Introduction

Oracle Health Insurance Claim Pricing is an enterprise strength healthcare payer back office application. It is designed as a component and holds only limited information and relies on integration with contingent systems to retrieve the information it needs to reprice healthcare claims.

The calculation that determines the amount for which the payer is liable depends on two contracts.

• The first is between the payer and the provider and specifies the height of the reimbursement for the health services that are performed by the provider. These are typically fee schedules that lists a large number of services and their corresponding prices.

• The second is between the payer and the member. This contract is the insurance policy that the member has with the payer. The policy specifies for which costs the payer provides coverage and to what extend the member is liable. For example the policy may state that the member is liable for 10% of the incurred costs for a particular health care service.

Oracle Health Insurance Claim Pricing automates the execution of the first contract, i.e., the one between the health service provider and the payer. The footprint of the core functionality offered by this component is best described by the following sequence of steps:

• It takes submitted healthcare claims,

• It calculates the allowable amount taking into account

  • the provider’s network status within the context of the patient’s insurance plan

  • the applicable reimbursement method (like a fee schedule) for that provider

  • the applicable adjustments and restrictions for that provider

• It stamps the applicable allowable amount per line of the claim

Oracle Health Insurance Claim Pricing prices claims in real-time. New claim submissions are sent in through a standard integration point. As soon as the claim is accepted by the application it is picked up by the embedded pricing workflow. Once the claim is priced, the application produces an event to notify downstream subscribers that the claim is ready for further processing. The down stream consuming systems can then retrieve a copy of the priced claim standard integration point.

Within the context of this document a claim represents a reimbursement request for the incurred cost of a healthcare services rendered by a healthcare professional ( referred to as the provider) to an insured patient (referred to as the member). The receiver of the reimbursement is typically also the party that submitted the claim, and could be either the member or the provider. This repriced amount represents the amount that flows from the contractual agreement between the payer and the provider and is referred to as the allowed amount.