Pend Reasons
This section describes external intervention rules, or, as they are often referred to, pend rules. A claim can trigger an external intervention rule at four different points in the flow. As soon as the claim pends, a workflow task event may be sent out (depending on the sort of pend it is) and the claim becomes accessible through special user interface pages that allow for the claim or its processing results to be modified.
An external intervention rule can pend a claim for manual change, manual pricing, manual pricing adjudication, manual benefits or for manual adjudication. If pended for pricing, the operator can modify the allowed amounts of claim lines. If pended for benefits, the operator can modify and recalculate the applied benefits. If pended to manual pricing adjudication or manual adjudication, the operator needs to manually decide to accept or deny the claim.
OHI Claims uses two concepts to support pends; rules and reasons. The external intervention rule describes the circumstance in which a claim pends. The pend reason describes why the claim has pended. Each external intervention rule must specify the pend reason that is attached to the claim (line) should that rule trigger. This separation allows a configuration operator to have multiple rules refer to the same pend reason. This allows a configuration operator to set up disjunctive pend conditions (that imply the same sort of pend) as separate external intervention rules rather than one single (complex) rule.
Concepts
If an external intervention rule triggers, a pend reason is attached to the specified level (claim, bill or claim line). Pend reasons have to be defined first and have the following attributes:
Pend Reason
Field | Description |
---|---|
Code |
Identifying code |
Description |
Description |
Priority |
Numeric priority of the pend reason. The priority is sent in the workflow task start message. Thus they can be used to differentiate between tasks of different priorities by putting them in different workflow queues. |
External Code |
External code which is sent in the workflow task start message. |
Ind Publish Message |
If checked, the pend reason and the object it is attached to (claim, bill or claim line) are included in the workflow task start message. |
Ind Non Clean |
If checked, attaching this pend reason to a claim marks the claim as non clean.* |
Ind Reattach |
If unchecked, this reason will not be attached, i.e., will not cause the claim to pend if the claim(line)'s history shows that the same pend reason has been attached in the past. If checked, then any pend history is ignored when attaching this pend reason. |
Ind Adjudication Only |
If checked, this pend reason is only enforced (meaning that it needs to be resolved before the claim can be (re)submitted for processing) in the Pricing Manual Adjudication status (for external benefits) or the Manual Adjudication status (for internal benefits). |
Claim Fields |
Dynamic function produces a list of name value pairs that are included in the workflow message. |
Bill Fields |
Dynamic function produces a list of name value pairs that are included in the workflow message. |
Claim Line Fields |
Dynamic function produces a list of name value pairs that are included in the workflow message. |
Alternative External Text |
An alternative text to be in the external output. Note that the use of placeholders is not supported. |
External Text Provider |
The text as presented in external output for the provider. Note that the use of placeholders is not supported. |
Access Restriction |
The access restriction restricting access to the pend reason. |
* This indicator is not tied to any hard coded logic in the application. This indicator can be used in dynamic logic, such as a dynamic check that determines whether a claim line is within the filing limit.
An external intervention rule configuration consists of three different sort of fields. Some identify the rule, some are used to describe the circumstance under which a claim pends and some drive what happens when the claim actually claim pends. An external intervention rule has the following fields:
External Intervention Rule
Field | Description |
---|---|
Code |
The code of the external intervention rule. |
Description |
The description of the external intervention rule. |
Level |
The level that is used to check the criteria specified in this rule, and also the level where the pend reasons is attached, should the rule trigger. This can be either the claim, the bill or the claim Line. |
Step |
The step in the claims processing where this rule is evaluated. This can be either Manual Change, Manual Pricing, Manual Pricing Adjudication, Manual Benefits or Manual Adjudication. |
Claim Type |
The claim type to which the external intervention rule applies: Provider Claim or Restitution Claim. If this field is left empty then the rule is executed for both claim types. |
Payer |
If specified, the payer code on the claim should match one of the codes belonging to the specified payer.* |
Brand |
If specified, this brand should match the brand of the claim.* |
Message Group |
For a claim level rule, one of the claim messages should match one of the messages in the group. For a bill level rule, one of the bill messages should match one of the messages in the group. For a claim line level rule, one of the claim line messages should match one of the messages in the group. |
Message Group (Pend Reason) |
If one or more of the messages on the claim, bill or line (depending on this rule’s level) match a message in the message group then the claim pends. For every message that causes the claim to pend in this way, the system attaches the pend reason with the same code. If no corresponding pend reason exists, the system attaches the pend reason set on this rule. |
Unfinalize Reason Group |
One of the claim unfinalize reasons should match one of the unfinalize reasons in the group (irrespective of the level). |
Diagnosis Group |
For a claim level rule, the primary claim diagnosis should match one of the diagnoses in the group.The criterion is met if the claim primary diagnosis is part of the diagnosis group on the claim date of the claim For a bill level rule, the primary bill diagnosis should match one of the diagnoses in the group. The criterion is met if the bill primary diagnosis is part of the diagnosis group on the bill date of the claim bill. For a claim line level rule, the primary claim line diagnosis should match one of the diagnoses in the group.The criterion is met if the claim line primary diagnosis is part of the diagnosis group on the start date of the claim line |
Procedure Group |
One of the procedures of the claim line should match one of the procedures in the group. This criterion is restricted to the claim line level. 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. This criterion is restricted to the claim line level. 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. This criterion is restricted to the claim line level. 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 |
