Authorizations
A carrier may require that the insured or provider obtains the carrier’s approval before a particular service is rendered. For example, before the insured can be reimbursed for a wheelchair from a durable medical equipment provider, he or she needs to obtain an approval from the carrier. In Claims, such a request for approval is stored as an authorization record.
Authorizations typically enforce some restrictions on the service they authorize. Typical examples are: an end date before which the service needs to be rendered, a limit on the amount that is approved and that specific provider that needs to render the service.
An authorization is valid for a specified period of time, and so it specifies a start date and (possibly) an end date. The absence of an end date indicates that an authorization is valid for an infinite amount of time. If the start and end date of the authorization are the same, then that authorization is valid only on that single day. In the scenarios where an authorized value on an authorization or authorization line applies on a per period basis (for example 1 unit of drug X per week), the authorization or authorization line can specify a renewal period (including a renewal reference).
An authorization can contain an authorized amount, an authorized number of units, an authorized number of service days or a combination of two or three of them. The authorized amount, authorized number of units and authorized number of service days are counted over all authorized lines. If a combination is specified, for example, both an amount and a number of units, then the authorization is fully consumed once the first of the boundaries is exceeded. When neither an amount nor a number of units nor a number of service days is specified, then there is no limitation on consumption. For example, consider an authorization that authorizes medication for a chronic health condition, such as batteries for a hearing aid. There may still be a limit on the coverage.
When the product of the person requires an authorization for a certain procedure or group of procedures, claims processing will try to find an authorization (including applicable authorization lines and authorization baskets with their details) that matches with the claim line. An example of such a matching function is provided in the Dynamic Logic implementation guide.
Authorization
An authorization has the following fields:
| Field | Description |
|---|---|
Code |
The unique code of the authorization as has been assigned by the payer in an external authorization application. |
Insurable Entity |
The person or object that is authorized. |
Type |
Specifies whether this is an Authorization, Notification or Referral. |
Form |
The form or category of the authorization. |
Service Provider |
The service provider for which the person or object is authorized. |
Specialty |
The specialty for which the person or object is authorized. |
Location Provider |
The location provider for which the person or object is authorized. |
Provider Group Scope |
Is the person or object authorized to go to an 'In' network provider or an 'Out' of network provider (or 'Either'). This with respect to the provider group scope of the policy product. This attribute can be used in the matching logic that identifies the authorizations that match with a claim line. |
Requested by Provider |
The provider that requested this authorization. |
Requested by Relation |
The relation that requested this authorization. |
Requester Reference |
The reference that the requester used for the request for authorization. |
Data Access Group |
The data access group used to differentiate over user access rights. |
Brand |
The brand used to differentiate over user access rights. The brand can also be used to match the authorization to a claim. |
Start Date |
The start date of the period when the person or object is authorized to receive the procedures on the authorization. |
End Date |
The end date of the period when the person or object is authorized to receive the procedures on the authorization. The end date can be left empty. |
Renewal Reference |
Specifies the as-of date that is used to determine which period applies for the authorization limit. The following as-of dates can be specified:
If no renewal reference is specified, this means that the authorization limit actually has no fixed period and therefore the counter period for such an authorization limit doesn’t refer to a time period: it just acts as a placeholder for all consumption. |
Renewal Period |
The length of the renewal period. Must be specified in combination with a renewal reference. |
Renewal Period Unit of Measure |
The unit of measure (Day, Month or Year) for the renewal period length. Must be specified in combination with a renewal reference. |
Authorized Amount |
The total amount authorized for all claim lines that match with this authorization. This amount is used as a boundary for the sum of all covered amounts. If the sum of the amount of the claim line and the consumption on the authorization exceeds the authorized amount, then the amount covered by the claim line will be reduced to the remaining open amount on the authorization. |
Authorized Amount Currency |
The currency of the authorized amount. |
Authorized Number of Units |
The total number of units for all claim lines that match with this authorization. This number is used as a boundary for the sum of all covered units. |
Authorized Service Days |
The total number of distinct service days for all claim lines that match with this authorization. This number is used as a boundary for the sum of all covered service days. |
Indicator Override Cover Limits |
Should the adjudication cover stop limits be overridden if this authorization is applied? If set to Yes, when evaluating the coverage regime any cover stop limit will be treated as a cover continue limit. |
Status |
The status of the authorization. Three final statuses are supported for an authorization:
Any additional information on how the authorization was approved or how it was denied, can be specified through authorization messages. |
Internal Remarks |
Manual remarks for the authorization for internal use. |
Authorization Line
An authorization can specify which services are authorized in multiple ways; the authorization can specify one or more service types (which can be used within the authorization matching dynamic logic to restrict the authorization to specific procedures), the authorization can specify a number of individual authorization lines and/or the authorization can specify authorization baskets (described in the Authorization Baskets section). The authorization is always specified. The authorization line is only specified when the authorization counts per procedure, procedure group or a dynamic dimension, rather than for the authorization as a whole. An authorization line has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization to which the line belongs to. |
