Track Provider Pricing Clauses
Storing information about the way an allowed amount is calculated serves a dual purpose, with both an internal and an external audience benefiting from that information:
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Internal
The claims operator is provided with information that is necessary to detect a faulty configuration or to answer questions from a provider about an allowed amount. -
External
The provider, claimant, payment receiver etc. can be provided with information about the rules that are being applied when needed.
Scope
What information should be stored? In providing more insight into the process of calculating the allowed amount, the following elements are essential:
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Which provider pricing clauses are applied?
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Which reimbursement method and pricing rules are applied?
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What was the outcome of applying a single reimbursement method or pricing rule?
Provider Pricing Clauses
By showing the provider pricing clause that is applied the selection process can be followed and configuration can be changed if necessary.
Only provider pricing clauses that are actually applied, are stored. Consider for example, that the selection of provider pricing clauses for an adjustment rule results in two candidates with both of them having the same priority. That being the case, a fatal message is attached to the claim line stating that no choice could have been made and no tracking is stored.
Reimbursement Method and Pricing Rules
ALL reimbursement methods and pricing rules that are triggered by a provider pricing clause are being tracked, even if a fatal message is attached to the provider pricing clause. Some of these reimbursement methods / pricing rules will have a direct impact on the height of the calculated allowed amount like a fee schedule or an adjustment rule. Others will lead to an informatory message (through a message rule) or to a dynamic field being populated (through a dynamic field rule), both having no direct impact on the allowed amount. But for clarity’s sake, all provider pricing clauses that were applied, are tracked.
For fee schedules, the fee schedule line is stored in the claim line provider pricing clause.
In accordance with benefits adjudication, process rules, dynamic checks and combination checks are not tracked; normally, the attached message provides sample information about the evaluation of these rules as opposed to the calculation of an allowed amount which is a result of subsequent steps. Compared to benefits adjudication where the covered amount is also the result of subsequent steps and where the information is stored in claim line rule coverages, showing the cover/withhold rules that were applied to a claim line.
How and when?
Directly after a provider pricing clause has been selected and applied, the results are stored in a claim line provider pricing clause. A claim line can have one or more claim line provider pricing clauses. A claim line provider pricing clause consists of the following fields:
| Field | Description |
|---|---|
Claim Line |
The claim line for which provider pricing clause is applied |
Provider Pricing Clause |
The provider pricing clause that is applied |
Fee Schedule Line |
The fee schedule line that is applied (only filled when a fee schedule is applied) |
Sequence |
The order in which the provider pricing clause is applied |
Mark |
The way a claim line is marked with respect to the pricing rule |
Amount |
The amount (plus, minus or zero) that shows the difference to the last outcome |
Currency |
The currency of the amount |
Note that the amount field is always specified if the currency is known, even for a message rule, where this amount is zero (as opposed to null). After internal calculation, the sum of the amounts of all the claim line provider pricing clauses adds up to the allowed amount of the claim line; when the allowed amount is changed manually, the claim line provider pricing clauses are kept until a recalculation so the numbers need not add up anymore.
In the UI, this model is shown in a more intuitive manner. The applied provider pricing clauses are shown in the order of execution during claims processing. More information is given in the Implementation Guide for Claims in the section on detail dialogs of claims pages.