Pricing Templates

Pricing templates are an efficiency tool, used to generate draft provider pricing clauses. A pricing template is set up beforehand, and then applied during the creation of provider pricing clauses that implement a contract with a healthcare provider. Instead of keying in all needed provider pricing clauses for the contract, a pricing configuration analyst can select and apply a pricing template which includes prebuilt provider pricing clauses.

A pricing template allows for reuse of prebuilt provider pricing clauses. This is desirable when different contracts with healthcare providers are similar. In reality, this is often the case: the contracts a healthcare payer negotiates with providers are often much alike, differing only in details such as heights of inflators or whether or not a specific set of services is reimbursed at all.

This text describes the functionality of pricing templates. Please refer also to the following texts in this implementation guide:

• "Page: Draft Provider Pricing Clauses - Worksheet" : describes draft provider pricing clauses.

• "Provider Pricing Clause Model" : describes real provider pricing clauses.

Structure Overview

Pricing templates consist of pricing options, grouped together in sections. A section is analogous to a section in a contract with a healthcare provider; it contains one or more sets of clauses which pertain to the pricing of particular healthcare services. A pricing option is analogous to a particular instance of such a set of clauses. A pricing option contains a set of prebuilt provider pricing clauses.

Upon applying a pricing template for a particular contract, a pricing configuration analyst walks though the sections in the template and selects from each section the option(s) needed for the particular contract. As such the pricing configuration analyst indicates which prebuilt provider pricing clauses should be copied to the contract being worked on.

The following example illustrates a pricing template. It shows a number of sections and options in a pricing template for contracts with hospitals regarding outpatient care:

• Template: Hospital Contract - Outpatient Care

  • Section: Emergency Room Rate

    • Option: Pay case rate

    • Option: Pay percent of charges

    • Option: Deny

  • Section: Observation Rate

    • Option: Pay by blocks of hours

    • Option: Pay case rate

    • Option: Pay hourly rate

    • Option: Pay percent of charges

    • Option: Deny

  • Section: Laboratory Rates

    • Option: Pay by fee schedule

The options contain the prebuilt provider pricing clauses. For example, the option "Pay by case rate" under section "Emergency Room Rate" may contain the following provider pricing clauses:

1. A provider pricing clause for claim classification "ER" under scheme "OUTPATIENT" that points to a fee schedule in which case rates for the concerned room and board revenue codes are set up

2. A provider pricing clause for claim classification "ER" under scheme "OUTPATIENT" that points to an inclusion rule which will include (i.e. not pay) all other claim lines in the (primary) room and board line.

3. A provider pricing clause for claim classification "ER" under scheme "OUTPATIENT" that points to a lower of rule for this particular set of services.

So instead of keying in these provider pricing clauses for a new contract, a pricing configuration analyst selects the concerned option from the template and gets these provider pricing clauses 'for free' in the contract at hand. Such reuse is not only efficient but also promotes consistency of provider pricing clauses across contracts.

Pricing options are created independently from pricing templates. This means that a pricing option may be reused in different templates. Also, configuration analysts may wish to apply a single option only, instead of an entire template. Therefore, OHI Claims offers two UI dialogs: one for applying a template (i.e. many related options) and one for applying a single option only.

Partial Provider Pricing Clauses

The prebuilt provider pricing clauses included in pricing options are called partial provider pricing clauses. Partial, because they only contain a subset of the fields that a real (or draft) provider pricing clause includes. The following provider pricing clause fields are not included in a partial provider pricing clause:

• Contract Reference

• Individual Provider (code and definition)

• Organization Provider (code and definition)

• Provider Group

• Product Category

• Start Date

These fields are not included in a partial provider pricing clause because they are likely to differ per contract, i.e. they are not reusable. Rather, upon applying a pricing template (or a single option) the pricing configuration analyst can indicate the values of these fields for that particular contract.

Even though partial provider pricing clauses do contain the field 'Conditions' (for dynamic conditions), upon applying a pricing template a condition can also be indicated. This condition will be added to the list of conditions of all generated draft provider pricing clauses. I.e., a generated draft provider pricing clause will get both the specified condition and the conditions configured in the partial provider pricing clause from which it was generated.

