Authorization Regimes

An authorization regime specifies (1) the function that is used to match a claim line to an authorization, (2) the function that is used to match the claim line with the authorization lines and authorization basket details, (3) specifies any thresholds based on a benefits input amount, allowed number of units (note that if the allowed number of units is not specified, then the claimed number of units is taken) or the service day, that must be met before the authorization requirement becomes active, and (4) specifies the messages and claim line coverages that are applied to a claim line to clarify what happened in case no authorization was found, or when the found authorizations are denied of have been fully consumed. Similar to a coverage regime an authorization regime consists of periods and tranches. For more details about the concept of regimes, periods and tranches, please read the Coverage Regime Model.

Authorization Regime

An authorization regime has the following fields:

Field	Description
Code	Identifier for this regime.
Description	Descriptor of this regime.
Indication Active	If unchecked, no more references to this regime may be made.
Type	The type of authorization that this regime requires, i.e., an (A)uthorization, a (N)otification or a ®eferral.
Repetitive Indicator	If checked, that means that the underlying authorization regime periods should repeat, e.g., when a payer wants to use an authorization cycle every three months
Reference	Specifies the as-of date that will be compared to the service date to determine which period applies. The following as-of dates can be specified: (1) The person’s date of birth or object’s object date; (2) the first day of the product subscription; (3) the first day of the calendar year; (4) the first day of the plan year (refers to the dd/mm of the start of the product subscription).
Currency	The currency for all amount fields in the tranches.
Auth Matching Function	The function dynamic logic that is applied when a claim line requires an authorization. It returns a list of eligible authorizations.
Auth Detail Matching Function	The function dynamic logic that is used to match the claim line with the authorization lines and authorization baskets and their details. It returns a list of eligible authorization lines and authorization basket details.
Auth Not Met Message	These are the messages that are attached to the claim line in case the claim line is fully or partially authorized. Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.
Auth Met Message	Auth Met And Exceeded Message
Auth Exceeded Message (Other Benefit)	These are the messages that are attached to the claim line in case the line is not authorized (in its entirety), but another benefit applies in absence of the authorization. Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.
Auth Not Found Message (Other Benefit)	Auth Denied Message (Other Benefit)
Auth Exceeded Message (No Benefit)	These are the messages that are attached to the claim line in case the line is not authorized (in its entirety) and no other benefit applies in absence of the authorization. Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.
Auth Not Found Message (No Benefit)	Auth Denied Message (No Benefit)
Auth Exceeded Label	These are the coverage labels that are used to create claim line coverages in the event that a claim line benefit input amount is only partially processed by a coverage regime. Read the section on authorization regime coverage labels for specifics.
Auth Not Found Label	Auth Denied Label

Field

Description

Code

Identifier for this regime.

Description

Descriptor of this regime.

Indication Active

If unchecked, no more references to this regime may be made.

Type

The type of authorization that this regime requires, i.e., an (A)uthorization, a (N)otification or a ®eferral.

Repetitive Indicator

If checked, that means that the underlying authorization regime periods should repeat, e.g., when a payer wants to use an authorization cycle every three months

Reference

Specifies the as-of date that will be compared to the service date to determine which period applies. The following as-of dates can be specified:

(1) The person’s date of birth or object’s object date; (2) the first day of the product subscription; (3) the first day of the calendar year; (4) the first day of the plan year (refers to the dd/mm of the start of the product subscription).

Currency

The currency for all amount fields in the tranches.

Auth Matching Function

The function dynamic logic that is applied when a claim line requires an authorization. It returns a list of eligible authorizations.

Auth Detail Matching Function

The function dynamic logic that is used to match the claim line with the authorization lines and authorization baskets and their details. It returns a list of eligible authorization lines and authorization basket details.

Auth Not Met Message

These are the messages that are attached to the claim line in case the claim line is fully or partially authorized.

Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.

Auth Met Message

Auth Met And Exceeded Message

Auth Exceeded Message (Other Benefit)

These are the messages that are attached to the claim line in case the line is not authorized (in its entirety), but another benefit applies in absence of the authorization.

Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.

Auth Not Found Message (Other Benefit)

Auth Denied Message (Other Benefit)

Auth Exceeded Message (No Benefit)

These are the messages that are attached to the claim line in case the line is not authorized (in its entirety) and no other benefit applies in absence of the authorization.

Which of these messages are attached depends on the outcome of the authorization matching function. Read the section on authorization regime messages for specifics.

Auth Not Found Message (No Benefit)

Auth Denied Message (No Benefit)

Auth Exceeded Label

These are the coverage labels that are used to create claim line coverages in the event that a claim line benefit input amount is only partially processed by a coverage regime. Read the section on authorization regime coverage labels for specifics.

Auth Not Found Label

Auth Denied Label

The authorization regime’s type is used to detect claim lines that ignore the requirement for an authorization. The claim line has a field called 'authorization exception type'; if this field has the same value as the authorization regime type, or if it has the value 'all', then OHI Claims Adjudication assumes that the authorization requirement has been satisfied upstream, i.e., outside of OHI Claims Adjudication. The effect is that OHI Claims Adjudication treats the line as though it has been fully processed under an authorization, even though it never actually looks for a matching authorization.

