Incurment Summary   Incurment Remaining         Determine the Incurment                           Design
                                        Summary                                                          Remaining using the same
                                                                                                         specifications listed in the
                                                                                                         Incurment Detail section
INCUR   ISUM               5   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the date of the day after                 Design
                                        Summary                                                          the incurment was met if the
                                                                                                         worker incurment detemination
                                                                                                         is Incurment Met and the
                                                                                                         incurment was met using current
                                                                                                         month medical bills or any
                                                                                                         combination of insurance
                                                                                                         premiums, medical bills, or
                                                                                                         current payments on old medical
                                                                                                         bills for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM               6   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the                      Design
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using past
                                                                                                         month bills only for the
                                                                                                         Coverage Begin Date field
INCUR   ISUM               7   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the                      Design
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using
                                                                                                         insurance premium payments
                                                                                                         only for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM               8   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the                      Design
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using a
                                                                                                         combination of medical bill
                                                                                                         carryover amounts, insurance
                                                                                                         premium payment carryover
                                                                                                         amounts, or current payments
                                                                                                         on old medical bill carryover
                                                                                                         amounts for the Coverage Begin
                                                                                                         Date field
Filename: CHIMES Requirements - Incurment Summary                                                              CHIMES                                                                                 Page 24
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                             Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                       Item/Response               "The system shall…"                 Comments
INCUR   ISUM               1   Web Page Incurment        Navigation          Navigation                  Allow access to this web page
                                        Summary                                                          as part of the incurment
                                                                                                         navigation flow
INCUR   ISUM               2   Web Page Incurment        Security            Security                    Allow only users with the same
                                        Summary                                                          jurisdiction as the worker
                                                                                                         currently assigned to the case,
                                                                                                         supervisors in any counties with
                                                                                                         the same jurisdiction as the as
                                                                                                         the worker currently assigned to
                                                                                                         the case, or with statewide
                                                                                                         update authority will be allowed
                                                                                                         to update information

INCUR   ISUM               3   Web Page Incurment        Incurment Summary   Incurment Summary           Display the most recent             Person, Incurment Amount, Incurment Remaining,
                                        Summary                                                          incurment summary information       Coverage Begin Date, How Met, Worker
                                                                                                                                             Determination, Cash Option Amount, Fiscal Authorized
                                                                                                         for the benefit month for each
                                                                                                         person with an incurment amount

INCUR   ISUM               4   Web Page Incurment        Incurment Summary   Incurment Remaining         Determine the Incurment             Would it make more sense to show the incurment
                                        Summary                                                          Remaining using the same            details (how the bills are applied to each person) for
                                                                                                                                             each person on this summary page?
                                                                                                         specifications listed in the
                                                                                                         Incurment Detail section
INCUR   ISUM               5   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the date of the day after
                                        Summary                                                          the incurment was met if the
                                                                                                         worker incurment detemination
                                                                                                         is Incurment Met and the
                                                                                                         incurment was met using current
                                                                                                         month medical bills or any
                                                                                                         combination of insurance
                                                                                                         premiums, medical bills, or
                                                                                                         current payments on old medical
                                                                                                         bills for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM               6   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using past
                                                                                                         month bills only for the
                                                                                                         Coverage Begin Date field
INCUR   ISUM               7   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using
                                                                                                         insurance premium payments
                                                                                                         only for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM               8   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is
                                                                                                         Incurment Met and the
                                                                                                         incurment was met using a
                                                                                                         combination of medical bill
                                                                                                         carryover amounts, insurance
                                                                                                         premium payment carryover
                                                                                                         amounts, or current payments
                                                                                                         on old medical bill carryover
                                                                                                         amounts for the Coverage Begin
                                                                                                         Date field
Filename: CHIMES Requirements - Incurment Summary                                                              CHIMES                                                                                                                    Page 25
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                                                                                                                                                                                                                  USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                      APPROVAL




                                                                                                                                                                                            Date Change from
                                                                                                                                                                                            Prev Version
  Ref
 Code   Ref Code                                                             Field/Attribute/Function/   Requirement Description             Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                       Item/Response               "The system shall…"                 Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   ISUM               9   Web Page Incurment        Incurment Summary   Coverage Begin Date         Display the first day of the                      Design
                                        Summary                                                          benefit month if the worker
                                                                                                         incurment detemination is Cash
                                                                                                         Option for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM           10      Web Page Incurment        Incurment Summary   How Met                     Display Cash Option in How Met                    Design
                                        Summary                                                          field if the worker determination
                                                                                                         is Cash Option
INCUR   ISUM           11      Web Page Incurment        Incurment Summary   How Met                     Display Past Month Bills in How                   Design
                                        Summary                                                          Met field if the incurment was
                                                                                                         met using only payments on
                                                                                                         past month bills
INCUR   ISUM           12      Web Page Incurment        Incurment Summary   How Met                     Display Premiums in How Met                       Design
                                        Summary                                                          field if the incurment was met
                                                                                                         using only premium payments
INCUR   ISUM           13      Web Page Incurment        Incurment Summary   How Met                     Display Current Bills in How Met                  Design
                                        Summary                                                          field if the incurment was met
                                                                                                         using only payments on current
                                                                                                         month bills
INCUR   ISUM           14      Web Page Incurment        Incurment Summary   How Met                     Display Combination in How Met                    Design
                                        Summary                                                          field if the incurment was met
                                                                                                         using more than one of the
                                                                                                         bills/payments from the
                                                                                                         categories Insurance Premiums,
                                                                                                         Medical Bills, or Current
                                                                                                         Payment on Old Medical Bills

INCUR   ISUM           15      Web Page Incurment        Incurment Summary   Cash Option Amount          Only display Cash Option                          Design
                                        Summary                                                          Amount if the worker incurment
                                                                                                         determination is Cash Option

