Retention Type Claim Based Pricing

The ASO service provider provides claim administrative services and pays the claim amount on behalf of the employer. Different charges, such as administration fees, network fees, managed care fees, are typically charged as retention type claim based fees. The system enables you to charge a flat or percentage based retention type claim based fee. The rate schedule defined in the respective rate option indicates whether the retention type claim based fee is a flat fee or percentage based fee. The system considers the claim line items for calculating the percentage based retention type claim based fee when the Retention Claim Based Percentage Calculation field is set to Yes.

You can define a retention type claim based pricing rule at the parent customer and bill group levels. The retention type claim based pricing rule at the bill group level takes precedence over the retention type claim based pricing rule at the parent customer level. You can define retention type claim based pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define a retention type claim based pricing rule using a retention type claim based pricing rule type. It is the retention type claim based pricing rule type which helps the system to determine:

  • Business object using which the retention type claim based pricing rule should be created in the system.

  • Algorithm which should be triggered while validating a transaction.

Note: An algorithm type for validating a transaction is not shipped from the product. You need to create a custom algorithm type, if required.

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

Note: You must create an algorithm using the C1_​ACCPRIDRV algorithm type and attach it to the Account and Price Item Derivation system event. The C1_​BAFTDRV algorithm sets the bill after date to the end date of the aggregation schedule which is specified in the respective rate option. For example, if the aggregation schedule is monthly, the bill after date is set to the last day of the month.

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

Note: You must create an algorithm using the C1_​BAFTDRV algorithm type and attach it to the Bill After Date Determination system event.

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

Note: A post-processing algorithm type is not shipped from the product. You need to create a custom algorithm type, if required.

  • Price items for which you can define retention type claim based pricing rules using the retention type claim based 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 defining retention type claim based pricing rules.

  • Additional information, such as:

    • Whether the price items included in the retention type claim based pricing rule type are used while accumulating 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.

    • Indicates how the claim must be disposed. If the Claim Disposition field in the transaction is set to Yes, you must set the disposition mode to Align Signage. However, if the Claim Disposition field in the transaction is set to No, you must set the disposition mode to Zero Out.

Note: If the Disposition Mode field is set to Align Signage, the claim based fees is positive for positive claims and the claim based fees is negative for negative claims. However, if the Disposition Mode field is set to Zero Out, the claim based fees for the negative claims is set to zero (0).
Once a retention type claim based pricing rule type is defined, you can create retention type claim based pricing rules using the retention type claim based pricing rule type. While defining a retention type claim based 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 which you want to use while defining the retention type claim based pricing.

  • Price item parameters based on which you want to define the pricing.

Note: You can only use those price item parameters which are included in the respective retention type claim based pricing rule type.

  • Flat or percentage based fee which you want to charge for a price item and price item parameters combination.

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

  • Price item parameters based on which you want to define the pricing.

Note: You can only use those price item parameters which are included in the respective retention type claim based pricing rule type.

  • Flat or percentage based fee which you want to charge for a price item and price item parameters combination.

The system enables you to define different flat or percentage based fee for different set of price item parameters combination. For example, you can define one flat fee for the claim transactions where health coverage is set to Dental and submission type is set to Paper and another flat fee for the claim transactions where health coverage is set to Dental and submission type is set to Paper.

Once a retention type claim based pricing rule is defined for a parent customer and bill group, the system creates one price assignment for each set of price item parameters combination, one price list, and one price list assignment.

Related Topics

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Pricing Rule Type screen Pricing Rule Type

Parent Topic: Self-Funded Pricing