Note that the fields 'End Date' and 'Enabled?' are not included in partial provider pricing clauses. It does not make sense to put an end date on a reusable provider pricing clause, nor does it make sense to disable a reusable provider pricing clause (a partial provider pricing clause is implicitly enabled).

Example

The following example illustrates how a pricing template is used to generate draft provider pricing clauses in a worksheet.

Setting:

• a new hospital has been contracted with (start date: 01/01/2013; contract reference: 2.71828; organization provider: 314159265) .

• this contract implements two payment styles; one for risk person (product lines HMO or POS) and one for referral persons (product line PPO).

• services for referral persons are reimbursed at a percent of charge; services for risk persons are reimbursed using different methods (amongst which case rates).

• a pricing configuration analyst creates a new worksheet that will contain all draft provider pricing clauses regarding outpatient services for the new contract .

• the pricing configuration analyst uses the pricing template "Hospital Contract - Outpatient Care" (illustrated above) to generate draft provider pricing clauses into the worksheet, rather than keying them in.

• In this example, the pricing configuration analyst will only select options for section "Emergency Room Rate". Normally, it would be likely that a pricing configuration analyst would select options for all (or most) sections.

Steps:

• The pricing configuration analyst generates the needed draft provider pricing clauses for risk persons. These are reimbursed at a case rate:

  • Using the pricing template, the pricing configuration analyst selects the option "Pay by case rate" under section "Emergency Room Rate. As described earlier, this option consists of three partial provider pricing clauses that together implement the case rate.

  • The pricing configuration analyst enters the following parameters with which to augment the partial provider pricing clauses and generate draft provider pricing clauses:

    • start date: 01/01/2013

    • contract reference: 2.71828

    • organization provider: 314159265

    • product categories: HMO ; POS

    • condition: Risk Person

  • The pricing configuration analyst submits and the draft provider pricing clauses are generated.

• The pricing configuration analyst generates the needed draft provider pricing clauses for referral person. These are reimbursed at a percent of charge:

  • Using the pricing template, the pricing configuration analyst selects the option "Pay percent of charges" under section "Emergency Room Rate. This option consists of one partial provider pricing clauses that points to a charged amount reimbursement method.

  • The pricing configuration analyst enters the following parameters with which to augment the partial provider pricing clauses and generate draft provider pricing clauses:

    • start date: 01/01/2013

    • contract reference: 2.71828

    • organization provider: 314159265

    • product categories: PPO

    • condition: Referral Person

  • The pricing configuration analyst submits and the draft provider pricing clauses are generated.

Resulting draft provider pricing clauses (not all fields are displayed):

Grouping Label	Code	Method / Rule	Type	Contract Ref.	Org. Provider	Product Category	Conditions	Start Date	Class. Scheme	Claim Class.
ER - Case Rate	0001	ER CASE RATES	Fee Schedule	2.71828	3141592	HMO	Risk Person;	01/01/2013	OUTPT	ER
ER - Case Rate	0002	GEN INRU	Inclusion	2.71828	3141592	HMO	Risk Person;	01/01/2013	OUTPT	ER
ER - Case Rate	0003	GEN LORU	Lower of	2.71828	3141592	HMO	Risk Person;	01/01/2013	OUTPT	ER
ER - Case Rate	0004	ER CASE RATES	Fee Schedule	2.71828	3141592	POS	Risk Person;	01/01/2013	OUTPT	ER
ER - Case Rate	0005	GEN INRU	Inclusion	2.71828	3141592	POS	Risk Person;	01/01/2013	OUTPT	ER
ER - Case Rate	0006	GEN LORU	Lower of	2.71828	3141592	POS	Risk Person;	01/01/2013	OUTPT	ER
ER - Percent of charges	0007	GEN CHAM	Charged Amount	2.71828	3141592	PPO	Referral Person;	01/01/2013	OUTPT	ER

Notes:

• The draft provider pricing clauses with codes 0001-0006 implement the case rate for risk persons. They were created in the first generation. The three partial provider pricing clauses in the option "Case Rate" are duplicated to six draft provider pricing clauses because the configuration analyst specified two product categories for the generation: HMO and POS.