INCUR   ISUM           16      Web Page Incurment        Incurment Summary   Cash Option Amount          Determine Cash Option amount                      Design
                                        Summary                                                          by subtracting any
                                                                                                         bills/payments that have been
                                                                                                         used to reduce the incurment
                                                                                                         amount from the incurment
                                                                                                         amount
INCUR   ISUM           17      Web Page Incurment        Incurment Summary   Fiscal Authorized Date      Only display Fiscal Authorized                    Design
                                        Summary                                                          date if a worker incurment
                                                                                                         determination is Cash Option
                                                                                                         and fiscal has authorized
INCUR   ISUM           18      Web Page Incurment        Finalize            Finalize                    Allow the worker to finalize the                  Design
                                        Summary                                                          worker determinations that were
                                                                                                         made
INCUR   ISUM           19      Web Page Incurment        Finalize            Incurment Amount            Validate the incurment amount                     Design      PCR 66
                                        Summary                              Remaining                   remaining and VA Aid &
                                                                                                         Attendence offset remaining are
                                                                                                         zero if the worker determination
                                                                                                         is incurment met
INCUR   ISUM           20      Web Page Incurment        Finalize            Incurment Determination     Set the incurment determination                   Design
                                        Summary                                                          to authorized when finalizing if
                                                                                                         the worker incurment
                                                                                                         determination is incurment met

INCUR   ISUM           21      Web Page Incurment        Finalize            Incurment Determination     Set the incurment determination                   Design
                                        Summary                                                          to approved when finalizing if
                                                                                                         the worker incurment
                                                                                                         determination is cash option
Filename: CHIMES Requirements - Incurment Summary                                                              CHIMES                                                                                 Page 26
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                             Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                       Item/Response               "The system shall…"                 Comments
INCUR   ISUM               1
                           9   Web Page Incurment        NavigationSummary
                                                         Incurment           NavigationBegin Date
                                                                             Coverage                    Allow access to day web page
                                                                                                         Display the first this of the
                                        Summary                                                          as part month incurment
                                                                                                         benefit of the if the worker
                                                                                                         navigation detemination is Cash
                                                                                                         incurment flow
                                                                                                         Option for the Coverage Begin
                                                                                                         Date field
INCUR   ISUM           10      Web Page Incurment        Incurment Summary   How Met                     Display Cash Option in How Met
                                        Summary                                                          field if the worker determination
                                                                                                         is Cash Option
INCUR   ISUM           11      Web Page Incurment        Incurment Summary   How Met                     Display Past Month Bills in How     What about carryover amounts? If the carryover
                                                                                                                                             amount for past month bills is used to meet the
                                        Summary                                                          Met field if the incurment was
                                                                                                                                             incurment do we display Past Month Bills in How Met
                                                                                                         met using only payments on          field?
                                                                                                         past month bills
INCUR   ISUM           12      Web Page Incurment        Incurment Summary   How Met                     Display Premiums in How Met         What about carryover amounts? If the carryover
                                        Summary                                                          field if the incurment was met      amount for premium payments is used to meet the
                                                                                                                                             incurment do we display Premiums in How Met field?
                                                                                                         using only premium payments
INCUR   ISUM           13      Web Page Incurment        Incurment Summary   How Met                     Display Current Bills in How Met    What about carryover amounts? If the carryover
                                        Summary                                                          field if the incurment was met      amount for medical bills is used to meet the incurment
                                                                                                                                             do we display Current Bills in How Met field?
                                                                                                         using only payments on current
                                                                                                         month bills
INCUR   ISUM           14      Web Page Incurment        Incurment Summary   How Met                     Display Combination in How Met
                                        Summary                                                          field if the incurment was met
                                                                                                         using more than one of the
                                                                                                         bills/payments from the
                                                                                                         categories Insurance Premiums,
                                                                                                         Medical Bills, or Current
                                                                                                         Payment on Old Medical Bills

INCUR   ISUM           15      Web Page Incurment        Incurment Summary   Cash Option Amount          Only display Cash Option
                                        Summary                                                          Amount if the worker incurment
                                                                                                         determination is Cash Option

INCUR   ISUM           16      Web Page Incurment        Incurment Summary   Cash Option Amount          Determine Cash Option amount        The bills/payments that can be used to reduce the
                                        Summary                                                          by subtracting any                  incurment amount can be found by looking at the
                                                                                                                                             specifications for the Incurment Detail section
                                                                                                         bills/payments that have been
                                                                                                         used to reduce the incurment
                                                                                                         amount from the incurment
                                                                                                         amount
INCUR   ISUM           17      Web Page Incurment        Incurment Summary   Fiscal Authorized Date      Only display Fiscal Authorized
                                        Summary                                                          date if a worker incurment
                                                                                                         determination is Cash Option
                                                                                                         and fiscal has authorized
INCUR   ISUM           18      Web Page Incurment        Finalize            Finalize                    Allow the worker to finalize the
                                        Summary                                                          worker determinations that were
                                                                                                         made
INCUR   ISUM           19      Web Page Incurment        Finalize            Incurment Amount            Validate the incurment amount
                                        Summary                              Remaining                   remaining and VA Aid &
                                                                                                         Attendence offset remaining are
                                                                                                         zero if the worker determination
                                                                                                         is incurment met
INCUR   ISUM           20      Web Page Incurment        Finalize            Incurment Determination     Set the incurment determination
                                        Summary                                                          to authorized when finalizing if
                                                                                                         the worker incurment
                                                                                                         determination is incurment met

INCUR   ISUM           21      Web Page Incurment        Finalize            Incurment Determination     Set the incurment determination
                                        Summary                                                          to approved when finalizing if
                                                                                                         the worker incurment
                                                                                                         determination is cash option
Filename: CHIMES Requirements - Incurment Summary                                                  CHIMES                                                                                                                   Page 27
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                                                                                                                                                                                                     USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                         APPROVAL