Code |
The identifying code of the authorization line (unique within an authorization). |
Procedure |
The procedure that is the subject of the authorization (cannot be specified in combination with a procedure group). |
Procedure Group |
The procedure group that is the subject of the authorization (cannot be specified in combination with a procedure). |
Renewal Reference |
Specifies the as-of date that is used to determine which period applies for the authorization line limit. The following as-of dates can be specified:
If no renewal reference is specified, this means that the authorization line limit actually has no fixed period and therefore the counter period for such an authorization line limit doesn’t refer to a time period: it just acts as a placeholder for all consumption. |
Renewal Period |
The length of the renewal period. Must be specified in combination with a renewal reference. |
Renewal Period Unit of Measure |
The unit of measure (Day, Month or Year) for the renewal period length. Must be specified in combination with a renewal reference. |
Authorized Amount |
The authorized amount for this line. |
Authorized Amount Currency |
The currency of the authorized amount. |
Authorized Number of Units |
The authorized number of units for this line. |
Authorized Service Days |
The authorized number of service days for this line. |
Start Date |
The start date of the authorization line. |
End Date |
The end date of the authorization line. |
The authorized number of units, authorized amount and authorized service days can be specified per line. These fields are used to limit the numbers, amounts and service days to which the authorization extends.
The authorized amount, authorized number of units and authorized service days (including the renewal reference and period) can be specified at three levels: the authorization, the authorization line and/or the authorization basket detail. This is interpreted as follows:
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When no authorized amount is specified at any level, this has the meaning of unlimited as far as amount goes.
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When an authorized amount is specified at the authorization level, this has the meaning of limiting the amount for all the authorization lines and authorization basket details together.
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When an authorized amount is specified at the authorization line level, this has the meaning of limiting the amount for that specific authorization line.
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When an authorized amount is specified at the authorization basket detail level, this has the meaning of limiting the amount for that specific authorization basket detail.
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When an authorized amount is specified both at the authorization and the authorization line or authorization basket detail level, both limits are applied. Consumptions are created based on the most restrictive limit.
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When an authorized amount is specified both at the authorization line and the authorization basket detail level, this will usually mean (has to be configured in the Authorization Detail Matching function dynamic logic) that the authorization line limit overrides the authorization basket detail limit. In that case only the authorization line limit is applied.
Note that whenever the authorized amount is mentioned, the same holds true in the event of an authorized number of units or authorized service days.
Although it is possible setup, it makes no sense to have an authorization line or authorization basket detail on which the authorized amount is less restrictive than the authorized amount on the authorization. However, there is no business rule that prevents the creation of such an authorization. Note that it is possible to have for example, both an authorized amount and an authorized number of units. If this is the case, then both limits are evaluated separately. The most restrictive limit is applied.
Authorization Basket
An authorization can specify which baskets are applicable to that authorization in the form of authorization baskets. An authorization basket has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization in which the basket was authorized. |
Basket |
The authorized basket. |
Start Date |
The start date of the authorization basket. |
End Date |
The end date of the authorization basket. |
Authorization Diagnosis
The authorization diagnoses specify the diagnoses for which the authorization is intended. An authorization diagnosis has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization in which the diagnosis was authorized. |
Diagnosis |
The diagnosis for which the authorization is intended. |
Authorization Service Type
The authorization service types specify the service types for which the authorization is intended. An authorization service type has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization in which the service type was authorized. |
Service Type |
The service type for which the authorization is intended. |
Authorization Message
Messages attached to an authorization can have two different functions:
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To transfer information into Claims on the processing details of the authorization
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To be attached to each claim line that makes use of the authorization
An authorization message has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization to which the message is attached. |
Message |
The message that is attached. |
Inherit |
Boolean. If true, then the messages will be attached to the claim line when the authorization applies. |
| Updates on Authorization Line, Authorization Baskets, Authorization Diagnoses, Authorization Service Type and Authorization Message are tracked on Authorization through audit tracking. For details on additional audit tracking refer chapter Additional Audit Columns for Claims in the Operations guide |
Authorization Counter
Each authorization record has a single counter. Each authorization line record also has a single counter. The same applies for each basket detail record that is linked to an authorization through an authorization basket. When for example an authorization contains both an authorized number and an authorized amount, the counter periods (explained in the section below) of the counter will contain both the current amount and the current number. Note that consumptions are also registered for unlimited (without a specified authorized amount, number of units and service days) authorizations, authorization lines and authorization basket details; the current values on the counter periods of the counters will be unspecified.
