Provider Pricing Clauses Model

Provider pricing clauses are used in the pricing of claim lines. A provider pricing clause is a formalized section of a contract with a provider regarding the price of the provider’s services. A contract with a provider can normally be broken down into many provider pricing clauses. During claims pricing, provider pricing clauses are evaluated to see if they apply and can be used to calculate a price for a claim line: the allowed amount. The allowed amount represents the sum of money a provider is entitled to for rendering the services specified on a claim line.

There are two general types of provider pricing clauses: (1) provider pricing clauses that refer to a reimbursement method and (2) provider pricing clauses that refer to a pricing rule. To price a claim line, multiple provider pricing clauses can be applied. One provider pricing clause is required that points to a reimbursement method with which the initial allowed amount can be calculated. Often, one or more other provider pricing clauses also apply that point to supplemental pricing rules. The final allowed amount is then calculated by applying all the pricing rules to the initial allowed amount in a predefined order.

A provider pricing clause specifies both when it applies and how it influences the allowed amount.

Consider the following example to understand how multiple provider pricing clauses may be applied to a single claim line:

• For pricing of a claim line a provider pricing clause is selected that points to the reimbursement method 'Fee Schedule'. It also specifies exactly which fee schedule to use.

• The price of the rendered procedure is looked up in the fee schedule and multiplied by the rendered units: $ 100 x 3 units = $ 300,-

• Another provider pricing clause is selected that points to a pricing rule which specifies that the rendered services are only paid at 80% of the fee schedule price: 80% x $ 300,- = $ 240,-

• Another provider pricing clause is selected that points to a pricing rule which specifies that the allowed amount cannot be higher than the amount which is actually charged by the claimant. In this case the charged amount is $ 230,- , therefore the allowed amount is capped at $ 230,-.

• No other provider pricing clauses are selected. The final allowed amount is set at $ 230,-

This chapter explains the model of provider pricing clauses. Provider pricing clauses refer to other components like reimbursement methods and pricing rules. For a description of these, please refer to the components model.

Fields

A provider pricing clause has the following fields:

Provider Pricing Clause

Field	Description
Description	The description of the provider pricing clause
Individual provider	The individual provider for whom this clause applies
Organization provider	The organization provider for which this clause applies
Provider group	The provider group for which this clause applies
Provider category	The provider category for which this clause applies
Reimbursement method	The reimbursement method to calculate the (initial) allowed amount
Pricing Rule	The pricing rule to adjust the allowed amount
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 (see text "Usage of the quantifier" below).
Quantifier Amount 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
Product category	The product category for which this clause applies
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 claim 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 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
Contract reference	The code of the contract reference that identifies the contract comprising the provider pricing clause
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)
Start date	The first service day for which this clause applies
End date	The last service day for which this clause applies
Enabled?	Is the provider pricing clause enabled?
Access Restriction	Determines whether or not the access to the provider pricing clause is restricted

The following table specifies the placeholder values for messages that are attached to claim lines when a provider pricing clause is applied:

• 0. Sub-step (e.g. Before Reimbursement Message Rule, After Reimbursement Method Message Rule, Charged Amount, Adjustment Rule)

• 1. Reimbursement method description or pricing rule description

• 2. Contract reference

• 3. Quantifier

• 4. Procedure group/Procedure condition description of the specified procedure groups/conditions (comma separated)

• 5. Provider category description

• 6. Product category description

• 7. Age from, Age to (as one item, separated by a dash)

• 8. Exempt?

• 9. Description

A provider pricing clause can specify classification schemes.

Provider Pricing Clause Classification Scheme

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

A provider pricing clause can specify claim classifications.

Provider Pricing Clause Claim Classification

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

A provider pricing clause can specify claim line classifications.

Provider Pricing Clause Claim Line Classification

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

A provider pricing clause can specify restrict to reimbursement methods.

Provider Pricing Clause Restrict Reimbursement Method

Field	Description
Provider Pricing Clause	The provider pricing clause to which the provider pricing clause restrict reimbursement method applies.
Reimbursement Method	The reimbursement method to which the provider pricing clause restrict reimbursement method applies.

A provider pricing clause can be made more specific by adding dynamic logic conditions to it. A provider pricing clause only applies to a claim line when all of the dynamic logic conditions evaluate to true. When no dynamic logic conditions are added to a provider pricing clause, the applicability of the clause is determined regardless of dynamic logic conditions.

