Scenario 1 - Externalized Benefit Selection

The customer intends to externalize the benefit selection by setting up a callout rule that sends the relevant claim information and gets a response with the applicable calculation and member liability parameters.

Configuration

The OHI production environment does not contain benefit specifications, but it does contain all the necessary regime configuration and the limit configuration to carry out calculations. It also includes the code of the matching authorization, if applicable.

Callout Rule

To retrieve the coverage regime (and maybe other overriding information like authorization or waiting period regime) from the external system a callout rule must be configured. In this example we will process the response message in the dynamic logic. An alternative approach would be sending a request for a Claims Update IP response message that includes the (overriding) coverage regime as part of claimLineOverride element.

The setup of a callout definition is a combination of functional setup in a UI page of OHI Claims and technical setup in the OHI Claims properties file.

Callout Definition

Field	Value	Comment
Code	ExternalBenefit
Description	External Benefit Selection
Messaging Pattern	Asynchronous	Upon executing the callout, the response of the external component can come later.
Request Logic	EXT_BEN_REQUEST	The dynamic logic that is executed to create the request message that is to be delivered to the external component by the callout
Response Logic	EXT_BEN_RESPONSE	The dynamic logic that is executed to process the response message of the external component.
Active?	Yes

Claim Callout Rule

Field	Value	Comment
Step	End Pricing
Sequence	1
Classification Scheme	<null>	In this example the callout will be done for claims in all classification schemes
Condition	<null>	Could add a dynamic logic condition to only do the call out for specific claims. In our example for all claims a callout will be done
Callout Definition	ExternalBenefit	See above
Skip tag	<null>
Only on Change?	N
Display in UI?	Y
Enabled?	Y

Request Dynamic Logic

Code:EXT_BEN_REQUEST

Description: Groovy code to send out External Benefit Request Call Out.

Assuming that the external benefits provider needs the following information to return the requested regime(s).

• Claim

  • Claim Code

  • Claim Form

  • Claim Type

  • Claim Date

  • Payer Code

• Claim Line List

  • Sequence Number

  • Member Date of Birth

  • Procedure Code

  • Benefits Provider Code

  • Start Date

  • End Date

then the dynamic logic that creates the request message looks something like this:

ExternalBenefitRequest(claimCode:claim.code){
  claimForm ( claim.claimForm.code )
  claimType ( claim.type?.code )
  claimDate ( claim.claimDate )
  payerCode ( claim.payerCode?.code )
  claimLines {
    claim.claimLineList.each { claimLine ->
      claimLine(sequence: claimLine.sequence) {
        memberDob ( claimLine.serviceEntityDate )
        procedureCode( claimLine.procedure.code )
        benefitsProvider( claimLine.benefitsProvider.code )
        startDate ( claimLine.startDate )
        endDate ( claimLine.endDate )
      }
    }
  }
}

Response Dynamic Logic

Code:EXT_BEN_RESPONSE

Description: Groovy code to process the response message of the external benefit request

Assuming that the external benefits provider returns a response message per request message, that is per claim. Each message can hold a list of claim line override values.

• Claim Line List

  • Sequence Number

  • Coverage Regime Code

  • Coverage Regime No Auth Code

  • Authorization Regime Code

  • Waiting Period Regime Code

  • Post Benefit Regime Code

  • Product Code

  • Product Family Code

  • Product Line Code

then the dynamic logic that processes the response message looks something like this:

def result = new XmlSlurper().parseText(externalBenefitResponse)

for (claimLineOverride in result?.claimLineOverrideList) {
   claimLine.setOverridingBenefits(new BenefitOverride()
  .withCoverageRegimeCode('')
  .withProductCode('')
  .withSubscriptionDate('')
  .withCoverageSpecificationCode('')
  .withCoverageRegimeNoAuthCode('')
  .withFamilyCode('')
  .withPostBenefitsRegimeCode('')
  .withAuthorizationRegimeCode('')
  .withWaitingPeriodRegimeCode('')
  .withFundingArrangementCode('')
  )
}

Property File - Callout Related Properties

Property Name	Value	Comment
ohi.servicecallout.ExternalBenefits.url	For example: ohi.servicecallout.ExternalBenefits.url=https://extben.domain.org/	Web Service endpoint URL for a Callout Rule
ohi.servicecallout.ExternalBenefits. completeness.interval	For example: ohi.servicecallout.ExternalBenefits.completeness.interval=5	Time interval in seconds used by the system to check if a response is received
ohi.servicecallout.ExternalBenefits. completeness.timeout	For example: ohi.servicecallout.ExternalBenefits.completeness.timeout=15	Time interval in seconds used by the system to determine if a response is received in time

Flow

Step 1 - Receive, Change or Enter Claim

A claim is sent in through the Claims In Integration Point with the following claim lines. None of the claims lines holds an overriding regime or an overriding coverage specification (no claimLineOverrde element on the claimLine).

