Derivation Rules

A derivation rule can write a value to one ore more fields on a claim, bill or claim line. This value is derived through dynamic logic and can be based on other fields on the claim. The application has two kinds of derivation rules: process field derivation rules and (non-process field) derivation rules. For simplicity’s sake, the latter will be just referred to as derivation rules.

Process field derivation rules calculate and set the values for a limited set of fixed fields on the claim line, known as "process" fields. These process fields drive claims processing, such as the 'benefits provider' and 'benefits input amount'. The 'regular' derivation rules can be used to calculate the value for any dynamic field and most of the fixed fields on the claim, bill or claim line.

Derivation rules can be executed at one of six specific moments in the claims flow: directly before claim edits are reversed, directly before a claim is priced, directly after enrollment data is gathered, directly after a claim is priced, directly before and directly after benefits have been applied. For the process field derivation rules, the moment of derivation is predetermined by the nature of the process field, e.g., the benefits input amount is derived directly before benefits are applied, while the price provider is derived directly before pricing. Other derivation rules can be configured to execute on any one of the six specified moments.

An important difference is that a single process field derivation rule derives the value for a single specified process field, while a single derivation rule can set the values for any number of dynamic and/or fixed fields.

Note that claim line level derivation rules are not evaluated for locked claim lines and replaced claim lines.

Concepts

Process field derivation rules

Process field derivation rule

Field	Description
Code	The code of the process field derivation rule.
Description	The description of the process field derivation rule.
Process field	One of the process fields listed below.
Overwrite value?	If unchecked and the specified field already has a value, then the rule is not executed. If checked then the rule is always executed and overwrites any prior value of the process field.
Claim type	This rule is only executed for claims of the specified type. If no type is specified, this rule executes regardless of the claim type. There are two claim types: provider claims and restitution claims.
Dynamic logic function	This function holds the calculation for the process field value. The input parameter for this function depends on the level of the process field: When level = claim, the input parameter is the claim. When level = claim line, the input parameters are the claim and the claim line. Rather than returning a value, the function allows the process field to be set in the function itself. OHI Claims checks whether the field that was set in the code is the same as the process field specified on the process field derivation rule.
Priority	The priority determines the precedence order of a process field derivation rule when multiple rules apply and one must be chosen.
Enabled indicator	This derivation rule is only executed when this box is checked.
Procedure group	One of the procedures of the claim line should match one of the procedures in the group. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line.
Procedure group 2	One of the procedures of the claim line should match one of the procedures in the group. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line.
Procedure group 3	One of the procedures of the claim line should match one of the procedures in the group. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line.
Procedure condition	A dynamic condition that defines a procedure group to which the derivation rule applies. The criterion is met if the procedure condition evaluates to True for one of the claim line’s procedures.
Procedure condition 2	A dynamic condition that defines a procedure group to which the derivation rule applies. The criterion is met if the procedure condition evaluates to True for one of the claim line’s procedures.
Procedure condition 3	A dynamic condition that defines a procedure group to which the derivation rule applies. The criterion is met if the procedure condition evaluates to True for one of the claim line’s procedures.
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.
Condition	The condition for refinement.
Start date	The first service day for which this rule applies.
End date	The last service day for which this rule applies.

The following processing fields are available. For each field, the step and the level is predetermined.

Process field

Field	Level	Step	Description
priceIndividualProvider	Line	Pre Pricing	The individual provider used to price the claim line.
priceOrganizationProvider	Line	Pre Pricing	The organization provider used to price the claim line.
priceInputDate	Line	Pre Pricing	The date that serves as the starting point for calculation of the allowed amount.
priceInputNumberOfUnits	Line	Pre Pricing	The number of units that serves as the starting point for calculation of the allowed amount.
pricePrincipalProcedure	Line	Pre Pricing	The indication that defines whether procedure1, procedure2 and/or procedure3 is marked as principal for pricing purposes. Only one process field record is chosen instead of three because in practice, the logic in the process field derivation rule will set all necessary indicators; this way, only one process field derivation rule is needed instead of three.
externalPricing	Claim	Pre Pricing	The indicator for external pricing of the claim (refer to the text on routing slips in the appendix of the implementation guide on the claims flow).
benefitsProvider	Line	Pre Pricing	The provider used to evaluate the product provider group and benefits specific provider group scope.
externalBenefits	Claim	Pre Pricing	The indicator for external benefits processing of the claim (refer to the text on routing slips in the appendix of the implementation guide on the claims flow).
benefitsAgeInputDate	Line	Pre Reservation	The date serves as a reference date for age determination in the context of benefits.
benefitsInputDate	Line	Pre Reservation	The date that serves as the starting point for the selection of benefits.
dueDate	Claim	Pre Benefits	Is intended to drive the need from Financial.
benefitsInputAmount	Line	Pre Benefits	The amount including currency that serves as the starting point for benefits calculation.

The reason that the benefits provider is set Pre Pricing (as opposed to Pre Benefits) is that a change - made as a consequence of a pend - would otherwise not be effectuated before a claim would be sent out for repricing.

A process field derivation rule may have one or more process field derivation forms. Adding claim form to a derivation rule has the meaning of conditioning the derivation rule, i.e., the rule is only executed if the claim is of one of the specified forms. Note that if no claim forms are specified, then the derivation rule applies regardless of the claim form.

Process field derivation form

Field	Description
Process field derivation rule	The process field derivation rule that is conditioned on claim form.
Claim Form	The claim form that conditions the derivation rule.

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.

• Only claim line level process field derivation rules may specify procedure groups and/or procedure conditions.

• End date should not lie before start date.

Derivation rules

Derivation rule

Field	Description
Code	The code of the derivation rule.
Description	The description of the derivation rule.
Step	Determines when the derivation rule is executed. The allowed values are: Pre Reversal, Pre Pricing, End Enrollment, End Pricing, Pre Benefits and End Benefits.
Level	Claim, Bill or Claim line. The value for this field pre filters the fields that can be set in the dynamic logic function, e.g., if the value is "claim line", then the dynamic logic function can only set values for fields that are on the claim line.
Claim type	This rule is only executed for claims of the specified type. If no type is specified, this rule executes regardless of the claim type. There are two claim types: provider claims and restitution claims.
Dynamic logic function	This function holds the calculation for the field values. The field values are set within the function.
Sequence	The order in which derivation rules are evaluated (nulls last)
Enabled indicator	This derivation rule is only executed when this box is checked

A derivation rule may have one or more derivation claim forms. Adding a claim form to a derivation rule has the meaning of conditioning the derivation rule, i.e., the rule is only executed if the claim is of one of the specified forms. Note that if no claim forms are specified, then the derivation rule applies regardless of the claim form.

Derivation claim form

Field	Description
Derivation rule	The derivation rule that is conditioned on claim form.
Claim Form	The claim form that conditions the derivation rule.