Claim Pricing

The ASO service provider processes the claims as part of the ASO agreement and pays the claim amount to either hospital or main subscriber. The employer, in turn, reimburses the claim amount to the ASO service provider at the end of the bill period (i.e. typically, every month). Apart from charging the claim amount to the employer, the ASO service provider charges various additional fees, such as fee for network access, fee for non-network access, fee for collection services provided by external vendor, fee for hospital audit performed by external vendor, and so on.

Oracle Revenue Management and Billing allows the ASO service provider to bill the employers for the claim amount and various additional fees. You can use any custom mechanism or the file upload utility in ORMB to upload the claim transactions. The pricing for the claim transactions can be defined using the claim pricing rules. You can define a claim pricing rule at the parent customer and bill group levels. The claim pricing rule at the bill group level takes precedence over the claim pricing rule at the parent customer level. You can define claim pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define a claim pricing rule using a claim pricing rule type.

• Pricing rule types which are related to claim pricing rule type.

• Transaction fields from where the data for claim, specific stop-loss, aggregate stop-loss, retention type claim based processing should be retrieved.

• Algorithm which should be triggered while validating a transaction.

• Algorithms which should be triggered while deriving bill group, account, and price item for a transaction.

• Algorithm which should be triggered while determining the bill after date.

• Post-processing algorithm which should be triggered once the claim pricing rule is derived.

• Price items for which you can define claim pricing rules using the claim pricing rule type.

• Rate options that you can use while defining the pricing for a price item.

• Different type of account to which the price item should be billed based on the specified priority.

• Price item parameters which you can use while accumulating specific stop-loss and aggregate stop-loss and while aggregating transactions.

• Claim templates which can be used while defining claim pricing rules using the claim pricing rule type.

• Additional information, such as:

  • Whether the price items included in the claim pricing rule type are eligible for specific stop-loss and aggregate stop-loss.

  • Identifiers which help to determine whether the claim transaction is received during the run-in period of the policy.

  • Billable charge line type using which you want to create markup or markdown calculation lines.

  • Transaction field which you want to use in the rules as the output parameter to determine whether the line item is eligible for billing.

  • Transaction field which you want to use in the rules as the output parameter to determine whether the markup or markdown calculation line is eligible for billing.

Once a claim pricing rule type is defined, you can create claim pricing rules using the claim pricing rule type. While defining a claim pricing rule for a parent customer and bill group, you need to specify the following:

• Price item for which you want to define the pricing.

• Pricing date range during which the pricing is effective.

• Rate option and claim template which you want to use while defining the claim pricing.

• Whether you want to markup or markdown the various charges.

• Whether you want to use a flat amount for markup or markdown on overall charges.

• Whether you want to calculate markup or markdown amount based on percentage for each eligible charge.

• Whether a line item is eligible for billing when the billing eligibility for the line item in the claim template is set to User Defined.

In addition, while defining a claim pricing rule for a bill group, you need to specify the status of the policy for which you want to define the claim pricing rule. You can also specify a pricing group while defining a claim pricing rule for a bill group. If you specify a pricing group while defining a claim pricing rule for a bill group, you will have to define the following details for each rule defined in the pricing group:

• Whether you want to markup or markdown the various charges.

• Whether you want to use a flat amount for markup or markdown on overall charges.

• Whether you want to calculate markup or markdown amount based on percentage for each eligible charge.

• Whether a line item is eligible for billing when the billing eligibility for the line item in the claim template is set to User Defined.

Once a claim pricing rule is defined for a parent customer and bill group, the system creates one price assignment, one price list, and one price list assignment.

Related Topics

Parent Topic: Self-Funded Pricing