                                                                                                                                                                               Date Change from
                                                                                                                                                                               Prev Version
  Ref
 Code   Ref Code                                                 Field/Attribute/Function/   Requirement Description            Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category              Item/Response               "The system shall…"                Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   ISUM           27   Web Page Incurment        Finalize   Incurment Determination     If the worker incurment                          Design
                                     Summary                                                 determination is Cash Option
                                                                                             the cash option amount applies
                                                                                             to everyones incurment amount
                                                                                             on the case that has selected
                                                                                             Cash Option as the worker
                                                                                             incurment determination

INCUR   ISUM           22   Web Page Incurment        Finalize   Password                    Require a valid user password                    Design
                                     Summary                                                 when finalizing
INCUR   ISUM           23   Web Page Incurment        Finalize   Carryover                   Medical Bills, health insurance                  Design
                                     Summary                                                 premiums, medicare premiums,
                                                                                             and current payments on old
                                                                                             medical bills that were entered
                                                                                             in a prior benefit month and not
                                                                                             completely applied to the
                                                                                             incurment in that month are
                                                                                             eligible for being carried over.
                                                                                             Remaining portions can be
                                                                                             carried over.

INCUR   ISUM           24   Web Page Incurment        Finalize   Carryover                   Set the carryover amount for a                   Design
                                     Summary                                                 bill to the remaining amount
                                                                                             which is determined by
                                                                                             subtracting the maximum
                                                                                             amount of a bill that has been
                                                                                             used to reduce the incurment
                                                                                             amounts for bill where the date
                                                                                             of service is within the last 3
                                                                                             months from the total bill
                                                                                             amount and has not been paid
                                                                                             by Medicaid
INCUR   ISUM           25   Web Page Incurment        Finalize   Cash Option Form            Create a cash option form                        Design
                                     Summary                                                 request if the worker incurment
                                                                                             determination is Cash Option
                                                                                             when finalizing
INCUR   ISUM           26   Web Page Incurment        Finalize   One Day Authorization       Create a One Day                                 Design
                                     Summary                     Form                        Authorization Form request if
                                                                                             the incurment was met by
                                                                                             bills/payments and one bill is
                                                                                             split (client responsible for a
                                                                                             portion and medicaid resposible
                                                                                             for the rest)
INCUR   ISUM           28   Web Page Incurment        Finalize   Deauthorize                 Deauthorize QI1 determinations                   Design
                                     Summary                                                 if the worker incurment
                                                                                             determination is incurment met
                                                                                             or cash option and the QI1
                                                                                             determination has not been
                                                                                             issued
Filename: CHIMES Requirements - Incurment Summary                                                    CHIMES                                                                                 Page 28
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                   Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                Item/Response               "The system shall…"                Comments
INCUR   ISUM            1
                       27   Web Page Incurment        Navigation
                                                      Finalize     NavigationDetermination
                                                                   Incurment                   Allow worker incurment page
                                                                                               If the access to this web
                                     Summary                                                   as part of the incurment
                                                                                               determination is Cash Option
                                                                                               navigation flow amount applies
                                                                                               the cash option
                                                                                               to everyones incurment amount
                                                                                               on the case that has selected
                                                                                               Cash Option as the worker
                                                                                               incurment determination

INCUR   ISUM           22   Web Page Incurment        Finalize     Password                    Require a valid user password
                                     Summary                                                   when finalizing
INCUR   ISUM           23   Web Page Incurment        Finalize     Carryover                   Medical Bills, health insurance
                                     Summary                                                   premiums, medicare premiums,
                                                                                               and current payments on old
                                                                                               medical bills that were entered
                                                                                               in a prior benefit month and not
                                                                                               completely applied to the
                                                                                               incurment in that month are
                                                                                               eligible for being carried over.
                                                                                               Remaining portions can be
                                                                                               carried over.

INCUR   ISUM           24   Web Page Incurment        Finalize     Carryover                   Set the carryover amount for a     Example: Suzie has a $200 bill. She uses $50 and Tom
                                     Summary                                                   bill to the remaining amount       uses $100 of the bill. The remaining carryover amount =
                                                                                                                                  $100
                                                                                               which is determined by
                                                                                               subtracting the maximum
                                                                                               amount of a bill that has been
                                                                                               used to reduce the incurment
                                                                                               amounts for bill where the date
                                                                                               of service is within the last 3
                                                                                               months from the total bill
                                                                                               amount and has not been paid
                                                                                               by Medicaid
INCUR   ISUM           25   Web Page Incurment        Finalize     Cash Option Form            Create a cash option form          Refer to the Reports and Forms specifications for
                                                                                                                                  details on the cash option form
                                     Summary                                                   request if the worker incurment
                                                                                               determination is Cash Option
                                                                                               when finalizing
INCUR   ISUM           26   Web Page Incurment        Finalize     One Day Authorization       Create a One Day                   Refer to the Reports and Forms specifications for
                                                                                                                                  details on the one day authorization form
                                     Summary                       Form                        Authorization Form request if
                                                                                               the incurment was met by
                                                                                               bills/payments and one bill is
                                                                                               split (client responsible for a
                                                                                               portion and medicaid resposible
                                                                                               for the rest)
INCUR   ISUM           28   Web Page Incurment        Finalize     Deauthorize                 Deauthorize QI1 determinations
                                     Summary                                                   if the worker incurment
                                                                                               determination is incurment met
                                                                                               or cash option and the QI1
                                                                                               determination has not been
                                                                                               issued
Filename: CHIMES Requirements - Medically Needy Cash Option                                                         CHIMES                                                                                                                  Page 29
Version #1
1/7/2011


                                                                                                                                                                                                                     USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                         APPROVAL




