Case Definitions
Consider the following setup:
Case Definition
| Field | Description |
|---|---|
Code |
CONFBARI |
Description |
Confined Bariatric |
Start Dynamic Function |
Service date - 1 week |
End Dynamic Function |
Service date + 1 week |
Primary Claim Line Recognition Message |
I-1221 |
Ancillary Claim Line Recognition Message |
I-1222 |
Message for Ancillary |
F-1234 |
Inheritable Primary Provider Group Scope |
IN |
Primary Claim Line Procedure Group |
BARIATRIC SURGERY |
Diagnosis Group Usage |
|
Primary Claim Line Diagnosis Group |
|
Primary Claim Line Condition |
Ancillary inclusion rule
| Procedure group | Diagnosis group usage | Diagnosis group | Dynamic condition |
|---|---|---|---|
Nutritional counseling |
and
Case Definition
| Field | Description |
|---|---|
Code |
EXTEBARI |
Description |
Extended Bariatric |
Start Dynamic Function |
Service date - 4 months |
End Dynamic Function |
Service date + 4 months |
Primary Claim Line Recognition Message |
I-1221 |
Ancillary Claim Line Recognition Message |
I-1222 |
Message for Ancillary |
F-1234 |
Inheritable Primary Provider Group Scope |
IN |
Primary Claim Line Procedure Group |
BARIATRIC SURGERY |
Diagnosis Group Usage |
|
Primary Claim Line Diagnosis Group |
|
Primary Claim Line Condition |
Ancillary inclusion rule
| Procedure group | Diagnosis group usage | Diagnosis group | Dynamic condition |
|---|---|---|---|
Nutritional counseling |
|||
Weight watchers |
IN |
MORBID OBESITY |
|
Fitness membership |
IN |
MORBID OBESITY |
|
Liposculpture |
IN |
MORBID OBESITY |
There are 2 products that we will use in the use cases
-
Product ABC
-
With a benefit specification that links to 'CONFBARI'
-
-
Product DEF
-
With a benefit specification that links to 'EXTEBARI'
-
Scenario A
Person A has product ABC.
Claim 1234, comes in with on line 1, procedure '99118 Bariatric surgery' with start date '07-14-2010'. When this claim line is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
CONFBARI is selected as a possible case definition |
Retrieve existing cases |
No existing cases are selected. |
Apply ancillary recognition rules |
Is skipped |
Attach as ancillary |
Is skipped |
Determine case end date |
Is skipped |
Set case end date |
Is skipped |
Apply primary recognition rules |
Claim line is recognized as primary because procedure 99118 is included in 'Bariatric Surgery' |
Determine case start date |
07-07-2010 |
Determine case end date |
07-21-2010 |
End overlapping case |
No existing cases, so no action |
Create new case |
A new case is created for
|
Claim 1235, comes in with 3 lines
-
line 1 procedure '88312 Nutritional counseling' with start date '07-05-2010'.
-
line 2 procedure '88312 Nutritional counseling' with start date '07-12-2010'
-
line 3 procedure '81671 Fitness membership' with start date '06-01-2010', diagnosis 'MORBID OBESITY'
When line 1 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
CONFBARI is selected as a possible case definition |
Retrieve existing cases |
The existing CONFBARI case from 07-07-2010 to 07-21-2010 is not selected, because line 1 is outside of the date range of this case |
Apply ancillary recognition rules |
Is skipped |
Attach as ancillary |
Is skipped |
Determine case end date |
Is skipped |
Set case end date |
Is skipped |
Apply primary recognition rules |
Line 1 is not recognized as a primary claim line |
Determine case start date + subsequent steps |
Are skipped |
When line 2 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
CONFBARI is selected as a possible case definition |
Retrieve existing cases |
The existing CONFBARI case from 07-07-2010 to 07-21-2010 is selected, because line 2 is within the date range of this case |
Apply ancillary recognition rules |
Line 2 is recognized as ancillary |
Attach as ancillary |
Line 2 of claim 1235 is attached as ancillary to the case |
Determine case end date |
The case already has an end date so determine case end date is not executed |
Set case end date |
Is skipped |
Apply primary recognition rules + subsequent steps |
Are skipped |
When line 3 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
CONFBARI is selected as a possible case definition |
Retrieve existing cases |
The existing CONFBARI case from 07-07-2010 to 07-21-2010 is not selected, because line 3 is outside of the date range of this case |
Apply ancillary recognition rules |
Is skipped |
Attach as ancillary |
Is skipped |
Determine case end date |
Is skipped |
Set case end date |
Is skipped |
Apply primary recognition rules |
Line 3 is not recognized as primary |
Determine case start date + subsequent steps |
Are skipped |
The final result is a case with the following data
-
Person A
-
Case definition: CONFBARI
-
Start date: 07-07-2010
-
End date: 07-21-2010
-
Primary claim line: Claim 1234, line 1, procedure '99118 Bariatric surgery' , start date '07-14-2010'
-
Ancillary claim line: Claim 1235, line 2, procedure '88312 Nutritional counseling' , start date '07-12-2010'
Scenario B
Person B has product DEF.