• The draft provider pricing clause with code 0007 implements the percent of charges for referral persons. It was created in the second generation.

• Upon generating a pricing option, its partial provider pricing clauses are generated in the order of their sequence into draft provider pricing clauses. Thus in the code of draft provider pricing clauses the sequential order of partial provider pricing clauses is retained (as demonstrated above).

• After generating there may still be some work to do. For example, the pricing configuration analyst should walk through the generated draft provider pricing clauses and specify (where needed) the correct quantifier.

Pricing Templates Model

Pricing Template

A pricing template has the following fields:

Pricing Template

Field	Description
Code	The code of the pricing template
Description	The description of the pricing template
Access Restriction	Determines whether or not the access to the pricing template is restricted

A pricing template includes zero, one or more pricing sections:

Pricing Section

Field	Description
Pricing Template	The pricing template to which the pricing section refers
Sequence	The sequence of the pricing section; pricing sections are displayed in the order of their sequence
Display Name	The display name of the pricing section

A pricing section includes zero, one or more pricing section options. These are references to pricing options which may be used in different pricing sections (see description of pricing options below):

Pricing Section Option

Field	Description
Pricing Section	The pricing section to which the pricing section option refers
Sequence	The sequence of the pricing section option; pricing section options are displayed in the order of their sequence
Pricing Option	The pricing option to which the pricing section option refers
Default?	Will the option be selected by default if the pricing template containing the pricing section is used?
Display Name Override	The display name of the pricing option within the pricing section; this overrides the display name of the pricing option. If not specified, the pricing option’s display name is used
Grouping Label Override	The grouping label of the pricing option within the pricing section; this overrides the grouping label of the pricing option. If not specified, the pricing option’s grouping label is used

Pricing Option

A pricing option is created independently from pricing templates. It has the following fields:

Pricing Option

Field	Description
Code	The code of the pricing option
Description	The description of the pricing option
Display Name	The display name of the pricing option
Grouping Label	The grouping label for draft provider pricing clauses created from the option; used for the sole purpose of grouping in UI pages
Access Restriction	Determines whether or not the access to the pricing option is restricted

Upon deleting a pricing option, it is automatically removed from all pricing templates where it was included. The templates in which an option is included are displayed in the UI page for pricing options. Thus, a pricing configuration analyst can determine the impact of deleting an option, before choosing to indeed delete it.

A pricing option contains zero, one or more partial provider pricing clauses. Note that partial provider pricing clauses, like draft provider pricing clauses, do not contain references to other configuration components but rather store their identifying codes. During the build of draft provider pricing clauses (which could be created from partial provider pricing clauses) all the identifying codes of configuration components are resolved to actual references. Thus, like draft provider pricing clauses, partial provider pricing clauses may a.o. contain codes of configuration components that do not yet exist (i.e. to which a reference cannot yet be made):

