Pricing Workflow

The adjudication process is an embedded workflow within Oracle Health Insurance Claim Pricing. It consists of a number of configurable steps, each of which has a specific purpose. This process includes steps that handle the following aspects:

Enrollment Information

The first step in the embedded flow is for the application to accept the submitted claim. If the request is well formed the application builds up the claim, matching member ID’s, provider ID’s and medical codes to the application’s reference tables.

Before the system is able to determine the appropriate price, it first needs to retrieve enrollment information on the member that is serviced on the claim. This happens through a web service call to the member enrollment system of record.

The response payload includes the health plan to which the member is enrolled as well as the member’s policy number. It could also contain additional information that is relevant to the repricing of the claim. For example, the following information can be included in the response payload:

  • Products identifiers that represent the set of active benefits by which the member is covered

  • Provider network parameters

  • One or more system messages that should be stamped on the claim

  • One or more uses configured fields and values

The provider network parameters support configuration strategy where a subset of a health plan’s features features are controlled by the enrollment system, rather than as features of the static health plan configuration templates.

Business Rules

Within the embedded claims flow there are two categories of configurable rules; those that determine the reimbursement method and rules and those that apply business rules. Oracle Health Insurance Claim Pricing includes the following configurable business rules:

Dynamic Checks - These are rules that deny a claim for policy reasons. For example, a rule to

  • automatically deny a claim for which the filing limit has expired

  • automatically deny a claim that requires additional information that the provider failed to submit

  • automatically deny a claim that is an exact duplicate of another claim

Pend Rules - These are rules that will suspend the claim from being processed so that either a human operator can make a judgement call or an automated process reprocesses the claim based on a timed schedule. For example, a rule to

  • pend a claim for which the repriced amount exceeds the configured threshold, and requires an operator to approve

  • pend a claim that is a suspected duplicate and requires an operator to confirm

  • pend a claim that has been submitted by a provider that is not contracted

Derivation Rules - These are rules that automatically enrich the claim by deriving and stamping on additional information that can be used for calculation or to inform downstream systems. For example, a rule

  • derive and stamp on the date that is used to determine the reimbursement method. Typical alternatives are the service date, member contract date or admission date.

  • derive and stamp on the provider that is used to determine network status within the context of the claim

  • derive and stamp on additional member and provider data that needs to be included for downstream purposes

Call Out Rules - These are rules that call out to external services to retrieve information that is required to adjudicate the claim correctly. Examples are

  • a call out to a claims editor, which may update the claim and its medical codes to conform to industry accepted practices and standards

  • a call out to a grouper, which bundles separate charges into a single one that represents a composite medical procedure

  • a call out to an external rules engine

Note that all mentioned business rules have

  • a set of configurable criteria that specify when the rule applies.

    For example, a business rule that applies only to inpatient claims.

  • a configurable execution moment.

        For example, a 'non-contracted provider' pend is triggered right after
submission, while a 'operator review' pend is executed after the claim went
through the embedded pricing workflow.

Reimbursement Method and Rule Selection

The second set of rules concern the selection of reimbursement method and pricing rules for a claim. Provider contracts are represented by a set of pricing specifications that are grouped together into templates. These pricing templates represent sets of pricing specifications that are reused for different providers, allowing for provider specific agreements through parameters that are built into the template.

These pricing specifications are referred to as provider pricing clauses. Each of provider pricing clause specifies a combination of medical codes that represent a healthcare service, and specific reimbursement method or rule that applies within the context of that service. They also specify the circumstances and conditions under which that benefit applies, such as the servicing provider’s participation status within the context of the applicable product’s network.

The pricing configuration model includes a number of different reimbursement methods and pricing rules. A reimbursement method represents a configured calculation or look-up that determines the base allowable amount. Pricing rules are configuration rules that make adjustments to that base amount. The application includes the following reimbursement methods:

  • Fee schedules with configurable dimensions (columns)

  • Percent of charge

  • Block rates that are correlated with the claimed volume

  • Analog Payment Functions

  • Percent Increase

The application includes the following adjustment rules:

  • percent increase or reduction based on line information

  • percent increase or reduction based on other services provided

  • episode of care detection episode based pricing

  • line replacement rules for custom edits

  • accumulation to enforce provider budgets

Finalize Claim

After the claim is priced the application finalizes the claim (for pricing). This means that all related increments to accumulators are made permanent and that the incurred increments to the accumulators become visible to other claims that are still in the process.

Pricing finalized claims can be retrieved through an embedded integration point, for the purpose of further adjudication.