                                                                                                                                                                                               Date Change from
                                                                                                                                                                                               Prev Version
  Ref
 Code   Ref Code                                                                 Field/Attribute/Function/   Requirement Description            Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                           Item/Response               "The system shall…"                Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   MNCO               1   Web Page Medically Needy   Navigation             Navigation                  Allow access to this web page                    Design
                                        Cash Option                                                          from the menue
INCUR   MNCO               2   Web Page Medically Needy   Security               Security                    Only users with fiscal authority                 Design
                                        Cash Option                                                          will be allowed to update
                                                                                                             information
INCUR   MNCO               3   Web Page Medically Needy   Batch Number           Change Create New           Allow user to view and add                       Design
                                        Cash Option                              Batch Number                batch numbers
INCUR   MNCO               4   Web Page Medically Needy   Batch Number           Total Payment Amount        Determine the total payment                      Design
                                        Cash Option                                                          amount for a batch when the
                                                                                                             finalize button is pressed
INCUR   MNCO               5   Web Page Medically Needy   Batch Number           Validation                  Validate the Batch Number has                    Design
                                        Cash Option                                                          not been previously used when
                                                                                                             saving
INCUR   MNCO               6   Web Page Medically Needy   Batch Number           Validation                  Validate the Batch Number                        Design
                                        Cash Option                                                          starts with MND followed by at
                                                                                                             least 1 number but not more
                                                                                                             than 7 numbers
INCUR   MNCO               7   Web Page Medically Needy   Batch Number           Save                        Only save batch numbers if                       Design
                                        Cash Option                                                          there are payment records
                                                                                                             associated with it
INCUR   MNCO               8   Web Page Medically Needy   Batch Number           Save                        Save the date the batch number                   Design
                                        Cash Option                                                          is created
INCUR   MNCO               9   Web Page Medically Needy   Cash Option Payments   Cash Option Payments        Allow user to view, modify, add,                 Design
                                        Cash Option                                                          and remove cash option
                                                                                                             payments
INCUR   MNCO           10      Web Page Medically Needy   Cash Option Payments   Default Number of Rows      Default the number of rows                       Design
                                        Cash Option                                                          displayed to 40 rows
INCUR   MNCO           11      Web Page Medically Needy   Cash Option Payments   Number of Rows              Validate the number of rows is                   Design
                                        Cash Option                                                          not more than 50 when saving
INCUR   MNCO           12      Web Page Medically Needy   Cash Option Payments   Batch Number                All fields will be display only                  Design
                                        Cash Option                                                          until a valid batch number is
                                                                                                             assigned
INCUR   MNCO           13      Web Page Medically Needy   Cash Option Payments   Sequence Number             Sequence Number field is                         Design
                                        Cash Option                                                          display only
INCUR   MNCO           14      Web Page Medically Needy   Cash Option Payments   Sequence Number             Generate the sequence number                     Design
                                        Cash Option                                                          and start with 1 for each batch
                                                                                                             number
INCUR   MNCO           15      Web Page Medically Needy   Cash Option Payments   Sequence Number             Sequence numbers will not be                     Design
                                        Cash Option                                                          reused within a batch if a
                                                                                                             payment is removed
INCUR   MNCO           16      Web Page Medically Needy   Cash Option Payments   Document Number             Validate the document number                     Design
                                        Cash Option                                                          is a valid document id for a
                                                                                                             payment slip when finalizing
INCUR   MNCO           17      Web Page Medically Needy   Cash Option Payments   Document Number             Validate the document number                     Design
                                        Cash Option                                                          is valid for the case number and
                                                                                                             benefit month when finalizing

INCUR   MNCO           18      Web Page Medically Needy   Cash Option Payments   Payment Amount              Validate the payment amount                      Design
                                        Cash Option                                                          matches the highest cash option
                                                                                                             amount for everyone on the
                                                                                                             case with a worker incurment
                                                                                                             determination of Cash Option