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Regime	Overriding Waiting Period Regime	Product
1	Ella Doe	A2341	Dr Jackson (PR123)
2	Ella Doe	B6687	Dr Smith (PR555)
3	John Doe	C9348	Dr Smith (PR555)
4	Ella Doe	D5678	Dr Smith (PR555)
5	Ella Doe	E4321	Dr Smith (PR555)

Step 2 - Enrollment Callout

The enrollment response from OHI Policies shows that the serviced member John Doe is subscribed to the BASE product and Ella Doe is subscribed to the BASE+ product on all service dates in the claim.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Regime	Overriding Waiting Period Regime	Product
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+
3	John Doe	C9348	Dr Smith (PR555)	BASE
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+
5	Ella Doe	E4321	Dr Smith (PR555)	BASE+

Step 3 - End Pricing Callout Rules

The Callout rule ExernalBenefits will fire. The sent out message will look something like this.

<ExternalBenefitRequest claimCode='12345'>
  <claimForm>387I</claimForm>
  <claimType>I</claimType>
  <claimDate>2019-08-01<claimDate>
  <payerCode>ABC</payerCode>
  <claimLines>
    <claimLine sequence='1'>
       <memberDob>1990-12-01</memberDob>
       <procedureCode>A2341</procedureCode>
       <benefitsProvider>PR123</locationProvider>
       <startDate>2019-08-01</startDate>
       <endDate>2019-08-01</endDate>
    </claimLine>
    <claimLine sequence='2'>
       <memberDob>1990-12-01</memberDob>
       <procedureCode>B6687</procedureCode>
       <benefitsProvider>PR555</locationProvider>
       <startDate>2019-08-02</startDate>
       <endDate>2019-08-10</endDate>
    </claimLine>
    ...
      }
    }
  }
}

The response message from the external system will look something like this.

<ExternalBenefitResponse claimCode='12345'>
  <claimLines>
    <claimLine sequence='1'>
       <coverageRegimeCode>Copay 20</coverageRegimeCode>
    </claimLine>
    <claimLine sequence='2'>
       <coverageRegimeCode>Cover in Full</coverageRegimeCode>
    </claimLine>
    <claimLine sequence='3'>
       <coverageRegimeCode>Cover in Full</coverageRegimeCode>
       <productCode>Base+<productCode>
       <subscriptionDate>2019-01-01</subscriptionDate>
    </claimLine>
    <claimLine sequence='4'>
       <coverageRegimeCode>Cover in Full</coverageRegimeCode>
       <waitingPeriodRegimeCode>Wait 60</waitingPeriodRegimeCode>
    </claimLine>
    <claimLine sequence='6'>
       <waitingPeriodRegimeCode>Wait 60</waitingPeriodRegimeCode>
    </claimLine>
      }
    }
  }
}

• The following values are set

  • Coverage regime 'Copay 20' for Ella Doe’s procedure A2341 by Dr.Jackson.

  • Coverage regime 'Covered in Full' for Ella Doe’s procedure B6687 by Dr Smith.

  • Coverage regime 'Covered in Full' for John Doe’s procedure C9348 by Dr Smith and also setting the product to BASE+

  • Coverage regime 'Covered in Full' and an overriding waiting period regime 'Wait 60' for Ella Doe’s procedure D5678 by Dr Smith

  • The callout did not return any values for Ella Doe’s E4321 procedure.

• If the response holds an unknown regime code, the system raises an error and the callout step is failed

• If the response holds, for example, a waiting period regime but no coverage regime or benefit specification, the system raises an error and the callout step is failed.

• If the response is not received on time the system raises an error, and the callout step is failed.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Regime	Overriding Waiting Period Regime	Product
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+	Copay 20
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	Covered in Full
3	John Doe	C9348	Dr Smith (PR555)	BASE	Covered in Full		BASE+
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	Covered in Full	Wait 60
5	Ella Doe	E4321	Dr Smith (PR555)	BASE+

Step 4 - Benefit Selection

Claim line 5 does not specify an overriding coverage regime so for this line internal benefit selection will not be skipped. Because no benefits are present in the system, line 5 will get an error message for no benefit found and the claim line will be denied. For this claim line message CLA-FL-BENS-017 is applied (There are no active benefits on benefits input date {date}).

Note that claim lines 1 - 4 also will have no benefit specifications but because they have an overriding coverage regime the validate selection step is skipped and does not lead to an error situation

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Regime	Overriding Waiting Period Regime	Product	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+	Copay 20
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	Covered in Full
3	John Doe	C9348	Dr Smith (PR555)	BASE	Covered in Full		BASE+
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	Covered in Full	Wait 60
5	Ella Doe	E4321	Dr Smith (PR555)	BASE+				CLA-FL-BENS-017

Step 5 - Evaluate Regimes

Waiting Periods

Claim Line 4 will be evaluated against the overriding waiting period Wait 60. In this example we assume that Ella Doe does not serve the waiting period Wait 60 for the product BASE+ .