An authorization counter acts as an umbrella for all of the consumption on an authorization, authorization line or authorization basket detail as well as the periods of time for an authorization, authorization line or authorization basket detail. An authorization counter has the following fields:
| Field | Description |
|---|---|
Authorization |
The authorization for which this counter is used. |
Authorization Line |
The authorization line for which this counter is used. |
Authorization Basket |
The authorization basket for which this counter is used. |
Basket Detail |
The basket detail for which this counter is used. Always specified in the combination with an authorization basket. |
Version |
The version of the counter (to detect concurrent use). The version is incremented when:
|
Authorization Counter Period
Authorization counter periods show the periods of time that are set out for an authorization counter. The start date and end date for such an authorization counter period are determined based on the renewal period length, unit of measure and reference (date) specified on the applicable authorization, authorization line or basket detail. An authorization counter period has the following fields:
| Field | Description |
|---|---|
Authorization Counter |
The authorization counter for which this period is set out. |
Start Date |
The start date of the period. Only set if a renewal reference and period are specified on the applicable authorization, authorization line or basket detail. |
End Date |
The end date of the period. Only set if a renewal reference and period are specified on the applicable authorization, authorization line or basket detail. |
Current Amount |
The current counted amount. This equals the sum of all (finalized) consumption amounts for this counter period. Not counted if the authorization, authorization line or basket detail has an unspecified authorized amount. |
Current Amount Currency |
The currency of the current amount. |
Current Number |
The current counted number of units. This equals the sum of all (finalized) consumption numbers for this counter period. Not counted if the authorization, authorization line or basket detail has an unspecified authorized number of units. |
Current Service Days |
The current counted number of service days. This equals the sum of all (finalized) distinct consumption service days for this counter period. Not counted if the authorization, authorization line or basket detail has an unspecified authorized service days. |
Authorization Consumption
The authorization consumption expresses how much has been used on an authorization. Consumption expresses usage that increments the current amount, number and/or service days (for authorizations, authorization lines and basket details that have limits on those values). Reversal of consumption expresses a reversal of usage and will decrement the current amount, number and/or service days (for authorizations, authorization lines and basket details that have limits on those values). An authorization consumption has the following fields:
| Field | Description |
|---|---|
Authorization Counter |
The authorization counter to which the consumption is linked. |
Counter Version |
The version of the counter at the time of writing this consumption. |
Claim |
The claim that is the source of the consumption. |
Claim Line |
The claim line that is the source of the consumption. |
Amount |
The amount consumed. The amount is always specified, even if the authorization, authorization lines or basket detail does not specify an authorized amount. |
Amount Currency |
The currency of the amount consumed. |
Number of Units |
The number of units consumed. The number of units is always specified, even if the authorization, authorization lines or basket detail does not specify an authorized number of units. |
Service Date |
The service date for which this consumption is registered. |
Reversal Date-time |
The date and time on which this consumption was logically deleted (due to reprocessing). |
Transaction Date-time |
The date and time on which this consumption became finalized. |
Preliminary Indicator |
Is this consumption linked to a non-finalized claim line? |
Marked For Reversal Indicator |
Is this consumption marked for reversal (through unfinalize)? |
Reversed Indicator |
Is this consumption reversed? |
Evaluation of Counters and Counter Periods
When a new claim line is evaluated, the system first checks if a counter (without a reference to an authorization line nor an authorization basket) exists for the selected authorization. If it does not exist, the counter is created including its counter period, counters and counter periods for the applicable authorization lines (if any), counters and counter periods for the applicable authorization basket details (if any) and consumptions for the newly created counters.
If the applicable counter already exists, the system evaluates its existing counter periods and the counters and counter periods of the applicable authorization lines (if any) and/or authorization basket details (if any) to decide what needs to happen: create new counters (for authorization lines and/or authorization basket details), create consumptions, create new counter periods and/or remove existing counter periods.
To get a clear understanding of how counters and counter periods are set out, refer to the following scenarios in the Adjudication Limits section of the Benefit Rules implementation guide:
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Scenarios A, B, C and D clarify the workings of the Calendar Year renewal reference
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Scenario L clarifies the workings of the First Claim renewal reference
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Scenario M clarifies the workings of the First Claim Irregular renewal reference
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Scenarios I and J clarify the workings of consumptions of different types
New Counter
If a counter (without a reference to an authorization line nor an authorization basket) for the selected authorization does not exist, it is created. After creating the new counter, the applicable counter period is created based on the authorization settings (renewal reference, renewal period and authorized values) and the claim line start date (referred to as service date in the sections below). The start and end dates [1] [2]) and the renewal period. If the authorization has a specified authorized value, the applicable current count on the counter period is set to 0 (for amounts the currency is set to the authorized amount currency). This can result in none, one or multiple current counts being set, depending on which authorized values are specified.