INCUR   MNCO           19      Web Page Medically Needy   Cash Option Payments   Case Number                 Validate the case number is a                    Design
                                        Cash Option                                                          valid case in the system when
                                                                                                             finalizing
INCUR   MNCO           20      Web Page Medically Needy   Cash Option Payments   Incurment Amount            Incurment Amount field is                        Design
                                        Cash Option                                                          display only
Filename: CHIMES Requirements - Medically Needy Cash Option                                                         CHIMES                                                                         Page 30
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                                 Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                           Item/Response               "The system shall…"                Comments
INCUR   MNCO               1   Web Page Medically Needy   Navigation             Navigation                  Allow access to this web page
                                        Cash Option                                                          from the menue
INCUR   MNCO               2   Web Page Medically Needy   Security               Security                    Only users with fiscal authority
                                        Cash Option                                                          will be allowed to update
                                                                                                             information
INCUR   MNCO               3   Web Page Medically Needy   Batch Number           Change Create New           Allow user to view and add         If the batch number entered has been used then
                                        Cash Option                              Batch Number                batch numbers                      retrieve the information otherwise the new batch
                                                                                                                                                number will be stored when finalized
INCUR   MNCO               4   Web Page Medically Needy   Batch Number           Total Payment Amount        Determine the total payment
                                        Cash Option                                                          amount for a batch when the
                                                                                                             finalize button is pressed
INCUR   MNCO               5   Web Page Medically Needy   Batch Number           Validation                  Validate the Batch Number has
                                        Cash Option                                                          not been previously used when
                                                                                                             saving
INCUR   MNCO               6   Web Page Medically Needy   Batch Number           Validation                  Validate the Batch Number
                                        Cash Option                                                          starts with MND followed by at
                                                                                                             least 1 number but not more
                                                                                                             than 7 numbers
INCUR   MNCO               7   Web Page Medically Needy   Batch Number           Save                        Only save batch numbers if
                                        Cash Option                                                          there are payment records
                                                                                                             associated with it
INCUR   MNCO               8   Web Page Medically Needy   Batch Number           Save                        Save the date the batch number
                                        Cash Option                                                          is created
INCUR   MNCO               9   Web Page Medically Needy   Cash Option Payments   Cash Option Payments        Allow user to view, modify, add,   Sequence Number, Document Number, Payment
                                        Cash Option                                                          and remove cash option             Amount, Case Number, Benefit Month, Incurment
                                                                                                                                                Amount, Error Message
                                                                                                             payments
INCUR   MNCO           10      Web Page Medically Needy   Cash Option Payments   Default Number of Rows      Default the number of rows
                                        Cash Option                                                          displayed to 40 rows
INCUR   MNCO           11      Web Page Medically Needy   Cash Option Payments   Number of Rows              Validate the number of rows is
                                        Cash Option                                                          not more than 50 when saving
INCUR   MNCO           12      Web Page Medically Needy   Cash Option Payments   Batch Number                All fields will be display only
                                        Cash Option                                                          until a valid batch number is
                                                                                                             assigned
INCUR   MNCO           13      Web Page Medically Needy   Cash Option Payments   Sequence Number             Sequence Number field is
                                        Cash Option                                                          display only
INCUR   MNCO           14      Web Page Medically Needy   Cash Option Payments   Sequence Number             Generate the sequence number
                                        Cash Option                                                          and start with 1 for each batch
                                                                                                             number
INCUR   MNCO           15      Web Page Medically Needy   Cash Option Payments   Sequence Number             Sequence numbers will not be
                                        Cash Option                                                          reused within a batch if a
                                                                                                             payment is removed
INCUR   MNCO           16      Web Page Medically Needy   Cash Option Payments   Document Number             Validate the document number
                                        Cash Option                                                          is a valid document id for a
                                                                                                             payment slip when finalizing
INCUR   MNCO           17      Web Page Medically Needy   Cash Option Payments   Document Number             Validate the document number
                                        Cash Option                                                          is valid for the case number and
                                                                                                             benefit month when finalizing

INCUR   MNCO           18      Web Page Medically Needy   Cash Option Payments   Payment Amount              Validate the payment amount
                                        Cash Option                                                          matches the highest cash option
                                                                                                             amount for everyone on the
                                                                                                             case with a worker incurment
                                                                                                             determination of Cash Option

INCUR   MNCO           19      Web Page Medically Needy   Cash Option Payments   Case Number                 Validate the case number is a
                                        Cash Option                                                          valid case in the system when
                                                                                                             finalizing
INCUR   MNCO           20      Web Page Medically Needy   Cash Option Payments   Incurment Amount            Incurment Amount field is
                                        Cash Option                                                          display only
Filename: CHIMES Requirements - Medically Needy Cash Option                                                       CHIMES                                                                                                                  Page 31
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                                                                                                                                                                                                                   USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                       APPROVAL