The other lines do not have a waiting period regime. These lines pass evaluation.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Regime	Overriding Waiting Period Regime	Product	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+	Copay 20
2	Ella Doe	B6687	Dr Jackson (PR123)	BASE+	Covered in Full
3	John Doe	C9348	Dr Jackson (PR123)	BASE	Covered in Full		BASE+
4	Ella Doe	D5678	Dr Jackson (PR123)	BASE+	Covered in Full	Wait 60		Wait 60 Error message
5	Ella Doe	E4321	Dr Jackson (PR123)	BASE+				CLA-FL-BENS-017

Authorization regimes

No authorization regimes defined is this example

Coverage Regimes

Assuming that no limits prevent coverage, the system creates claim line rule coverages and claim line coverages for the claim lines 1, 2 and 3 and the covered amount is updated. At the claim level, the total covered amount is updated.

A claim line benefit specification is created with a reference to the product and the (overriding) coverage regime. The reference to the coverage specification remains empty (as none was applied).

Post benefit regimes

No post benefit regimes defined is this example.

Step 6 - Rest of the steps

All other steps are executed as normal.

Scenario 2 - Overriding Internal Benefit Selection

The customer intends to override the internal benefit selection by specifying the applicable benefit specification code on the claim line. The claim line is then adjudicated as though the overriding benefit specification was the result of the internal selection. The production environment contains the full product benefit specification configuration.

Configuration

This scenario does not require additional configuration. The overriding benefit specification is sent in as part of claim entry. .

Flow

Step 1 - Receive, Change or Enter Claim

A claim is sent in through the Claims In Integration Point with the following claim lines. None of the claims lines is sent in with an overriding coverage regime.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Specification	Overriding Waiting Period Regime	Selected Coverage Specification	Selected Coverage Regime	Result
1	Ella Doe	A2341	Dr Jackson (PR123)
2	Ella Doe	B6687	Dr Smith (PR555)		CS1111
3	John Doe	C9348	Dr Smith (PR555)		CS2222
4	Ella Doe	D5678	Dr Smith (PR555)		CS1111	Wait 60

Step 2 - Enrollment Callout

The enrollment response from OHI Policies shows that the serviced member John Doe is subscribed to the BASE product and Ella Doe is subscribed to the BASE+ product on all service dates in the claim.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Specification	Overriding Waiting Period Regime	Selected Coverage Specification	Selected Coverage Regime	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	CS1111
3	John Doe	C9348	Dr Smith (PR555)	BASE	CS2222
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	CS1111	Wait 60

Step 3 - End Pricing Callout Rules

In this example no callout rule is used as we assume that the overriding values are already included when the claim is sent in. However for the rest of the example it would make no difference if the overriding coverage specification had been entered through an external benefit callout.

Step 4 - Benefit Selection

Because Claim line 2, 3 and 4 specify an overriding coverage specification the internal benefit selection is skipped. Claim line 1 does not specify an overriding coverage specification so for this line internal benefit selection will not be skipped.

In a situation that no overriding coverage specification would have been defined on line 2, 3 and 4, the benefit selection for these lines might have resulted in waiting period specifications and/or authorization specifications. But in this example there is such an overriding coverage specification and therefor all other benefit selection is skipped.

In this example the coverage specification CS3333 was found for Ella Doe’s A2341 procedure by Dr Jackson.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Specification	Overriding Waiting Period Regime	Selected Coverage Specification	Selected Coverage Regime	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+			CS3333
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	CS1111
3	John Doe	C9348	Dr Smith (PR555)	BASE	CS2222
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	CS1111	Wait 60

Step 5 - Evaluate Regimes

Waiting Periods

Claim Line 4 will be evaluated against the overriding waiting period regime Wait 60. In this example we assume that Ella Doe does not serve the waiting period Wait 60 for the product BASE+ .

The other lines do not have a waiting period regime. These lines pass waiting period evaluation.

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Specification	Overriding Waiting Period Regime	Selected Coverage Specification	Selected Coverage Regime	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+			CS3333
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	CS1111
3	John Doe	C9348	Dr Smith (PR555)	BASE	CS2222
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	CS1111	Wait 60			Wait 60 Error message

Authorization regimes

No authorization regimes defined is this example

Coverage Regimes

Assuming that coverage specification CS2222 has a coverage regime 'Covered in Full' and coverage specifications CS1111 and CS3333 have a coverage regime 'Copay 20', the results of the coverage regime evaluation are:

Sequence	Serviced Member	Procedure	Benefits Provider	Policy Product	Overriding Coverage Specification	Overriding Waiting Period Regime	Selected Coverage Specification	Selected Coverage Regime	Result
1	Ella Doe	A2341	Dr Jackson (PR123)	BASE+			CS3333	Copay 20
2	Ella Doe	B6687	Dr Smith (PR555)	BASE+	CS1111			Copay 20
3	John Doe	C9348	Dr Smith (PR555)	BASE	CS2222			Covered in Full
4	Ella Doe	D5678	Dr Smith (PR555)	BASE+	CS1111	Wait 60			Wait 60 Error message

Assuming that no limits prevent coverage, the system creates claim line rule coverages and claim line coverages for the claim lines 1, 2 and 3 and the covered amount is updated. At the claim level, the total covered amount is updated. A claim line benefit specification is created with a reference to the product and the selected coverage regime. The reference to the coverage specification is filled with the overriding or the selected coverage specification (whichever applies).

Post benefit regimes

No post benefit regimes defined is this example.

Step 6 - Rest of the steps

All other steps are executed as normal.

==