The system then selects the applicable authorization lines (if any) and/or authorization basket details (if any) using the Authorization Detail Matching dynamic logic function (see Dynamic Logic implementation guide for more information) and creates a counter (with a reference to the authorization line or authorization basket and basket detail) and counter period for every selected authorization line or authorization basket detail in the same way as specified above.
After creating the counters and counter periods, a preliminary consumption (based on the most restrictive authorized value) is created for every new counter. When this consumption is finalized (in the Finalize step of the claims flow), the applicable counter period is updated: the current counts is/are set based on the consumption. Note that it is possible that the preliminary consumption is deleted before the claim finalizes, because a fatal message is attached to the claim line (for example a fatal Authorization Met and Exceeded message or a fatal Manual Adjudication message). In that scenario the counter and counter period are also deleted if the deleted preliminary consumption was the only consumption.
Existing Counter
If a counter (without a reference to an authorization line nor an authorization basket) for the selected authorization already exists, the system performs the following steps:
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Select the applicable authorization lines and/or authorization basket details
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Check the existing counter periods of the authorization, the applicable authorization lines and/or authorization basket details
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Create new counter periods and remove existing counter periods if needed
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Check if there is room left on all applicable counter periods
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If there is no room left,finish the evaluation
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If there is no room left, check if new counters need to be created for the applicable authorization lines and/or authorization basket details
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Create counters (and counter periods) for the applicable authorization lines and/or authorization basket details if needed
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Create a consumption for every applicable counter
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The steps are described in more detail in the sections below.
Step 1
The system selects the applicable authorization lines (if any) and/or authorization basket details (if any) using the Authorization Detail Matching dynamic logic function (see Dynamic Logic implementation guide for more information). This is the same as in the New Counter mechanism.
Step 2
After the applicable authorization lines and/or authorization basket details have been selected, the system checks all existing counter periods of the authorization, the applicable authorization lines and/or authorization basket details. The following sub-steps are performed for the authorization counter, every applicable authorization line counter and every applicable authorization basket detail counter separately.
Applicable Counter Period
The system first checks if the applicable counter period exists, based on the authorization, authorization line or basket detail settings (renewal reference, renewal period and authorized values) and the claim line start date (referred to as service date in the sections below).
The applicable counter period has correct start and end dates [3] based on the service date, the reference date (calendar year start date or first service date [4]) and the renewal period. It has the applicable current counts specified based on the specified authorized values on the authorization, authorization line or basket detail, and it has the same current amount currency as the authorized amount currency (if specified). For example, if the authorization has an authorized number of units, the current number of units must be specified; if the authorization has an unspecified authorized number of units, the current number of units must be unspecified.
If the applicable counter period exists, step 2 is finished for the counter in context. If the applicable counter period does not exist, it is created with the correct start date and end date (same as in the New Counter mechanism). Afterwards, the system checks if there are any existing final (non-reversed and not marked for reversal) consumptions that fall within the new counter period and count towards it. The current counts on the new counter period is/are set based on those consumptions. Note that all final (non-reversed and not marked for reversal) consumptions are taken into account, so also consumptions in a currency that differs from the authorized amount currency. These consumptions will not count towards the current amount, but might count towards the current number or current service days (if an authorized number of units and/or authorized service days is specified).
Existing Counter Periods
If other counter periods exist, they are checked to verify if they are still valid based on the current authorization, authorization line or basket detail settings. The system first checks if the specified current values on the counter periods match the authorized values. For example, if the authorization has an authorized number of units, the current number of units must be specified; if the authorization has an unspecified authorized number of units, the current number of units must be unspecified. If an authorized amount is specified, the currency of the current amounts must match the authorized amount currency.
If the current values match the authorized values, the start dates and end dates of the counter periods are checked based on the current authorization, authorization line or basket detail settings (it is possible that the reference date, the renewal reference and/or the renewal period have/has been updated).
If the checked counter periods are not valid, they are removed and new counter periods are created based on the existing final (non-reversed and not marked for reversal) consumptions and the current authorization, authorization line or basket detail settings. Note that all final (non-reversed and not marked for reversal) consumptions are taken into account (same as for the Applicable Counter Period).
Step 3
The system checks if there is room left on the applicable counter periods based on their current counts (including the preliminary consumptions of other claim lines within the same claim that count towards the counter periods) and the authorized values specified on the authorization, the applicable authorization lines and/or authorization basket details.
If there is no room left on at least one applicable counter period, the system removes the applicable counter periods that have no final (non-reversed and not marked for reversal) consumptions and the evaluation of the authorization in context is finished.
If there is room left on all counter periods, the evaluation of the authorization continues. The system checks if applicable authorization lines and/or authorization basket details exist without a counter. If so, for every such authorization line and authorization basket detail a counter and a counter period are created. Afterwards a preliminary consumption is created for every applicable counter. The creation of the counters, counter periods and consumptions is the same as in the New Counter mechanism.