                                                                                                                                                                                             Date Change from
                                                                                                                                                                                             Prev Version
  Ref
 Code   Ref Code                                                               Field/Attribute/Function/   Requirement Description            Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #    Category   Sub Category                            Item/Response               "The system shall…"                Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   MNCO           21   Web Page Medically Needy    Cash Option Payments   Error Message               Error Message field is display                   Design
                                     Cash Option                                                           only
INCUR   MNCO           22   Web Page Medically Needy    Cash Option Payments   Finalize                    Allow the user to finalize the      9/6/2005     Design
                                     Cash Option                                                           cash option payments that were
                                                                                                           entered.
INCUR   MNCO           23   Web Page Medically Needy    Cash Option Payments   Finalize                    Validate there is at least one                   Design
                                     Cash Option                                                           person on the case with an
                                                                                                           incurment and the worker
                                                                                                           incurment determination is Cash
                                                                                                           Option for benefit month
INCUR   MNCO           24   Web Page Medically Needy    Cash Option Payments   Finalize                    Require a valid user password                    Design
                                     Cash Option                                                           when finalizing
INCUR   MNCO           25   Web Page Medically Needy    Cash Option Payments   Finalize                    Disable Finalize button once the                 Design
                                     Cash Option                                                           batch information has been
                                                                                                           successfully finalized
INCUR   MNCO           26   Web Page Medically Needy    Cash Option Payments   Finalize                    Lock all information for the                     Design
                                     Cash Option                                                           batch from any changes once
                                                                                                           the batch has been successfully
                                                                                                           finalized
INCUR   MNCO           27   Web Page Medically Needy    Cash Option Payments   Finalize                    Set incurment determination to                   Design
                                     Cash Option                                                           authorized for any persons
                                                                                                           whose incurment was met with
                                                                                                           the payment amount on the
                                                                                                           case and the incurment
                                                                                                           determination was Cash Option
INCUR   MNCO           28   Web Page Medically Needy    Cash Option Payments   Add Rows                    Provide the ability to add Cash     5/4/2007     Design
                                     Cash Option                                                           Option Payments rows.
INCUR   MNCO           29   Web Page Medically Needy    Cash Option Payments   Add Rows                    Provide the ability to enter how    5/4/2007     Design
                                     Cash Option                                                           many Cash Option Payments
                                                                                                           rows to add.
INCUR   MNCO           30   Web Page Medically Needy    Cash Option Payments   Add Rows                    Default the number of rows to       5/4/2007     Design
                                     Cash Option                                                           add to one.
INCUR   MNCO           31   Web Page Medically Needy    Cash Option Payments   Add Rows                    When the Add button is              5/4/2007     Design
                                     Cash Option                                                           pressed, the indicated # of rows
                                                                                                           to add will be displayed.
INCUR   MNCO           32   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Provide the ability to remove       5/4/2007     Design
                                     Cash Option                               Payments                    Medical Bills rows.
INCUR   MNCO           33   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Require a Cash Option               5/4/2007     Design
                                     Cash Option                               Payments                    Payments row to be selected for
                                                                                                           removal when pressing the
                                                                                                           Remove button.
INCUR   MNCO           34   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Present the user with one blank     5/4/2007     Design
                                     Cash Option                               Payments                    Cash Option Payment row if all
                                                                                                           other Cash Option Payment
                                                                                                           rows are removed.
Filename: CHIMES Requirements - Medically Needy Cash Option                                                       CHIMES                                 Page 32
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                               Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #    Category   Sub Category                            Item/Response               "The system shall…"                Comments
INCUR   MNCO            1
                       21   Web Page Medically Needy    Navigation Payments
                                                        Cash Option            Navigation
                                                                               Error Message               Allow Message field is display
                                                                                                           Error access to this web page
                                     Cash Option                                                           from the menue
                                                                                                           only
INCUR   MNCO           22   Web Page Medically Needy    Cash Option Payments   Finalize                    Allow the user to finalize the
                                     Cash Option                                                           cash option payments that were
                                                                                                           entered.
INCUR   MNCO           23   Web Page Medically Needy    Cash Option Payments   Finalize                    Validate there is at least one
                                     Cash Option                                                           person on the case with an
                                                                                                           incurment and the worker
                                                                                                           incurment determination is Cash
                                                                                                           Option for benefit month
INCUR   MNCO           24   Web Page Medically Needy    Cash Option Payments   Finalize                    Require a valid user password
                                     Cash Option                                                           when finalizing
INCUR   MNCO           25   Web Page Medically Needy    Cash Option Payments   Finalize                    Disable Finalize button once the
                                     Cash Option                                                           batch information has been
                                                                                                           successfully finalized
INCUR   MNCO           26   Web Page Medically Needy    Cash Option Payments   Finalize                    Lock all information for the
                                     Cash Option                                                           batch from any changes once
                                                                                                           the batch has been successfully
                                                                                                           finalized
INCUR   MNCO           27   Web Page Medically Needy    Cash Option Payments   Finalize                    Set incurment determination to
                                     Cash Option                                                           authorized for any persons
                                                                                                           whose incurment was met with
                                                                                                           the payment amount on the
                                                                                                           case and the incurment
                                                                                                           determination was Cash Option
INCUR   MNCO           28   Web Page Medically Needy    Cash Option Payments   Add Rows                    Provide the ability to add Cash
                                     Cash Option                                                           Option Payments rows.
INCUR   MNCO           29   Web Page Medically Needy    Cash Option Payments   Add Rows                    Provide the ability to enter how
                                     Cash Option                                                           many Cash Option Payments
                                                                                                           rows to add.
INCUR   MNCO           30   Web Page Medically Needy    Cash Option Payments   Add Rows                    Default the number of rows to
                                     Cash Option                                                           add to one.
INCUR   MNCO           31   Web Page Medically Needy    Cash Option Payments   Add Rows                    When the Add button is
                                     Cash Option                                                           pressed, the indicated # of rows
                                                                                                           to add will be displayed.
INCUR   MNCO           32   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Provide the ability to remove
                                     Cash Option                               Payments                    Medical Bills rows.
INCUR   MNCO           33   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Require a Cash Option
                                     Cash Option                               Payments                    Payments row to be selected for
                                                                                                           removal when pressing the
                                                                                                           Remove button.
INCUR   MNCO           34   Web Page Medically Needy    Cash Option Payments   Remove Cash Option          Present the user with one blank
                                     Cash Option                               Payments                    Cash Option Payment row if all
                                                                                                           other Cash Option Payment
                                                                                                           rows are removed.
Filename: CHIMES Requirements - Provider Search                                                                CHIMES                                                                                                                    Page 33
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                                                                                                                                                                                                                  USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                      APPROVAL




                                                                                                                                                                                            Date Change from
                                                                                                                                                                                            Prev Version
  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description              Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                      Item/Response               "The system shall…"                  Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   PS                 1   Web Page Provider Search   Navigation        Navigation                  Allow access to this web page                      Design
                                                                                                        from the incurment bill entry
                                                                                                        page
INCUR   PS                 2   Web Page Provider Search   Security          Security                    Allow only users with the same                     Design
                                                                                                        jurisdiction as the worker
                                                                                                        currently assigned to the case,
                                                                                                        supervisors in any counties with
                                                                                                        the same jurisdiction as the as
                                                                                                        the worker currently assigned to
                                                                                                        the case, or with statewide
                                                                                                        update authority will be allowed
                                                                                                        to update information

INCUR   PS                 3   Web Page Provider Search   Search Fields     Search Fields               Allow the user to search for a                     Design
                                                                                                        provider
INCUR   PS                 4   Web Page Provider Search   Search Fields     State                       Allow user to select State from a                  Design
                                                                                                        predetermined list
INCUR   PS                 5   Web Page Provider Search   Search Fields     State                       Default State field to Montana                     Design
INCUR   PS                 6   Web Page Provider Search   Search Fields     Validation                  Require at least two search                        Design
                                                                                                        fields to contain data before
                                                                                                        performing search
INCUR   PS                 7   Web Page Provider Search   Provider Search   Search Results              Display provider search results                    Design




INCUR   PS                 8   Web Page Provider Search   Provider Search   Provider                    Only display providers that are                    Design
                                                                                                        part of the provider list provided
                                                                                                        from ACS




INCUR   PS                 9   Web Page Provider Search   Provider Search   Provider                    Allow user to select a provider                    Design
                                                                                                        from the providers found in the
                                                                                                        search results
INCUR   PS             10      Web Page Provider Search   Provider Search   Provider                    Allow the user to enter a                          Design
                                                                                                        provider that was not found in
                                                                                                        ACS provider list


