Pricing Adjudication

In this step the external intervention criteria for step 'Manual Pricing Adjudication' are evaluated. At the end of the flow, the status of the Claim Lines is set. The pricing adjudication flow is schematically depicted by the following figure:

Pricing Adjudication

Level 2: Pricing Adjudication

Evaluate External Intervention Rules

First, the application checks if there are any existing pend reasons on the claim, bill and/or claim line level (there can be unresolved 'adjudication only' pend reasons); if this is the case the claim will be pended (note that this check is only performed if the claim is marked for external benefits). After the 'existing pend reasons' check all external intervention rules of the sub type MANUAL PRICING ADJUDICATION are evaluated, regardless of already existing unresolved 'adjudication only' pend reasons. If a claim, claim line or bill successfully meets all of the criteria set by the rule, then the rule is 'triggered'.

For each triggered external intervention rule, the specified pend reason is checked: if the reattach indicator is unchecked and the pend reason history indicates that the same pend reason has been previously attached on the same level (claim, bill or line), then the pend reason is not attached and the claim will not pend because of this external intervention rule. Otherwise, the specified pend reason is attached to the claim, claim line or bill, and added to the claim pend reason history.

If no pend reasons are attached as a result of the external intervention rule evaluation, then the claim skips ahead to the "Set Claim Line Status" step. Otherwise, the claim status is set to MANUAL PRICING ADJUDICATION. See the implementation guide on claims flow configuration for more details on how to configure external intervention rules.

Manual Pricing Adjudication

If the claim is pended by a claim level external intervention rule with a checked Lock Claim Lines indicator, then all non-replaced claim lines of that claim are locked for any changes. If a specific claim line is pended by a claim line level external intervention rule with a checked Lock Claim Lines indicator, then that specific claim line is locked for any changes.

If the claim, claim line or bill has at least one pend reason with a checked 'publish message indicator', then the workflow integration point sends out a <task> event to notify an workflow management system that a new task is ready. The event contains all pend reasons that configured to be published. For more detail, see the chapter on the workflow integration point in the implementation guide on claims flow configuration.

The assumption is that the external workflow management system assigns a manual pricing adjudication task to a user. The user opens the UI page for manual pricing adjudication and can choose to perform one of the following actions:

  • Accept the entire claim.

  • Deny the entire claim.

  • Revert to a status that makes it possible to change the claim, e.g., changing the serviced person.

  • Revert to a status that makes it possible to change the pricing results on the claim lines.

Replaced claim lines and locked claim lines are ignored during this step, i.e., these lines will not trigger an external intervention rule for manual adjudication. It is still possible that the claim pends for manual adjudication triggered by other lines, the bill or the claim header. It is also possible that a locked claim line pends by an existing unresolved 'adjudication only' pend reason on the claim line.

Changing the claim

This option returns the claim to the start of the claims flow, so that the fields on the claim itself can be changed. The claim indicators "Preprocessing Done?" and "Pricing Done?" are unchecked.

The claim status is set to CHANGE and it re-enters the level 2: Receive, Enter and Change Claim flow. Note that the claim, bill and claim line pend reasons remain attached.

Changing pricing results

This option sets the claim back to an earlier status in the flow so that the pricing results can be changed. The claim indicator "Pricing Done?" is unchecked. The claim status is set to MANUAL PRICING and it re-enters the level 2: Pricing flow. Note that the claim, bill and claim line pend reasons remain attached.

The claim pricing results can be edited in the "Manual Pricing" page.

Accept Claim

When a claim is accepted, it is checked whether there is an open workflow task for that claim. This is derived from a technical field on the claim. If so, the workflow integration point sends out a message to inform the workflow distribution system that the task can be closed.

Next, any resolved pend reasons are removed from the claim, bill and claim line. Note that these pend reasons are retained in the pend reason history. It is possible that one or more unresolved pend reasons remain attached to the claim, bill or claim line.

If any pend reasons remain, there are two possibilities:

  • if the claim is marked for external benefits, then the claim’s status remains MANUAL PRICING ADJUDICATION.

  • if the claim is marked for internal benefits, then it is checked if all pend reasons with indicator 'Adjudication Only' set to false are resolved:

    • if so, then the claim continues on its way in the claims flow at the "Set Claim Line Status" step. In effect, it is allowed to have one or more pend reasons with indicator 'Adjudication Only' set to true left unresolved, because they can later be handled in the MANUAL ADJUDICATION step.

    • if not, then the claim’s status remains MANUAL PRICING ADJUDICATION.

In both possibilities, if at least one of the remaining pend reasons has a checked publish message indicator, a new workflow integration point is message sent out.

Deny Claim

When choosing to deny the whole claim, an LOV with messages appears enforcing the user to pick a fatal message which is attached to the claim. When a claim is denied, it is checked whether there is an open workflow task for that claim. This is derived from a technical field on the claim. If so, the workflow integration point sends out a message to inform the workflow distribution system that the task can be closed. All pend reasons, both resolved and unresolved, are removed from the claim, bill(s) and claim line(s). The Keep Pricing and Manual Pricing indicators on the claim lines are unchecked; the pricing results of the claim lines are kept (this is described in more detail in the Manual Pricing Adjudication page description).

The end-pricing derivation rules are executed a second time. The rationale is that end-pricing derivation rules are typically used to aggregate the results of the pricing calculation. Because the claim has been denied after the initial execution of the end-pricing derivation rules, they have to be executed a second time. The end pricing derivation rules are evaluated in the following order: claim line first, bill second, claim (header) last.

Set Claim and Claim Line Status

If the claim is marked for internal benefits, then the claim line status remains unchanged: it will be set to DENIED or APPROVED later on in the adjudication step.

If the claim is marked for external benefits, then the claim line status will be set to DENIED or APPROVED right now. The status of a claim line is set to DENIED if the claim line has a product independent fatal message (directly or indirectly though the bill or claim to which the claim line belongs) of one of the origins EXTERNAL, MANUAL, SANITY CHECKS, PRE PRICING, ENROLLMENT, RESERVATION, PRICING, PRICING LIMIT or PRICING NO RECALCULATION. Otherwise the claim line status is set to APPROVED. If the status of the claim line is set to DENIED, then the Ignored indicator on the preliminary provider limit consumptions is checked.

Note that the status of the claim line is not set if it is already set; locked claim lines can already have a status. If the status on locked claim lines is not already set, then it is set based only on the claim line messages; messages from higher levels are ignored.

Finally, the status of the claim is always set to "PRICING ADJUDICATION DONE".