Claim Template Extendable Lookup

The ASO service provider may bill different charges for a claim transaction to different employers. The system enables you to create different claim templates for different employers. A claim template contains a set of charges (i.e. line items) which can be billed to a parent customer or bill group. You can define multiple claim templates in the system. Each claim template must be defined in the system using the Claim Template (C1-ExtLookClaimTemplate) extendable lookup. A claim template encapsulates the following information:

  • Whether the claim template can be used while defining a claim pricing rule for a policy which is in the In Force/Active, Post Runout, or Runout status.

  • Line items which can be billed to a parent customer or bill group.

  • Whether you want to calculate the markup or markdown on the line items which are included in the claim template.

  • Whether you want to specify a flat markup or markdown amount for the line items or the markup or markdown percentage for the line items which are eligible for percentage based markup or markdown

  • Whether a line item is eligible for billing or not.

  • Whether you want to define rule based billing eligibility for a line item.

  • Whether you want to define billing eligibility for a line item while defining a claim pricing rule.

  • Rule type which indicates the rules that should be executed to determine whether the line item is eligible for billing.

  • Whether the line item is eligible for percentage based markup or markdown when the markup or markdown type is set to Percentage.

Once a claim template is defined in the extendable lookup, you can associate the claim template with a claim pricing rule type. You can associate multiple claim templates with a claim pricing rule type. Then, while defining a claim pricing rule for a parent customer, you can use any one of the claim template associated with the respective claim pricing rule type. The system then inherits the line items and the default markup and markdown values in the claim pricing rule from the claim template.

However, while defining a claim pricing rule for a policy of a bill group, you can only use the claim templates which are defined for the respective policy status and associated with the respective claim pricing rule type.

For example, the following table illustrates few claim templates with different line items:
Claim Template Policy Status Line Item Billing Eligibility Pricing Strategy Markup or Markdown Type Markup or Markdown Amount Markdown or Markdown Percentage
CT1 In Force/Active CDH Yes Markup Flat Amount $2 -
THC Yes
PCC No
CT2 Runout CDH Yes Markdown Percentage - 2.00
THC Yes
CT3 Post Runout PCC Yes None - - -
NAF No

The Extendable Lookup Query screen allows you to search for an extendable lookup. It contains the following zone:

Related Topics

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How to search for the Claim Template extendable lookup Searching for the Claim Template Extendable Lookup
How to view the values of the Claim Template extendable lookup Viewing the Values of the Claim Template Extendable Lookup

Parent Topic: Self-Funded Pricing