INCUR   PS             11      Web Page Provider Search   Provider Search   Provider                    Require a provider name when                       Design
                                                                                                        saving a new unfound provider
INCUR   PS             12      Web Page Provider Search   Provider Search   Provider                    Return the selected provider                       Design
                                                                                                        information to the calling page
INCUR   PS             13      Web Page Provider Search   Page Buttons      Submit                      Validate a provider has been                       Design
                                                                                                        selected when the submit button
                                                                                                        is pressed
INCUR   PS             14      Web Page Provider Search   Page Buttons      Cancel                      Allow the user to not select or                    Design
                                                                                                        enter a provider and return to
                                                                                                        the calling page
Filename: CHIMES Requirements - Provider Search                                                                CHIMES                                                                                     Page 34
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                            Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                      Item/Response               "The system shall…"                  Comments
INCUR   PS                 1   Web Page Provider Search   Navigation        Navigation                  Allow access to this web page
                                                                                                        from the incurment bill entry
                                                                                                        page
INCUR   PS                 2   Web Page Provider Search   Security          Security                    Allow only users with the same
                                                                                                        jurisdiction as the worker
                                                                                                        currently assigned to the case,
                                                                                                        supervisors in any counties with
                                                                                                        the same jurisdiction as the as
                                                                                                        the worker currently assigned to
                                                                                                        the case, or with statewide
                                                                                                        update authority will be allowed
                                                                                                        to update information

INCUR   PS                 3   Web Page Provider Search   Search Fields     Search Fields               Allow the user to search for a       Clinic Name, Provider Name, City, and State
                                                                                                        provider
INCUR   PS                 4   Web Page Provider Search   Search Fields     State                       Allow user to select State from a
                                                                                                        predetermined list
INCUR   PS                 5   Web Page Provider Search   Search Fields     State                       Default State field to Montana
INCUR   PS                 6   Web Page Provider Search   Search Fields     Validation                  Require at least two search
                                                                                                        fields to contain data before
                                                                                                        performing search
INCUR   PS                 7   Web Page Provider Search   Provider Search   Search Results              Display provider search results      Clinic/Practice/Office Name, Provider Name, Provider
                                                                                                                                             Number, Provider Tax ID, Provider Type, Provider
                                                                                                                                             Specialty, Provider Physical Address, Provider Mailing
                                                                                                                                             Address, Provider Effective Date, Provider Office
                                                                                                                                             Phone Number, Provider End Date


INCUR   PS                 8   Web Page Provider Search   Provider Search   Provider                    Only display providers that are      Any providers that were entered by the user will not be
                                                                                                                                             returned in the search results.
                                                                                                        part of the provider list provided
                                                                                                                                             This will cause the user to have to enter the provider
                                                                                                        from ACS                             multiple times for the same provider. If ACS later adds
                                                                                                                                             this provider to the list how do we reconcile the multiple
                                                                                                                                             instances or do we care?


INCUR   PS                 9   Web Page Provider Search   Provider Search   Provider                    Allow user to select a provider
                                                                                                        from the providers found in the
                                                                                                        search results
INCUR   PS             10      Web Page Provider Search   Provider Search   Provider                    Allow the user to enter a            Clinic/Practice/Office Name, Provider Name, Provider
                                                                                                                                             Type, Provider Tax ID, Provider Physical Address,
                                                                                                        provider that was not found in
                                                                                                                                             Provider Specialty, Provider Office Phone Number,
                                                                                                        ACS provider list                    Provider Mailing Address
                                                                                                                                             Does the address information need to be captured like
                                                                                                                                             all other addresses?
INCUR   PS             11      Web Page Provider Search   Provider Search   Provider                    Require a provider name when         This requirement does not belong here.
                                                                                                        saving a new unfound provider
INCUR   PS             12      Web Page Provider Search   Provider Search   Provider                    Return the selected provider
                                                                                                        information to the calling page
INCUR   PS             13      Web Page Provider Search   Page Buttons      Submit                      Validate a provider has been
                                                                                                        selected when the submit button
                                                                                                        is pressed
INCUR   PS             14      Web Page Provider Search   Page Buttons      Cancel                      Allow the user to not select or      Cancel button
                                                                                                        enter a provider and return to
                                                                                                        the calling page
Filename: CHIMES Requirements - Provider Details                                                                 CHIMES                                                                                                               Page 35
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                                                                                                                                                                                                               USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                   APPROVAL




                                                                                                                                                                                         Date Change from
                                                                                                                                                                                         Prev Version
  Ref
 Code   Ref Code                                                              Field/Attribute/Function/   Requirement Description         Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category                        Item/Response               "The system shall…"             Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   PD                 1   Web Page Provider Details   Navigation         Navigation                  Allow access to this web page                 Design
                                                                                                          from the incurment bill entry
                                                                                                          page
INCUR   PD                 2   Web Page Provider Details   Provider Details   Provider Details            Display provider information                  Design




INCUR   PD                 3   Web Page Provider Details   Provider Details   Provider Details            Display provider details as a    5/4/2007     Design
                                                                                                          popup window
Filename: CHIMES Requirements - Provider Details                                                                 CHIMES                                                                            Page 36
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                                              Field/Attribute/Function/   Requirement Description
 Area    Module    Ref #       Category   Sub Category                        Item/Response               "The system shall…"             Comments
INCUR   PD                 1   Web Page Provider Details   Navigation         Navigation                  Allow access to this web page
                                                                                                          from the incurment bill entry
                                                                                                          page
INCUR   PD                 2   Web Page Provider Details   Provider Details   Provider Details            Display provider information    Clinic/Practice/Office Name, Provider Name, Provider
                                                                                                                                          Number, Provider Tax ID, Provider Type, Provider
                                                                                                                                          Specialty, Provider Physical Address, Provider Mailing
                                                                                                                                          Address, Provider Effective Date, Provider Office
                                                                                                                                          Phone Number, Provider End Date


