Pricing Finalization
This part of the flow describes what happens to a claim when it is finalized for pricing. Pricing finalization is only executed when the benefits for a claim are not calculated internally and the claim is to be sent out to an external Benefits component.
Before the application finalizes a claim for pricing, it first makes sure that the calculated results have not been invalidated in the time period between the calculation and the pricing finalization. This check precludes a situation where two claims, concurrently processed, fail to see each others results and therefore overtake a provider limit.
The pricing finalization flow is schematically depicted by the following figure:
Detecting concurrent use is part of the "optimistic locking" mechanism that OHI Claims uses to prevent claims from exceeding provider limits. In this context, optimistic means that OHI Claims assumes that no other claims will use the counter, leaving the counter accessible to other claims, and validating the truth of this assumption at the end of the flow. The downside to this approach is, in the event of concurrent use, a claim is processed twice. The merit of this approach is that counters do not need to be locked. The implication of locking counters would be that if a claim stops being processed after locking a counter (e.g. the claim pends) then all other claims having the claim lines for the same person or object, that need to use the same counter, would be waiting for that counter to unlock.
Detect Concurrent Use
In the 'Select and Apply Reimbursement Methods and Pricing Rules' step of Pricing one of the substeps is the select and apply of provider limit rules. Consumption is calculated based on the provider limit counters at that moment in time. Another substep is the select and apply of combination adjustment rules. Marking a claim line as primary or secondary takes into account the approved claim lines of finalized claim lines at that time for the same combination adjustment rule, information which is also stored by means of a counter.
The first step in finalization of a claim is to see whether those counters have not been changed by any other claim since then. Note that this optimistic locking strategem is not necessary for:
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Claims with a checked Ignore History indicator, because there is no risk of two claims addressing the same counter; this holds true for both the provider limit counter and the combination adjustment counter.
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Claim lines with a checked Keep Pricing indicator
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Claim lines with a skip tag for allowed
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Claim lines that have preliminary provider limit consumptions with a checked Ignored indicator
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Clam lines that are locked (with a checked Locked indicator)
Therefore, the version id which was used during the calculation is compared to the current version id on the counter. Two outcomes are possible:
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The versions id are the same, i.e., no other claims have touched the counter used by the claim.
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The versions id are different, i.e., during the time that it took this claim to calculate the pricing rules and reach the pricing finalization step, another claim that used the same counter has either finalized for pricing or finalized. As a consequence the application of reimbursement methods and pricing rules needs to be reevaluated based on the updated counters (see section below).
Recalculate Pricing
The following Pricing substeps are executed in this step:
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Clean Up Pricing Results
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This substep is identical to the one described in Clean Up Pricing Results, except that the messages with origin PRICING NO RECALCULATION are not removed
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Select and Apply Reimbursement Methods and Pricing Rules
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This substep is identical to the one described in Select and Apply Reimbursement Methods and Pricing Rules with the following exceptions:
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Replacement Rules are neither selected nor applied
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During the evaluation of Pricing External Intervention Rules, if the pend reason history indicates that the same pend reason (regardless of the reattach indicator) has been previously attached on the same level (claim, bill or line) in the most recent iteration of the claims flow (i.e. the steps that are executed after the claim’s most recent Pricing Finalized status), then the pend reason is not attached and the claim will not pend because of this external intervention rule.
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Evaluate External Intervention Rules
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This step is identical to the one described in Pricing, with the following exception: if the pend reason history indicates that the same pend reason (regardless of the reattach indicator) has been previously attached on the same level (claim, bill or line) in the most recent iteration of the claims flow (i.e. the steps that are executed after the claim’s most recent Pricing Finalized status), then the pend reason is not attached and the claim will not pend because of this external intervention rule.
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End Pricing Derivation Rules
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Pricing Done
Pricing Readjudicate Claim
This step is identical to the one described in Pricing Adjudication, with the following exception regarding the evaluation of external intervention rules: if the pend reason history indicates that the same pend reason (regardless of the reattach indicator) has been previously attached on the same level (claim, bill or line) in the most recent iteration of the claims flow (i.e. the steps that are executed after the claim’s most recent Pricing Finalized status), then the pend reason is not attached and the claim will not pend because of this external intervention rule.
Record Consumption
Any consumption that is marked for reversal is reversed. To understand why it is reversed as the first step of re finalizing the claim rather than directly after unfinalizing the claim, consider the following scenario:
A provider limit is applied to claim 1 up to the provider limit. Claim 1 has status Pricing Finalized and is then unfinalized. If the provider limit consumption would be reversed during unfinalize the provider limit would be open again, and the following undesirable situation would occur:
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Claim 2 is processed. The provider limit that was applied to claim 1 is now applied to claim 2. The provider limit is again met, but now by claim 2.
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Claim 1 is again pricing finalized. No provider limit is applied to claim 1, because the provider limit was met on claim 2
Any consumption that is not marked for reversal remains untouched. Subsequently, any preliminary consumption (recorded during the current flow) for a claim or a reservation claim with an unchecked Ignore indicator is finalized and the version id is incremented. This has the following effects:
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the counter consumption becomes visible to other claims
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the increment of the version forces other claims (that have concurrently used the same counter) to recalculate.