Claim 1234, comes in with on line 1, procedure '99118 Bariatric surgery' with start date '07-14-2010'. When this claim line is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
EXTEBARI is selected as a possible case definition |
Retrieve existing cases |
No existing cases are selected. |
Apply ancillary recognition rules |
Is skipped |
Attach as ancillary |
Is skipped |
Determine case end date |
Is skipped |
Set case end date |
Is skipped |
Apply primary recognition rules |
Claim line is recognized as primary because procedure 99118 is included in 'Bariatric Surgery' |
Determine case start date |
03-14-2010 |
Determine case end date |
11-14-2010 |
End overlapping case |
No existing cases, so no action |
Create new case |
A new case is created for
|
Claim 1235, comes in with 3 lines
-
line 1 procedure '88312 Nutritional counseling' with start date '07-05-2010'.
-
line 2 procedure '88312 Nutritional counseling' with start date '07-12-2010'
-
line 3 procedure '81671 Fitness membership' with start date '06-01-2010', diagnosis 'MORBID OBESITY'
When line 1 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
EXTEBARI is selected as a possible case definition |
Retrieve existing cases |
The existing EXTEBARI case from 03-14-2010 to 11-14-2010 is selected. |
Apply ancillary recognition rules |
Line 1 is recognized as ancillary |
Attach as ancillary |
Line 1 is attached as ancillary to the existing case |
Determine case end date |
The case already has an enddate. |
Set case end date |
Is skipped |
Apply primary recognition rules + subsequent steps |
Are skipped |
When line 2 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
EXTEBARI is selected as a possible case definition |
Retrieve existing cases |
The existing EXTEBARI case from 03-14-2010 to 11-14-2010 is selected. |
Apply ancillary recognition rules |
Line 2 is recognized as ancillary |
Attach as ancillary |
Line 2 of claim 1235 is attached as ancillary to the case |
Determine case end date |
The case already has an end date so determine case end date is not executed |
Set case end date |
Is skipped |
Apply primary recognition rules + subsequent steps |
Are skipped |
When line 3 is processed the steps in this flow produce the following results
| Step | Result |
|---|---|
Select case definitions |
EXTEBARI is selected as a possible case definition |
Retrieve existing cases |
The existing EXTEBARI case from 03-14-2010 to 11-14-2010 is selected. |
Apply ancillary recognition rules |
Line 3 is recognized as ancillary. |
Attach as ancillary |
Line 3 of claim 1235 is attached as ancillary to the case |
Determine case end date |
The case already has an end date so determine case end date is not executed |
Set case end date |
Is skipped |
Apply primary recognition rules + subsequent steps |
Are skipped |
The final result is a case with the following data
-
Person B
-
Case definition: EXTEBARI
-
Start date: 03-14-2010
-
End date: 11-14-2010
-
Primary claim line: Claim 1234, line 1, procedure '99118 Bariatric surgery' , start date '07-14-2010'
-
Ancillary claim line: Claim 1235, line 1, procedure '88312 Nutritional counseling' , start date '07-05-2010'
-
Ancillary claim line: Claim 1235, line 2, procedure '88312 Nutritional counseling' , start date '07-12-2010'
-
Ancillary claim line: Claim 1235, line 3, procedure '81671 Fitness membership' , start date '06-01-2010'
Scenario C
Person C has product ABC and DEF. The same set of claims and claim lines arrives for person C as for person A and person B. Because person C has 2 products both 'Confined Bariatric' and 'Extended Bariatric' applies. The result is that Claim 1234, line 1 is the primary claim line for 2 cases and the claim lines can be ancillary to 2 cases.
The final results for person C are the following 2 cases
-
Person C
-
Case definition: CONFBARI
-
Start date: 07-07-2010
-
End date: 07-21-2010
-
Primary claim line: Claim 1234, line 1, procedure '99118 Bariatric surgery' , start date '07-14-2010'
-
Ancillary claim line: Claim 1235, line 2, procedure '88312 Nutritional counseling' , start date '07-12-2010'
-
Person C
-
Case definition: EXTEBARI
-
Start date: 03-14-2010
-
End date: 11-14-2010
-
Primary claim line: Claim 1234, line 1, procedure '99118 Bariatric surgery' , start date '07-14-2010'
-
Ancillary claim line: Claim 1235, line 1, procedure '88312 Nutritional counseling' , start date '07-05-2010'
-
Ancillary claim line: Claim 1235, line 2, procedure '88312 Nutritional counseling' , start date '07-12-2010'
-
Ancillary claim line: Claim 1235, line 3, procedure '81671 Fitness membership' , start date '06-01-2010'