Consumption
A claim line may count towards specific limits, authorizations and regime tranches in order to maximize a benefit or apply different benefits once a certain tranche is full. The contribution of a claim line towards such a limit or tranche is called consumption. Once a claim or reservation is finalized, that consumption becomes "visible" to other claims that are still being processed, so that eventually the limit or tranche maximum is reached.
Keeping track of consumption is complex primarily because the claims flow supports parallel processing which introduces the possibility that different claims attempt to register consumption on the same limit at the exact same time. Oracle Health Insurance uses an optimistic lock mechanism to handle this situation, which requires the possibility for a claim to be recalculated on the fly.
This document describes various indicators on the consumption and how they help in keeping track of the consumption.
Note that a reserved consumption that is, a consumption created by a claim with process type 'Reservation' follows the same principles as a consumption registered by a claim line that belongs to a claim with process type 'Claim'. Also, note that the offset consumption (that is, registered by a claim line that refers a reservation to 'offset' the reserved consumption) follows its actual consumption: when the actual consumption is finalized, the offset is also finalized. If actual consumption is marked for reversal, the offset is also marked for reversal and so forth.
Quote consumption always stay preliminary and are never visible to other claims or reservations still being processed.
For simplicity’s sake the guide below describes the process of tracking consumption of the claim line that belongs to a claim with process type 'Claim'.
Preliminary Versus Final Consumption
Consumption records are attached to claim lines as the result of benefits calculation. This consumption is marked as 'preliminary'. The reason for marking it as preliminary is that the consumption may still change before the claim is finalized. Specifically, consumption will have to be recalculated in a situation where the claim is overtaken by another claim that finalizes first. To clarify, consider the following scenario:
A person has a deductible of $500, but only $100 remains before the deductible is reached. Two claims are sent in for the person, claim A for $80 and claim B for $60. The deductible applies to both claims.
Claim A is sent in first. Claims checks the current state of the deductible and sees that $100 remains. The result of the calculation is that the full $80 is withheld as deductible. The deductible counter cannot updated yet, because the claim may still be denied later in the flow, but a preliminary consumption for $80 is created. After benefits calculation claim A pends for manual adjudication.
Claim B is sent in next. Claims checks the current state of the deductible and (still) sees the remaining $100. The result of the calculation is that the full $60 is withheld as deductible. A preliminary consumption for $60 is created. After the calculation, the claim finalizes. The preliminary consumption turns into final consumption, and as a result, the deductible counter is updated so that only $40 remains.
Next, claim A is manually accepted and continues in the process flow. The calculated preliminary consumption still indicates that the full $80 should be withheld, even though this is no longer accurate. When the claim is finalized, Claims detects that the claim needs to be recalculated. The new result is that only $40 should be withheld (maxing out the deductible) and that $40 should be paid. The old preliminary consumption of $80 is removed, and a new preliminary consumption $40 is created. When the claim tries to finalize again, it succeeds and the preliminary consumption is turned into final consumption, making it apparent to all other claims that the deductible has been reached.
Essentially, consumption can only be made final when Claims has ascertained that there has been no concurrent use.
Unfinalizing and Re-finalizing a Claim
When a finalized claims is unfinalized and reprocessed the finalized consumption is marked and retained until the claim re-finalizes. This prevents the situation where other claims 'steal' consumption in the time window between the subject claim unfinalizing and re-finalizing. To clarify, consider the following (undesirable) scenario where it is assumed that consumption is removed as soon as the claim unfinalizes.
A person has a deductible of $500, and the deductible has been maxed out. Claim A is finalized and has counted $100 towards the deductible. Claim A needs to be recalculated because the procedure code on the claim line needs to be changed.
Claim A is unfinalized, which removes its consumption. This resets the deductible to $400, leaving it open for $100. Claim A is handled by a claims operator who changes the procedure code. In the time that it takes the operator to change claim A, another claim for the same person is processed, that is, claim B. Claim B also counts towards the deductible and sees that $100 still remains before the deductible is reached. Claim B takes the $100 deductible, and finalizes, maxing out the deductible.
Once the operator is done, claim A is resubmitted. Since the deductible has been maxed out by claim B, no deductible is taken. As a consequence, the consumption moved from claim A to claim B, entailing a number of financial transactions to reflect this.
Now consider the same scenario where final consumption is removed when the claim re-finalizes:
Claim A is unfinalized, but its consumption remains intact. The deductible remains maxed out. Claim B is processed before claim A re-finalizes, but sees that the deductible is full and so no consumption is created for claim B. Claim A is then recalculated. During calculation, claim A ignores its own final consumption. As a result, the benefits are calculated assuming there is $100 remaining deductible. Claim A takes the remaining $100 as preliminary consumption, and then re-finalizes, replacing the old final consumption with new final consumption.
