Line Item Extendable Lookup

Different charges, such as consumer-driven amount, traditional health insurance amount, network access fees, and so on are received as part of the claim transaction. These charges which contribute to the total claim amount are defined as the line items in the system. Each line item must be defined in the system using the Line Item (C1-ExtLookPricingRuleLineItem) extendable lookup. A line item encapsulates the following information:

• Service Quantity Identifier (SQI) which indicates the transaction field in which the charge amount is stored. It is also used while calculating the percentage based markup or markdown for the charge.

• Billable charge line type using which you want to create the calculation line for the charge.

• Whether the system should write off the charge when it is not eligible for billing.

• Billable charge line type using which you want to create the write off calculation line for the charge.

• Whether the charge should be considered while calculating the percentage based retention type claim based fee.

• The pricing rule type categories to which the charge is associated.

The CDH and THC line items can be included in a claim template. They can also be considered while calculating specific and aggregate stop-loss. The CDH and PCC line items can be considered while defining pricing arrangements in an ancillary pricing rule type. In addition, any charge received for the CDH and THC line items in a claim transaction will be written off when these line items are not eligible for billing.

The C1-ExtLookPricingRuleLineItem extendable lookup is redesigned to:

• Specify a billable charge line type using which the calculation line should be created for a rate type when the system calculates the fees separately for each applicable claim charge

• Specify a billable charge line type using which the calculation line should be created for a rate type when the system calculates the minimum and maximum markup or markdown separately for each eligible claim charge

• Specify a billable charge line type using which the calculation line should be created for a rate type when the system calculates the minimum and maximum amount for a line item

Once you derive the pricing information from a claim pricing rule in a specific stop-loss pricing rule, you need to specify whether the additional fee (if any) is eligible for specific stop-loss. If so, it is considered for calculating specific stop-loss.

Once you derive the pricing information from a claim pricing rule in an aggregate stop-loss pricing rule, you need to specify whether the additional fee (if any) is eligible for aggregate stop-loss. If so, it is considered for calculating aggregate stop-loss.

Once you derive the pricing information from a claim pricing rule in a level-funded pricing rule, you need to specify whether the additional fee (if any) should be settled through level funding. If so, it is considered while accumulating level funded charges.

Until now, when the Include In Settlement column was selected corresponding to a line item in a level funded pricing rule, the system settled the charge as well as its markup or markdown through level funding. However, now, the system provides two different options - one which helps to determine whether the charge should be settled through level funding and another which helps to determine whether the corresponding markup or markdown should be settled through level funding.

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

• Extendable Lookup Search

Related Topics

Parent Topic: Self-Funded Pricing