Payment Functions

A payment function is a reimbursement method where the allowed amount is determined by a mathematical function rather than a predefined contracted rate. When applicable, payment functions can use reference sheets to incorporate lists of weights and indices used in the calculation.

To appreciate the applicability of the payment function reimbursement method, consider the following scenario:

Anesthesia is reimbursed in 15 minute units. Separate from the charged units, each individual anesthesia service code corresponds to a 'base' units value. The number of base units is listed, per individual service code, in a look-up table. To determine the claim line allowed amount, the sum of the base unit value and the number charged units is multiplied with the anesthesia fee.

The following table describes the payment function model.

Payment Function

Field	Description
Code	The functional identifier of this payment function
Description	The description visible in e.g. a list of values
Dynamic Logic Function	The logic that represents that mathematical function calculating the reimbursement
Message	The message that is attached to the claim line if the reimbursement method applies
Type	The payment function type to which the payment function belongs.
Access Restriction	Determines whether or not the access to the payment function is restricted

The following list specifies the placeholder values for the message that is attached to the claim line upon applying a payment function:

• 0. The code of the payment function

• 1. The description of the payment function

• 2. The provider pricing clause quantifier

The dynamic logic function receives the claim, claim line and the provider pricing clause as input and uses the price input date as the as-of date. The outcome is the claim line allowed amount, i.e., a twelve digit number of which two are decimals. The dynamic logic function can be linked to one or more reference sheets (see Implementation Guide on Dynamic Logic) so that the reference sheets can be accessed in the payment function dynamic logic function.

The configuration example implementing the anesthesia scenario described earlier, is described in detail in the section on Reference Sheets in the Implementation Guide on Dynamic Logic. The function does two things; it accesses the reference sheet table to retrieve the applicable base unit value and it executes the formula that calculates the allowed amount. The last part of the set up is the payment function itself. It connects the calculation function and the reference sheet into a single reusable reimbursement method:

Payment Function

Field	Description
Code	ANESTHESIA
Description	Calculation function for anesthesia minutes
Dynamic Logic Function	ANESTHESIA_CALCULATION

The dynamic logic function has a link to the base units reference sheet:

Dynamic Logic Reference Sheet

Field	Description
Dynamic Logic	ANESTHESIA_CALCULATION
Reference Sheets	ANESTHESIA_BASE_UNITS, ANESTHESIA_FEES

Payment function types can be referred to by payment functions for administrative purposes. Pricing rules can also refer to payment function types. If a payment function type is specified on a pricing rule then the rule is only applied if a payment function of that type has been applied (in combination with an 'In' usage) or has not been applied (in combination with a 'Not In' usage) to calculate the price on the claim line.

Payment Function Type

Field	Description
Code	The code of the payment function type
Description	The description of the payment function type