The latter scenario reflects how Claims handles consumption for unfinalized claims. In order to clarify the difference between final consumption on a finalized claim and final consumption on an unfinalized claim, the consumption on unfinalized claims is "marked" for reversal.
Storing Consumption on the Claim Header
Claims allows claim lines of an unfinalized claim to be removed. This can be either through a manual delete through the user interface, or through the claims in integration point, which has the ability to overwrite claims.
A to-be-deleted line potentially has final, or even preliminary consumption attached to it. Deleting the consumption presents a problem: the line is gone, but the consumption that it took can not be removed until the claim re-finalizes again (because otherwise there is an opportunity for other claims to "steal" consumption).
To prevent the consumption from being taken by other claims, the consumption that was attached to the deleted line is stored on claim header; keeping the current count intact. The link between the 'old' consumption and the claim line from which it originated is gone, since that claim line no longer exists.
Recalculation of Provider Limits
Claims that are both internally priced and adjudicated for benefits can sometimes trigger a recalculation, even before the claim finalizes. This happens in the adjudication step, if the claim line was successfully priced based on a provider limit but was denied after pricing. Because the line is denied, the consumption that it took during the pricing step is returned to the limit so that other lines - within the same claim - are repriced with that consumption available.
This automated recalculation is a shorter version of the regular claims flow; it only executes the pricing and benefit calculation. Process rules such as dynamic checks, call out rules and pend rules are not part of the recalculation. There is no second enrollment call out either; the same enrollment information is used.
The important difference with the regular claims flow calculation is that the recalculation - the repricing in particular - excludes the post-pricing denied lines to prevent these lines from taking consumption again. So, when the system sends a claim back to be repriced, it marks the provider limit consumption on those denied lines (to be ignored). This lets the recalculation know that (1) the consumption on those lines does not count and can be taken freely by other lines in the claim and (2) that those lines should not be repriced.
The system recalculation is triggered when
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the system detects a line that has been denied after it was priced based on a provider limit or
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the claims processor saves or submits the claim in the manual adjudication page
There are two reasons for marking the provider limit consumption to be ignored, rather then simply removing the consumption. The first is that marking the provider limit consumption is the only way the system knows to not reprice the line. The second is that by removing the provider limit consumption, the system would create a situation where the line can be approved without taking consumption.
Suppose a claim is priced based on a provider limit and is then denied because there was no authorization. A day later the claim is reprocessed with 'pricing done' set to yes, which means the pricing step is completely skipped. The authorization is now found and the line is approved. If the consumption would be deleted in the first processing cycle, the line would have been approved in the second cycle without any consumption.
Consumption Flow Scenarios
In order to clarify how Claims deals with these situations this appendix includes a number of scenarios that explain how consumption is handled. Each scenario refers to an image of a simplified claims flow. This simplified flow displays only those process steps that deal with handling consumption.
The flow of consumption
Remove Consumption of Deleted Lines
This step removes any preliminary consumption that is, stored on the claim header. This is preliminary consumption that belonged to lines that have been deleted after the claim had been rerouted to the change status.
Keep Benefits?
Per claim line, it is determined whether previously calculated benefits should remain intact or not. Benefits should remain intact when the claim line "keep benefits?" indicator is checked.
If neither indicator is checked, then all existing preliminary consumption is removed and the claim line benefits and consumption are calculated.
If either one of the indicators is checked, then no consumption is calculated for that particular claim line, but, if no preliminary consumption exists, a preliminary copy of the old final consumption is created. The rationale is that any claim, regardless of whether the benefits are (partially) kept, can end up in a manual benefits status. So, once the flow gets to the step where external intervention rules are evaluated, any line that used a limit or regime tranche must have preliminary consumption.
All calculated and/or copied consumption is stored as preliminary.
Concurrent Use of Counters?
This step checks all counters for which claim line consumptions were created during the benefits step, providing that the keep benefits indicator is unchecked. If Claims detects that another claim has used one of those counters, and has finalized in the time that it took the checked claim to go from the benefits step to the finalization step, then the checked claim requires recalculation.
If a claim needs recalculation, all the steps required for benefit calculation are repeated for that claim. This includes another check for concurrent use.