Partial Provider Pricing Clause

Field	Description
Pricing Option	The pricing option to which the partial provider pricing clause refers
Sequence	The sequence of the partial provider pricing clause. This field has two purposes: (1) Partial provider pricing clauses are displayed in the order of their sequence (2) Upon applying a pricing option its partial provider pricing clauses are copied to draft provider pricing clauses in the order of their sequence
Description	The description of the clause
Provider category	The provider category for which this clause applies
Reimbursement method	The reimbursement method to calculate the (initial) allowed amount
Reimbursement method type	The type of the reimbursement method
Pricing rule	The pricing rule to adjust the allowed amount
Pricing rule type	The type of the pricing rule
Exempt?	Does the provider pricing clause specify exemption from a pricing rule?
Quantifier	Dependent on the reimbursement method type or pricing rule type referred to, the quantifier specifies an applicable number, amount or percentage.
Quantifier Currency	The currency that applies to the quantifier of the type amount
Priority	The priority determines the precedence order of a provider pricing clause when multiple clauses of the same type apply and one must be chosen
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The procedure group to which this clause applies
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition to which this clause applies
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second procedure group to which this clause applies
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition to which this clause applies
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third procedure group to which this clause applies
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition to which this clause applies
Location type group usage	Is the location type group in scope or not in scope?
Location type group	The location type group to which this clause applies
Classification scheme usage	How should the classification scheme list be evaluated? In: When one of the classification schemes in the list is present on the claim Not In: When none of the classification schemes in the list are present on the claim
Claim classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim Not In: When none of the classifications in the list are present on the claim
Claim line classification usage	How should the claim line classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line
Restrict to reimbursement method usage	How should the restrict to reimbursement method list be evaluated? In: When one of the reimbursement methods in the list is applied to the claim line Not In: When none of the reimbursement methods in the list are applied to the claim line
Message	The message that is attached to the claim line if the provider pricing clause is applied
Age from	The start age of the serviced person
Age to	The end age of the serviced person (up to and including)

A partial provider pricing clause can specify classification schemes (also stored by identifying codes, not with references):

Partial Provider Pricing Clause Classification Scheme

Field	Description
Partial Provider Pricing Clause	The partial provider pricing clause to which the partial provider pricing clause classification scheme applies.
Classification Scheme	The classification scheme to which the partial provider pricing clause classification scheme applies.

A partial provider pricing clause can specify claim classifications (also stored by identifying codes, not with references):

Partial Provider Pricing Clause Claim Classification

Field	Description
Partial Provider Pricing Clause	The partial provider pricing clause to which the partial provider pricing clause claim classification applies.
Classification	The classification to which the partial provider pricing clause claim classification applies.

A partial provider pricing clause can specify claim line classifications (also stored by identifying codes, not with references):

Partial Provider Pricing Clause Claim Line Classification

Field	Description
Partial Provider Pricing Clause	The partial provider pricing clause to which the partial provider pricing clause claim line classification applies.
Classification	The classification to which the partial provider pricing clause claim line classification applies.

A partial provider pricing clause can specify restrict to reimbursement methods (also stored by identifying codes, not with references):

Partial Provider Pricing Clause Restrict Reimbursement Method

Field	Description
Partial Provider Pricing Clause	The partial provider pricing clause to which the provider pricing clause restrict reimbursement method applies.
Reimbursement Method	The reimbursement method to which the partial provider pricing clause restrict reimbursement method applies.
Reimbursement Method Type	The type of the reimbursement method to which the partial provider pricing clause restrict reimbursement method applies.

A partial provider pricing clause can be made more specific by adding dynamic logic conditions to it (also stored by identifying codes, not with references):

Partial Provider Pricing Clause Dynamic Logic

Field	Description
Partial Provider Pricing Clause	The partial provider pricing clause to which the condition applies
Condition	A dynamic logic condition that serves as a condition that must be met by a provider pricing clause.

Dynamic fields

It is possible to define dynamic fields on the table for partial provider pricing clauses. During generation, the values of these dynamic fields are copied to corresponding dynamic fields on the draft provider pricing clauses. However, to successfully copy a dynamic field value from a partial provider pricing clause to a draft provider pricing clause, the dynamic field should be defined in parallel on both the tables for partial and draft provider pricing clauses. Dynamic fields in both tables are matched by their field usage name.

The generation of a pricing option will fail if a dynamic field value cannot be copied. In this case one of the following messages is displayed:

Code	Sev	Message
PRI-DPPC-028	Fatal	Pricing option "{displayName}" (code: {code}) could not be generated because the dynamic field usage {dynamicFieldUsageName} is not defined on the table PRI_DRAFT_PROV_PRI_CLAUSES
PRI-DPPC-029	Fatal	Pricing option "{displayName}" (code: {code}) could not be generated because setup of dynamic field usage {dynamicFieldUsageName} for tables and PRI_DRAFT_PROV_PRI_CLAUSES is not compatible.