Dynamic Logic Condition |
The dynamic logic condition that is used to check the claim, bill or claim line depending on the level. If the condition evaluates as true, the claim pends. |
Pend Reason |
The pend reason that is attached to the appropriate level (claim, bill or claim line). |
Ind Suppress When Fatal |
If checked and the level is "claim", then this rule does not trigger a pend (will not attach a pend reason nor lock the claim lines) if a fatal claim message exists. If checked and the level is "bill", then this rule does not trigger a pend (will not attach a pend reason) if a fatal claim or bill message exists. If checked and the level is "claim line", then this rule does not trigger a pend ((will not attach a pend reason nor lock the claim line) if a fatal claim, bill or non-product specific claim line message exists. When checking for the presence of fatal messages, messages that have been added in a previous iteration in the processing flow are ignored. In other words: (1) for manual change, fatal messages of the following origins are taken into account: external, manual and sanity checks (2) for manual pricing, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing and pricing no recalculation (3) for manual pricing adjudication, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing, pricing limit and pricing no recalculation (4) for manual benefits, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing, pricing limit, pricing no recalculation, payment status, pre-benefits and benefits (5) for manual adjudication, all product independent fatal messages are taken into account |
Ind Lock Claim Lines |
If checked on a claim level rule, then the non-replaced claim lines of the claim will be locked for any changes (Ind Locked checked) when the claim is pended by this external intervention rule. If checked on a claim line level rule, then the non-replaced claim line will be locked for any changes (Ind Locked checked) when it is pended by this external intervention rule. This indicator can only be checked on rules for steps Manual Pricing Adjudication and Manual Adjudication. Note that the indicator is ignored on bill level rules. See Claim Line Locking Scenarios in the Appendices part of the Claims Flow guide for more information. |
Ind Enabled |
This external intervention rule is only executed when this box is checked |
Ind Replace Pend Messages |
This can only checked (Y) if the pend reason message group is set. If this is checked it discards the message itself as soon as it finds the pend reason with the same code.If it is unchecked it keeps the message. It is set (N) by default. |
* It is not allowed to specify both a payer and a brand. Claims have a similar restriction. As a consequence, an external intervention rule that would specify both a payer and brand would never trigger.
External Intervention Rule Claim Form
Field | Description |
---|---|
External Intervention Rule |
The external intervention rule for which specific claim forms are defined. |
Claim Form |
The form of the incoming claim. |
The form of the claim must either match one of the defined external intervention rule claim forms, or no external intervention rule claims forms should be specified. In the latter case, the external intervention rule applies to all claims, irrespective of the claim form.
Note that a rule can specify multiple fields of the claim(line) to be checked, e.g., a single rule can check for the diagnoses, the procedure, the messages and the unfinalize reasons. If a single rule configures multiple fields to be checked, then the claim(line) needs to match all of them in order for that rule to trigger and the claim to pend.
Use Cases
Consider the following configuration, all for manual adjudication (MA):
Step | Level | Message group | Diagnosis group | Procedure group | Condition dynamic logic | Pend reason | When fatal? |
---|---|---|---|---|---|---|---|
MA |
Line |
Reconstructive surgery procedures |
Plastic surgery |
No |
|||
MA |
Line |
Messages indicating partial auth match |
Partial auth |
Yes |
|||
MA |
Line |
Messages from the auth indicating external intervention |
Auth intervention |
No |
|||
MA |
Claim |
Covered amount over $ 10,000.00 |
High dollar amount |
No |
|||
MA |
Line |
Neuromotor injury related diagnoses |
PT visits |
Rare diags |
No |
When the claims processing reaches the step to evaluate the external intervention rules for manual adjudication, each of these five rules is of the right step.
Now first all the claim level rules are evaluated (in the example the one for the high dollar amount): if the total covered amount of the claim exceeds $ 10,000.00, the pend reason 'High dollar amount' is attached to the claim.
Next all the bill level rules are evaluated (in the example none) for each bill. If all conditions hold true, then a pend reason will be attached to the bill.
Then all the claim line level rules are evaluated for each claim line. The second rule (partial auth) will only be evaluated when no fatal messages are attached to the claim line in question. If all conditions hold true, then a pend reason will be attached to the claim line. In the example, a maximum of 4 pend reasons could thus be attached to a single claim line.
After all the rules have been evaluated, a start task message may have to be sent. If at least one pend reason with the publish message indicator checked, is attached to any of the levels, then such a message for Manual Adjudication is sent out (for more details, see the chapter on Workflow Integration Point in the Claim Flow Configuration Implementation Guide). This message will include information about the pend reasons and the priority that has been configured.
Pend Reason Message Group Use Case
When the external intervention rule is evaluated, if the claim or claim line has one or more messages that are included in pend reason message group, then the system retrieves the pend reasons with a matching code and attaches those pend reasons and pends the claim. If the system cannot find a pend reason with a matching code, it will instead attach the pend reason that is directly attached on the external intervention rule by default. If the replace pend messages indicator is checked then the system removes all the claim or claim line messages that it successfully matched to a pend reason.This can be exemplified in the below use case:
Pend Reason Message Group |
A |
||
Messages: |
X |
Y |
|
Pend Reason |
X |
Z (default) |
|
Replace Pend Messages? |
Yes |
If the claim line comes in with message X and message Y, the claim pends because at least one message is on group A, then the pend reason X is attached. Pend reason Y cannot be found, so pend reason Z is attached instead. Message X is removed because replace indicator = Y, Message Y is not removed because it could not be matched to a pend reason.