Case Recognition Scenario

Sequence	Procedure	Benefits Provider	Person	Comment
1	A2341	Dr Jackson (OON)	John Doe	Ancillary to case ABC
2	B6687	Dr Smith (IN)	John Doe	Not case related
3	C9348	Dr Smith (IN)	John Doe	Primary case ABC
4	D3921	Dr Jackson (OON)	John Doe	Ancillary to case ABC

Dr Jackson is not in a product provider group. Dr Smith is.

Person John Doe is subscribed to the BASE product on all service dates in the claim.

Product Benefit Specifications

Product	Code	Proc Grp Contains	Product Netw	Case Def	Regime
BASE	B1	A2341 and D3921	IN	ABC	Covered in Full
BASE	B2	A2341 and D3921	OON	ABC	Coinsurance 20
BASE	B3	A2341	IN		Copay 20
BASE	B4	B6687	IN		Covered in Full
BASE	B5	B6687	OON		Copay 20
BASE	B6	C9348	EITHER	ABC	Covered in Full

Case Definition

Recognition rules for ABC. If the primary line is IN, then out of network ancillary lines treated as IN as well.

Type	Proc Grp Contains
Primary	C9348
Ancillary	A2341 and D3921

Flow

Starting assumptions: there is no case for case definition ABC

Benefit Selection Phase 1

The lines are processed in sequence 1,2,3,4.

Line 1: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B1, B2 and B3. Because this set contains at least one specification with a case definition (two to be exact, B1 and B2) OHI Claims continues to evaluate if line 1 qualifies as a primary line.

Before checking if line 1 qualifies as a primary line, it needs to be made sure that line 1 does not also qualify as an ancillary line to an already existing case, as this takes precedence. First, it is checked if line 1 can be attached to an existing case ABC; which it can not. Second, it is checked if line 1 is recognized as primary; again, it does not. Line 1 is marked as possible ancillary. B1, B2 and B3 are marked as possible candidates for line 1.

Line 2: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B4 and B5. Neither benefit specification refers to a case definition, so line 2 continues with the evaluation of the product provider group status. The result is that B4 remains as the only candidate for line 2.

Line 3: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B6. Since B6 refers to a case definition, so OHI Claims continues by evaluating if line 3 is a primary line.

Before checking if line 3 qualifies as a primary line, it needs to be made sure that line 3 does not also qualify as an ancillary line to an already existing case (since this takes precedence). First, it is checked if line 3 can be attached to an existing case ABC; which it can not. OHI Claims then checks to see if line 3 qualifies as primary; which it does. Line 3 creates a new case. B6 is marked as the only possible candidate for line 3.

Line 4: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B1 and B2. Because this set contains at least one specification with a case definition (in fact both specifications) OHI Claims continues to evaluate if line 4 qualifies as a primary line.

Before checking if line 4 qualifies as a primary line, it needs to be made sure that line 4 does not also qualify as an ancillary line to an already existing case (since this takes precedence). First, it is checked if line 4 can be attached to an existing case ABC; which it can. Because this takes precedence, it’s no longer necessary to check if line 4 would start a case. Line 4 is marked as possible ancillary. B1 and B2 are marked as possible candidates for line 4.

On overview of the results after phase 1:

Claim				Results
Sequence	Procedure	Benefits Provider	Person	Possible Ancillary?	Ben Specs
1	A2341	Dr Jackson (OON)	John Doe	Yes	B1, B2 and B3
2	B6687	Dr Smith (IN)	John Doe	No	B4
3	C9348	Dr Smith (IN)	John Doe	No	B6
4	D3921	Dr Jackson (OON)	John Doe	Yes	B1 and B2

Benefit Selection Phase 2

Phase two only processes lines that are possible ancillaries to an existing case. This means line 1 and 4.

Line 1: Line 1 starts with the selection from phase 1, that is, B1, B2 and B3. First, OHI Claims attempts to attach line 1 to an existing case. The case created by line 3 in phase 1 is found and line 1 qualifies as an ancillary line to that case.

The next step is that the remaining benefit specification is filtered in context of case definitions: because B3 does not specify a case definition, it is eliminated.

The last filter is in the context of the provider group status. Because line 1 is part of a case of definition ABC, it is treated as IN given that the primary line (line 3) is IN. Therefore, benefit specification B2 is eliminated. Only B1 remains.

Line 4: Line 4 starts with the selection from phase 1, that is, B1 and B2. First, OHI Claims attempts to attach line 4 to an existing case. The case (of definition ABC) created by line 3 in phase 1 is found and line 4 qualifies as an ancillary line to that case.

The next step is that the remaining benefit specification is filtered in context of case definitions: both B1 and B2 specify case definition ABC, neither is eliminated.

The last filter is in the context of the provider group status. Because line 1 is part of a case of definition ABC, it is treated as IN given that the primary line (line 3) is IN. Therefore, benefit specification B2 is eliminated. Only B1 remains.

On overview of the results after phase 2:

Claim				Results
Sequence	Procedure	Benefits Provider	Person	Ben Specs
1	A2341	Dr Jackson (OON)	John Doe	B1
2	B6687	Dr Smith (IN)	John Doe	B4
3	C9348	Dr Smith (IN)	John Doe	B6
4	D3921	Dr Jackson (OON)	John Doe	B1

After phase 2, the evaluation of the regimes can start.