Claims Classification Model
The purpose of classifying claims is to simplify the pricing of claim lines which follows in a later step. Pricing makes use of configurable components like provider pricing clauses. Instead of equipping these components each with many intricate conditions to define the claim lines they apply to, this can be reduced to specifying which classification they apply to. As such, complexity is moved from every single pricing component into one generic structure for all claims: claim classification.
Claim classification also aligns OHI Claims with the perspective of its users. For example, users might see a claim as a SNF (skilled nursing facility) claim or as a REHAB claim. By explicitly classifying claims, the classifications SNF and REHAB are no longer only words spoken by OHI Claims users, but are captured in OHI Claims, visible in the user interface, usable in the configuration of pricing.
Classification Scheme Model
A classification scheme looks as follows:
Classification Scheme
| Field | Description |
|---|---|
Code |
The code of the classification scheme. |
Description |
The description of the classification scheme. |
Location Type Group Usage |
How should the location type group be evaluated? In: When the location type group includes the location type specified on the claim header Not In: When the location type group does not include the location type specified on the claim header (if at all specified) |
Location Type Group |
The location type group to which the location type specified on the claim header is compared. |
Claim condition |
The dynamic logic condition that defines the claims to which the classification scheme applies. |
Detail condition |
This condition is evaluated as if it were attached to every classification scheme detail under this scheme. |
Classification Scheme Claim Forms
| Field | Description |
|---|---|
Classification scheme |
The classification scheme to which the classification scheme claim form refers. |
Claim form |
The claim form to which the classification scheme applies. |
The location type group usage must be specified when a location type group is used and may not be specified when it is not used.
A classification scheme has one or more details which are used to classify claim lines:
Classification Scheme Details
| Field | Description |
|---|---|
Classification scheme |
The classification scheme to which the classification scheme detail refers. |
Classification |
The classification to classify the claim line with when the classification scheme detail is applicable to the claim line. |
Priority |
The priority of the classification scheme detail. This is used to (1) determine precedence when more than one detail applies to a claim line and (2) for the 'overall' claim classification. |
Location type group usage |
How should the location type group be evaluated? In: When the location type group includes the location type specified on the claim line Not In: When the location type group does not include the location type specified on the claim line (if at all specified) |
Location type group |
The location type group to which the location type specified on the claim line is compared. |
Claim line condition |
The dynamic logic condition that defines the claim lines to which the classification scheme detail applies. |
Procedure group |
The group with the procedures to which the classification scheme detail applies. |
Procedure condition |
The procedure condition that defines the procedures to which the classification scheme detail applies. |
Procedure group 2 |
The second group with the procedures to which the classification scheme detail applies. |
Procedure condition 2 |
The second procedure condition that defines the procedures to which the classification scheme detail applies. |
Procedure group 3 |
The third group with the procedures to which the classification scheme detail applies. |
Procedure condition 3 |
The third procedure condition that defines the procedures to which the classification scheme detail applies. |
Modifier usage |
How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line. |
Diagnosis usage |
How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line. |
Diagnosis group |
The group with the diagnoses to which the classification scheme detail applies. |
Diagnosis condition |
The diagnosis condition that defines the diagnoses to which the classification scheme detail applies. |
Provider group |
The group with the providers to which the classification scheme detail applies. |
Provider category |
The provider category to which the classification scheme detail applies. |
Product category |
The product category to which the classification scheme detail applies. |
Authorization condition |
Reference to a dynamic logic condition. If specified, this classification scheme detail only applies if the referenced condition returns "True" for any of the person’s or object’s authorizations. For this, the person’s or object’s authorizations are evaluated against the specified condition, one by one, new to old. When an authorization is 'hit' that returns 'True', this classification scheme detail applies to the claim line - further evaluation of authorizations is then omitted. |
Start date |
The start date of the classification scheme detail. |
End date |
The end date of the classification scheme detail. |
Classification Scheme Detail Modifiers
| Field | Description |
|---|---|
Classification scheme detail |
The classification scheme detail to which the classification scheme detail modifier refers. |
Modifier |
The modifier to which the classification scheme detail modifier refers. |
Constraints:
-
The location type group usage must be specified when a location type group is used and may not be specified when it is not used.
-
Either a diagnosis group or a diagnosis condition can be specified, but not both.
-
The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.
-
The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.
Classification Components Model
The claims classification models comprises several reusable components specific to claims classification.
Classification priorities
Classification priorities are used to determine which classification scheme detail takes precedence when multiple are applicable and one must be selected.
Classification priorities have a user friendly display name which is displayed in the setup of classification schemes.
Classification Priorities
| Field | Description |
|---|---|
Code |
The code of the classification priority |
Priority |
The relative priority when evaluating classification scheme details (1 means highest priority) |
Display Name |
The display name of the classification priority |