Defining Claim Pricing Information in a Level Funded Pricing Rule

Procedure

To define the claim pricing information in the level funded pricing rule:

  1. Ensure that the Pricing Information for rule type category : Claim zone is expanded when you have selected an option from the Price Item field of the Main section while defining or editing a level funded pricing rule for a bill group.
    The Pricing Information for rule type category : Claim zone contains the following fields:
    Field Name Field Description Mandatory (Yes or No)
    Pricing Rule Type Used to indicate the claim pricing rule type effective for level funded pricing. Yes
    Derive Using Used to indicate the method through which the claim pricing rule information is derived. The valid values are:

    • LF Line Items

    • Pricing Rules

    		 Yes
    If LF Line Items option is selected from the Derive Using field, the following sub-sections appear:

    • Domestic Provider Claims - Used to specify the domestic provider claims while calculating the level funding line items.

    • Markup or Markdown Values - Used to define the markup or markdown values for level funding line items.

    • Line Items - Used to associate the line items which are eligible for billing.

    The Domestic Provider Claims section contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Exclude LF (Percentage) Used to specify the billable charge line excluding the level funding charge in the percentage to create the domestic provider claim calculation lines. No

    The Markup or Markdown Values section contains the following fields:

    Field Name Field Description Mandatory (Yes or No)
    Pricing Strategy Used to indicate the pricing strategy for the claim line items. The valid values are:

    • Markdown

    • Markup

    • None

    		 Not applicable
    Markup or Markdown Type Used to indicate the markup or markdown value type for the claim line items. The valid values are:

    • Flat Amount

    • Percentage

    		 Not applicable
    Markup or Markdown Amount Used to specify the markup or markdown amount for the claim line items.
    Note: This field displays amount when Markup or Markdown Type field is set as Flat Amount.
    		 Not applicable
    Markup / Markdown Included in Settlement? Used to specify whether markup or markdown amount should be included in the level funding settlement. The valid values are:

    • Yes

    • No

    Note: This field is required when Flat Amount option is selected from the Markup or Markdown Type field.
    		 Yes (Conditional)
    Note: This field is required when Flat Amount option is selected from the Markup or Markdown Type field.

    The Line Items section contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Line Item Used to indicate the line item which is eligible for level funded pricing.
    Note:

    The Search (The Search Icon) icon appears corresponding to the Line Item field. On clicking the Search (The Search Icon) icon corresponding to the Line Item field, the Pricing Rule Line Item Search window appears.

    On specifying the pricing rule line item, the description of the pricing rule line item appears corresponding to the Line Item field.

    		 No
    If Pricing Rule Type option is selected from the Derive Using field, following sub-sections appear:

    • Claim Pricing Rule - Used to indicate the claim pricing rule. It contains the following sub-sections:

      • Domestic Provider Claims - Used to specify the domestic provider claims while calculating the level funded pricing.

      • Markup or Markdown Values - Used to define the markup or markdown values for the billable charge line items.

      • Line Items - Used to associate the line items which are eligible for billing.

    The Claim Pricing Rule section contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Effective Claim Pricing Rule Used to indicate the claim pricing rule effective for level funded pricing. No
    Note: If you are editing a bill group's level funded pricing rule for the Claim rule type category (where the bill group's pricing has ended), aReapply button appears corresponding to the Effective Claim Pricing Rule field. You can select an effective claim pricing rule and click the Reapply button to set a new pricing for the claim rule type that is eligible for level funding.

    The Domestic Provider Claims section contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Exclude LF (Percentage) Used to specify the billable charge line excluding the level funding charge in the percentage to create the domestic provider claim calculation lines. No

    The Markup or Markdown Values section contains the following fields:

    Field Name Field Description Mandatory (Yes or No)
    Pricing Strategy Used to indicate the pricing strategy for the claim line items. The valid values are:

    • Markdown

    • Markup

    • None

    		 Not applicable
    Markup or Markdown Type Used to indicate the markup or markdown value type for the claim line items. The valid values are:

    • Flat Amount

    • Percentage

    		 Not applicable
    Markup or Markdown Amount Used to specify the markup or markdown amount for the claim line items.
    Note: This field displays amount when Markup or Markdown Type field is set as Flat Amount.
    		 Not applicable
    Markup / Markdown Included in Settlement? Used to specify whether markup or markdown amount should be included in the level funding settlement. The valid values are:

    • Yes

    • No

    Note: This field is required when Flat Amount option is selected from the Markup or Markdown Type field.
    		 Yes (Conditional)
    Note: This field is required when Flat Amount option is selected from the Markup or Markdown Type field.

    The Line Items section contains the following fields:

    Field Name Field Description Mandatory (Yes or No)
    Sequence Displays the sequence number for the line items. Not applicable
    Line Item Displays the billing line items. Not applicable
    Include in Settlement Used to indicate whether the line item should be included in the level funded claim pricing settlement. No
    Markup or Markdown Included in Settlement Used to indicate whether markup or markdown should be included in the level funded claim settlement. No
    Markup or Markdown Percentage Eligibility Used to indicate whether the line item is eligible or not eligible for markup or markdown percentage. The valid values are:

    • Eligible

    • Not Eligible

    		 Not applicable
    Markup or Markdown Percentage Used to indicate the percentage for markup or markdown value. Not applicable
  2. Enter the required details in the appropriate sections, based on the option that is selected from the Derive Using field.
  3. If you want to add information for more than one claim pricing rule type to the level funded pricing rule, click the Add (The Add Icon) icon and then repeat step 2.
    Note: However, if you want to remove information of more than one claim pricing rule type from the level funded pricing rule, click the Delete (The Delete Icon) icon corresponding to the pricing rule type field.
  4. Click Save.
    The claim line items are defined in the level funded pricing rule.

Related Topics

For more information on... See...
How to define level funded pricing rule for a bill group Defining a Level Funded Pricing Rule for a Bill Group
How to edit level funded pricing rule for a bill group Editing a Level Funded Pricing Rule of a Bill Group