Defining Claim Pricing Rules in an Aggregate Stop-Loss Pricing Rule

Procedure

To define claim pricing rules in an aggregate stop-loss pricing rule:

  1. Ensure that the Pricing Information section is expanded when you have selected an option from the Parent Customer's SSL or ASL Pricing Rules field of Main section while defining or editing an aggregate stop-loss pricing rule.
    The Pricing Information section contains the following section:

    • 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 claim while calculating aggregate stop-loss.

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

      • Line Items - Used to associate line items 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 pricing. No
    On clicking the Reapply Claim Template button to the right side of the Effective Claim Pricing Rule field you can reapply for claim pricing rule.
    Note: The Reapply Claim Template button appears when you are editing an aggregate stop-loss.

    The Domestic Provider Claims section contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Exclude ASL (Percentage) Used to specify the domestic provider claim billable charge line excluding the aggregate stop-loss in percentage to create 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 Indicates the pricing strategy. The valid values are:

    • Markdown

    • Markup

    • None

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

    • Flat Amount

    • Percentage

    		 Not applicable
    Markup or Markdown Amount Displays the markup or markdown amount.
    Note: This field displays amount when Markup or Markdown Type field is Flat Amount.
    		 Not applicable

    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
    Eligible for Specific Stop-Loss Used to specify whether the line item is eligible or not eligible for aggregate stop-loss. No
    Markup or Markdown Percentage Eligibility Displays 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 Displays the percentage for markup or markdown value. Not applicable
  2. Select the required details in the Claim Pricing Rule section, if required.
  3. Enter the required details in the Domestic Provider Claims section, if required.
  4. Select the required details in the Line Items section, if required.
  5. Click Save.
    The claim line items are defined in the aggregate stop-loss pricing rule.
  6. You can define eligibility claim line items for each rule in an aggregate stop-loss pricing rule.
    Note: You can exclude a rule from the aggregate stop-loss pricing by selecting the Exclude Rule checkbox.

Related Topics

For more information on... See...
How to define an aggregate stop-loss pricing rule for a bill group Defining an Aggregate Stop-Loss Pricing Rule for a Bill Group
How to edit an aggregate stop-loss pricing rule of a bill group Editing an Aggregate Stop-Loss Pricing Rule of a Bill Group