Authorization Regime Periods and Tranches

OHI Claims allows a payer to set up thresholds based on a benefits input amount or allowed number of units, that must be met before the authorization requirement becomes active. These tranches must be applied per period, e.g., the first 10 units (= tranche) per calendar year (=period) do not require an authorization.

It is possible to not define a tranche maximum or period length. This is in fact the most common configuration for an authorization regime and has the effect that an authorization is simply always required.

An authorization regime period has the following fields:

Field	Description
Sequence	In the event of multiple periods the sequence specifies the order in which the periods should be applied.
Length	An integer representing the length of the time period.
Period	Specifies whether the length should be interpreted as number of days, months or years.

Field

Description

Sequence

In the event of multiple periods the sequence specifies the order in which the periods should be applied.

Length

An integer representing the length of the time period.

Period

Specifies whether the length should be interpreted as number of days, months or years.

An authorization regime period tranche has the following fields:

Field	Description
Sequence	In the event of multiple tranches, the sequence specifies the order in which the tranches should be applied.
Maximum Amount	The maximum allowed amount that can be consumed in this tranche. Once this amount is exceeded, a subsequent tranche will apply. Only the amount consumed within this tranche counts towards the maximum.
Maximum Amount Currency	The currency of the maximum amount field; it will automatically be set to the currency that is specified on the authorization regime.
Maximum Number	The maximum number of allowed units that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of units consumed within this tranche counts towards the maximum.
Maximum Service Days	The maximum number of (distinct) service days that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of service days consumed within this tranche counts towards the maximum.
Authorization Needed Indicator	Indicates whether an authorization is needed for this tranche.

Field

Description

Sequence

In the event of multiple tranches, the sequence specifies the order in which the tranches should be applied.

Maximum Amount

The maximum allowed amount that can be consumed in this tranche. Once this amount is exceeded, a subsequent tranche will apply. Only the amount consumed within this tranche counts towards the maximum.

Maximum Amount Currency

The currency of the maximum amount field; it will automatically be set to the currency that is specified on the authorization regime.

Maximum Number

The maximum number of allowed units that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of units consumed within this tranche counts towards the maximum.

Maximum Service Days

The maximum number of (distinct) service days that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of service days consumed within this tranche counts towards the maximum.

Authorization Needed Indicator

Indicates whether an authorization is needed for this tranche.

The attribute that defines the as-of date used for the tranche period is specified in the authorization regime. This imposes that all configured periods use the same as-of date. Consider the following examples to appreciate the applicability of periods and tranches:

Payer A requires an authorization for all orthodontic services for all patients over the age of 22. For all patients under the age of 22, payer A requires no authorization up to a maximum of $1000 per calendar year. After this limit is reached, payer A requires an authorization.

Payer B requires no authorization for the first 2 physical therapy sessions every quarter. After this limit is reached, payer B requires an authorization for each session.

Authorization Regime Messages

The messages attached to an authorization regime can access the following placeholder values:

0. The amount, number and/or service days counted under the authorization (line / basket detail)
1. The amount, number and/or service days of the authorization (line / basket detail)
2. The code of the authorization
3. The start date of the authorization
4. The end date of the the authorization
5. The consumed count on the authorization (line / basket detail) after the claim line
6. The unconsumed count on the authorization (line / basket detail)after the claim line
7. The amount and/or number by which the claim line exceeds the authorization (line / basket detail)
8. The code of the authorization regime

The following applies to placeholders 0, 1, 5, 6 and 7:

If amount and number are used, this is displayed as amount (number)
If amount and service days are used, this is displayed as amount (service days)
If number and service days are used, this is displayed as number (service days)
If amount, number and service days are used, this is displayed as amount (number - service days)
Whenever an amount is shown, it is postfixed by a space and the appropriate currency display code

Note that for some messages these placeholder values may be empty as they do not apply in the situation where the message is attached. For example, when no authorization is found at all, placeholder values 0 through 7 are not available.

Partial Authorization

The following three messages may be attached to the claim line in case the claim line benefits input amount is only partially authorized:

Authorization not met - This message applies when the matching function finds one or more approved authorizations and the claim line benefits input amount is fully authorized by one or several of those authorizations and after processing the claim line there is still space left on at least one authorization.

Authorization met - This message applies when the matching function finds one or more approved authorizations and the claim line benefits input amount is fully authorized by one or several of those authorizations but after processing the claim line there is no more space left on any matching authorization. This message is for each matching authorization that is fully consumed by the claim line.

Authorization met and exceeded - This message applies when the matching function finds one or more approved authorizations but their combined remainder of authorized units, amount or service days is not sufficient to cover the full claim line benefits input amount.

Note that:

The claim line can end up with a combination of these messages; suppose there are two approved matching authorizations and the claim line uses up the first and uses part of the second. The line ends up with an 'authorization met and not exceeded' for the first auth and an 'authorization not met' message for the second auth.
These messages will not be attached to the claim line if the 'consume auth.?' field on the related benefit specification is set to 'no', because in that scenario only the existence of an approved authorization is of importance. There will be no consumptions on the returned authorizations, so these messages do not apply.