Provider Pricing Clause Dynamic Logic

Field	Description
Provider Pricing Clause	The 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.

Constraints:

• A provider pricing clause must either refer to a reimbursement method or to a pricing rule, not to both.

• The "Restrict to reimbursement method" list can only be specified for a provider pricing clause that refers to a pricing rule. Also, the list may only be specified if the provider pricing clause refers to a pricing rule that is evaluated after selection of a reimbursement method.

• The "Exempt?" indicator can only be checked when the provider pricing clause refers to a pricing rule.

• If the "Exempt?" indicator is checked, the quantifier cannot be specified.

• The quantifier may not be specified for a provider pricing clause that refers to a diminishing rate, lower of rule, inclusion rule, message rule, encounter rule or pricing external intervention rule.

• The quantifier is mandatory for provider pricing clauses that refer to dynamic field rules that specify a quantifier type. The quantifier may not be specified for provider pricing clauses that refer to dynamic field rules that do not specify a quantifier type

• Age from should not be larger than age to.

• End date should not lie before start date.

• Location type group usage and location type group should both be specified or both be left empty.

• The claim classification usage must be specified when a claim classification list is used and may not be specified when a claim classification list is not used.

• The claim line classification usage must be specified when a claim line classification list is used and may not be specified when a claim line classification list is not used.

• The classification scheme usage must be specified when a classification scheme list is used and may not be specified when a classification scheme list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

• The restrict to reimbursement method usage must be specified when a restrict to reimbursement method list is used and may not be specified when a restrict to reimbursement method list is not used.

• A logical key, i.e. uniqueness constraint, is enforced. Included in the logical key are all fields described in the above table, except the fields 'Quantifier', 'Message', 'Description', 'End Date' and 'Enabled?'. Included in the logical key are also the dynamic logic conditions, claim classifications, claim line classifications, classification schemes and restrict reimbursement methods (see below, regardless of their particular order). OHI Claims will prohibit the creation of two or more provider pricing clauses that share the same functional key.

• Quantifier value and currency must be specified for the reimbursement method bundled amount

• Quantifier value and currency must both be specified for the quantifier of the type amount, specifying only of them is not allowed.

Usage of the quantifier

The usage of the quantifier depends on the type of the reimbursement method or pricing rule to which the provider pricing clause refers and on the "Exempt?" indicator:

Type		Exempt?	Quantifier data type	Meaning when specified	Meaning when left empty
Reimbursement method	Bundled Amount	Field not applicable	Amount	The price that applies	N/A
	Fee schedule	Field not applicable	Percentage	Percentage at which the fee schedule is applied. This percentage is multiplied by the amount or percentage of the fee schedule line that is applied.	100%
	Charged amount	Field not applicable	Percentage	Percentage of the charged amount that is used to calculate the allowed amount	100%
	Diminishing Rate	Field not applicable	n/a
	Payment Function	Field not applicable	Percentage	The percentage with which the outcome of the payment function is multiplied	100%
Pricing Rule	Adjustment rule*	N	Percentage	Percentage to which the allowed amount is adjusted	Adjustment rule percentage is applied
	Combination adjustment rule*	N	Percentage	Percentage to which the allowed amounts of secondary claim lines are adjusted	Adjustment rule percentage is applied
	Dynamic Field Rule	N	Amount, Number (units), Number (service days), Percentage	The type of the quantifier can be configured on the dynamic field rule. It is expected that the dynamic field rule uses the quantifier in some way, if the rule specifies a quantifier type.	Quantifier is not used by the dynamic field rule
	Provider limit rule	N	Percentage (limit category in amount)	The percentage applied to the maximum amount of the limit rule height	100%
N	Number (limit category in units)	The maximum number of units to apply	Limit rule height is applied	N	Number (limit category in service days)
The maximum number of distinct service days to apply	Limit rule height is applied	Replacement Rule	N	Percentage	Percentage to which the allowed amount of a replacement claim line is adjusted. Only applies if a replacement claim line’s allowed amount is set using the replacement rule’s "Field Value Function".
100%	Lower of rule	N	- Quantifier not applicable -	Inclusion rule	N
Message rule	N	Pricing external intervention rule	N	Encounter rule	N

^(*) For simple and combination adjustment rules, calculation of adjustments may be coded in dynamic logic. If this is the case, it is possible that the quantifier is not used at all in the calculation.