INCUR   PD                 3   Web Page Provider Details   Provider Details   Provider Details            Display provider details as a
                                                                                                          popup window
Filename: CHIMES Requirements - Incurment History                                                                        CHIMES                                                                                                                      Page 37
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                                                                                                                                                                                                                              USER REQUIREMENT
REQUIREMENTS TRACEABILITY MATRIX                                                                                                                                                                                                  APPROVAL




                                                                                                                                                                                                        Date Change from
                                                                                                                                                                                                        Prev Version
  Ref
 Code   Ref Code                                            Field/Attribute/Function/                              Requirement Description               Date Req.    Phase Req.   Req.     Date Req.                      Date User
 Area    Module    Ref #       Category   Sub Category      Item/Response                                          "The system shall…"                   Introduced   Introduced   Source   Removed                        Approved Approving User
INCUR   IHIST              1   Web Page Incurment History   Navigation                  Navigation                 Allow access to this web page                       Design      PCR 12
                                                                                                                   from a menu
INCUR   IHIST              2   Web Page Incurment History   Navigation                  Navigation                 Allow access to this web page                       Design      PCR 12
                                                                                                                   as part of the incurment
                                                                                                                   navigation flow
INCUR   IHIST              3   Web Page Incurment History   Navigation                  Navigation                 Provide the ability to navigate to                  Design      PCR 12
                                                                                                                   the Incurment Detail web page
                                                                                                                   for a version of the incurment
                                                                                                                   determination
INCUR   IHIST              4   Web Page Incurment History   Incurment History Detail    Incurment History Detail   Display the incurment                               Design      PCR 12
                                                                                                                   determination history
                                                                                                                   information for persons on a
                                                                                                                   case
INCUR   IHIST              5   Web Page Incurment History   Incurment History Detail    Incurment History Detail   Display information for the                         Design      PCR 12
                                                                                                                   benefit month selected and the
                                                                                                                   three prior benefit months
INCUR   IHIST              6   Web Page Incurment History   Incurment History Detail    Sort Order                 Sort the Eligibility Determination                  Design      PCR 12
                                                                                                                   Date with the most recent being
                                                                                                                   first
INCUR   IHIST              7   Web Page Incurment History   Incurment History Detail    Sort Order                 Sort the incurment records                          Design      PCR 12
                                                                                                                   within an eligibility determination
                                                                                                                   by the Incurment Determination
                                                                                                                   Date with the most recent being
                                                                                                                   first
INCUR   IHIST              8   Web Page Incurment History   Incurment History Detail    Description                Display description of what the                     Design      PCR 12
                                                                                                                   information shown represents



INCUR   IHIST              9   Web Page Incurment History   Incurment History Detail    Program Descrption         Append program description to                       Design      PCR 12
                                                                                                                   the coverage group description
                                                                                                                   if the coverage group is Family
                                                                                                                   and the program is either
                                                                                                                   Medically Needy, Transitional,
                                                                                                                   or Extended
Filename: CHIMES Requirements - Incurment History                                                                        CHIMES                                                                                      Page 38
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REQUIREMENTS TRACEABILITY MATRIX



  Ref
 Code   Ref Code                                            Field/Attribute/Function/                              Requirement Description
 Area    Module    Ref #       Category   Sub Category      Item/Response                                          "The system shall…"                   Comments
INCUR   IHIST              1   Web Page Incurment History   Navigation                  Navigation                 Allow access to this web page
                                                                                                                   from a menu
INCUR   IHIST              2   Web Page Incurment History   Navigation                  Navigation                 Allow access to this web page
                                                                                                                   as part of the incurment
                                                                                                                   navigation flow
INCUR   IHIST              3   Web Page Incurment History   Navigation                  Navigation                 Provide the ability to navigate to
                                                                                                                   the Incurment Detail web page
                                                                                                                   for a version of the incurment
                                                                                                                   determination
INCUR   IHIST              4   Web Page Incurment History   Incurment History Detail    Incurment History Detail   Display the incurment                 Eligibility Determination Date, Coverage Group,
                                                                                                                                                         Incurment Amount, Incurment Determination Date,
                                                                                                                   determination history
                                                                                                                                                         Worker Determination
                                                                                                                   information for persons on a
                                                                                                                   case
INCUR   IHIST              5   Web Page Incurment History   Incurment History Detail    Incurment History Detail   Display information for the
                                                                                                                   benefit month selected and the
                                                                                                                   three prior benefit months
INCUR   IHIST              6   Web Page Incurment History   Incurment History Detail    Sort Order                 Sort the Eligibility Determination
                                                                                                                   Date with the most recent being
                                                                                                                   first
INCUR   IHIST              7   Web Page Incurment History   Incurment History Detail    Sort Order                 Sort the incurment records
                                                                                                                   within an eligibility determination
                                                                                                                   by the Incurment Determination
                                                                                                                   Date with the most recent being
                                                                                                                   first
INCUR   IHIST              8   Web Page Incurment History   Incurment History Detail    Description                Display description of what the       Description: This web page shows determinations for
                                                                                                                   information shown represents          the benefit month displayed and the three months prior
                                                                                                                                                         to the displayed benefit month. To view more history,
                                                                                                                                                         change the case information to a different benefit month.


INCUR   IHIST              9   Web Page Incurment History   Incurment History Detail    Program Descrption         Append program description to
                                                                                                                   the coverage group description
                                                                                                                   if the coverage group is Family
                                                                                                                   and the program is either
                                                                                                                   Medically Needy, Transitional,
                                                                                                                   or Extended

				
DOCUMENT INFO
Description: Blank Medical Bill Forms document sample