Other Benefit Applies

The next three messages may be attached to the claim line in case the full claim line benefits input amount is unauthorized, but another (presumably lesser) benefit applies in absence of the required authorization.

Authorization exceeded (Benefit) - This message applies when the matching function finds one or more approved authorizations, but none of these authorizations have any remaining authorized units, amount or service days on them. This message is attached for each exceeded authorization found. Note that this message will not be attached to the claim line if the 'consume auth.?' field on the related benefit specification is set to 'no', because in that scenario only the existence of an approved authorization is of importance (it does not matter if the returned authorizations have any remaining authorized units, amount or service days on them).

Authorization denied (Benefit) - This message applies when the matching function finds only authorizations with either a denied or voided status. This message is attached for each denied authorization found.

Authorization not found (Benefit) - This message applies when the matching function finds no authorizations at all.

No Other Benefit

The last three messages may be attached to the claim line in case the full claim line benefits input amount is unauthorized and no other benefit applies in absence of the required authorization.

Authorization exceeded (No benefit) - This message applies when the matching function finds one or more approved authorizations, but none of these authorizations have any remaining authorized units, amount or service days on them. This message is attached for each exceeded authorization found. Note that this message will not be attached to the claim line if the 'consume auth.?' field on the related benefit specification is set to 'no', because in that scenario only the existence of an approved authorization is of importance (it does not matter if the returned authorizations have any remaining authorized units, amount or service days on them).

Authorization denied (No benefit) - This message applies when the matching function finds only authorizations with either a denied or voided status. This message is attached for each denied authorization found.

Authorization not found (No benefit) - This message applies when the matching function finds no authorizations at all.

Authorization Regime Coverage Labels

All three coverage labels must have the action value 'withhold'.

Authorization exceeded coverage label - This coverage label is used to explain the part of the benefits input amount that is withheld because it was not authorized by an authorization. This coverage label is only applied when (1) at least part of the benefits input amount is actually authorized or does not require an authorization, (2) the 'consume auth.?' on the authorization specification is set to 'yes' and (3) the benefit specification selection does not contain any coverage specification where the 'auth. missing?' field is set to 'yes', for the same product.

Authorization denied coverage label - This coverage label is used to explain the part of the benefits input amount that is withheld because the authorization is denied. This coverage label is only applied when (1) at least part of the benefits input falls under a tranche that does not require an authorization, (2) only denied authorizations are found for the part of the benefits input amount that does require an authorization and (3) the benefit specification selection does not contain any coverage specification where the 'auth. missing?' field is set to 'yes', for the same product.

Authorization not found coverage label - This coverage label is used to explain the part of the benefits input amount that is withheld because the authorization is not found. This coverage label is only applied when (1) at least part of the benefits input falls under a tranche that does not require an authorization, (2) no authorizations are found for the part of the benefits input amount that does require an authorization and (3) the benefit specification selection does not contain any coverage specification where the 'auth. missing?' field is set to 'yes', for the same product.

All of these are mandatory fields on the authorization regime.

Authorization Matching

In an Authorization Matching dynamic logic function the payer specifies the criteria OHI Claims Adjudication has to use to search for matching authorizations, i.e., the type of authorization (authorization, referral or notification), provider or provider group and time validity of the authorization. In an optional Authorization Detail Matching dynamic logic function the payer specifies the criteria OHI Claims Adjudication has to use to search for matching authorization lines and/or authorization basket details of the eligible authorizations, i.e., the procedure or procedure group and time validity of the authorization line.

The authorization evaluation returns the authorizations (including their eligible authorization lines and authorization basket details) that can be met according to the logic and the available space for consumption on every authorization (including their eligible authorization lines and authorization basket details). After authorization evaluation OHI Claims Adjudication determines the authorization(s) to be used for the claim line.

The matching strategy should not implement any restrictions on the status on authorizations, nor on the available space left on authorizations. All of these authorizations should be returned as possible matches: at this point the OHI Claims Adjudication logic takes over and checks for denied authorizations and the space that is still available on the returned authorizations.

For example Authorization Matching and Authorization Detail Matching functions, refer to the Dynamic Logic implementation guide.

Scenarios

Payer A sets up a distinct set of periods and tranches for orthodontic patients, reflecting that once a patient claims in excess of $1000 an authorization is required. This scenario requires the following setup:

Regime <orthodontic Child> applies per <calendar year>
- Period of <unspecified length>
  - Tranche of <$1000 maximum> <No Authorization needed>
  - Tranche <unspecified maximum> <Authorization needed>

Payer B sets up a regime that requires an authorization for every visit in excess of the second visit per three months. This scenario requires the following setup:

Regime <Physical therapy> applies per <Calendar year> and < Underlying periods are repetitive>
- Period of <3 months>
  - Tranche of <maximum number 2> <No Authorization needed>
  - Tranche <unspecified maximum> <Authorization needed>