Reverse Marked Consumption and Write Final Consumption
Once Claims has ascertained that no other claim has changed the counter, the old final consumption is reversed. Reversing means that the consumption record gets a reversal date filled, in essence meaning that this record no longer has any impact on the consumption.
| Claim | Claim Line | Amount | Service Date | Transaction Date | Reversal Date |
|---|---|---|---|---|---|
CL01 |
1 |
$ 100 |
3/15/10 |
3/25/10 |
3/31/10 |
acts as shorthand for
| Claim | Claim Line | Amount | Service Date | Transaction Date |
|---|---|---|---|---|
CL01 |
1 |
$ 100 |
3/15/10 |
3/25/10 |
CL01 |
1 |
- $ 100 |
3/15/10 |
3/31/10 |
Reversing marked consumption includes any final consumption on the claim header, that is, consumption of deleted claim lines. At the same time, the preliminary consumption is turned into final consumption. Turning it into final consumption means that other claims can see that consumption and take it into account when calculating their benefits.
The reversal of old final consumption and creation of new final consumption is part of the same transaction, as explained in the section on un- and refinalizing claims.
Scenario 1: Happy Flow
A claim is processed for the first time. The claim has one line. The claim line field "keep benefits?" is unchecked. The following happens in each of the (consumption) flow steps:
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Keep benefits? No
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There is no preliminary consumption to remove.
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New preliminary consumption is calculated
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The calculated preliminary consumption is stored2.
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Concurrent use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: No final consumption is present, nothing happens.
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Finalize Preliminary Consumption: The calculated preliminary consumption turns into finalized consumption.
Scenario 2: Unfinalize and Re-finalize
A finalized claim has one line with consumption on it. The claim is unfinalized and reprocessed. The claim line field "keep benefits?" is unchecked. The following happens in each of the (consumption) flow steps:
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Mark Final Consumption for Reversal: The consumption on the claim line is kept intact, but is marked for reversal. This signifies that other claims will still see that consumption, but the consumption is ignored when the claim itself recalculates.
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Keep Benefits? No
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There is no preliminary consumption to remove.
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New preliminary consumption is calculated
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The calculated preliminary consumption is stored
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Concurrent Use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: The old final consumption (marked for reversal in step 1) is reversed.
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Finalize Preliminary Consumption: The calculated preliminary consumption turns into finalized consumption.
Scenario 3: Concurrent Use of Counters
Claim A is processed. Moments after claim A has been processed, claim B is processed and uses the same limit. Claim A pends. Claim B does not pend and is finalized. Claim A is unpended. The following happens in each of the (consumption) flow steps, for claim A.
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Keep Benefits? No
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There is no preliminary consumption to remove.
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New preliminary consumption is calculated
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The calculated preliminary consumption is stored
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At this time, claim A pends. While claim A is pended, claim B goes through the happy flow (scenario 1), calculates consumption for the same limit as used by claim A, and is finalized. Claim A re-enters the flow:
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Concurrent Use? Claims detects that another claim has used the same limit and has finalized while claim A was pended. Claim A is rerouted back to the benefits steps.
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Keep Benefits? No
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The "old" preliminary consumption is removed
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New preliminary consumption is calculated
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The newly calculated preliminary consumption is stored3. Concurrent use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: No final consumption is present, nothing happens.
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Finalize Preliminary Consumption: The calculated preliminary consumption turns into finalized consumption.
Scenario 4: Keeping Benefits after Un-finalize
A finalized claim has one line with consumption on it. The benefits results of the line have been manually changed, so the claim line keep benefits indicator is checked. The claim is unfinalized and reprocessed. The following happens in each of the (consumption) flow steps:
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Mark Final Consumption for Reversal: The final consumption on the claim line is marked for reversal.
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Keep Benefits? Yes
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Since there is no preliminary consumption, a preliminary copy is made of the marked final consumption.
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The copied preliminary consumption is stored
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Concurrent Use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: The old final consumption is reversed.
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Finalize Preliminary Consumption: The copied preliminary consumption turns into finalized consumption.
The reason why Claims still creates preliminary consumption and reverses the existing final consumption, even though the line has a checked "keep benefits" indicator, is that the claim may still pend for manual benefits, and an operator may still decide to alter the benefits on that line.
Scenario 5: Keeping Benefits After Un-finalize and Reset to Change
A finalized claim has two lines, both with consumption on it. The benefits results of line 1 have been manually changed, so the claim line keep benefits indicator is checked. For line 2 the keep benefits indicator is unchecked. The claim is unfinalized. The following happens in each of the (consumption) flow steps:
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Mark Final Consumption for Reversal: The final consumption on both lines is marked for reversal.
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Keep Benefits?
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For line 1: Yes
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Since preliminary consumption already exists, no new copy is made.
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There is no new consumption to store.
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For line 2: No
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The preliminary consumption is removed.
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New preliminary consumption is calculated
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The calculated consumption is stored
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Concurrent Use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: The old final consumption is reversed.
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Finalize Preliminary Consumption: The preliminary consumption is finalized.
Scenario 6: Deleting a Line of an Un-finalized Claim
A finalized claim has two lines, both with consumption on it. Neither line has a checked "keep benefits?" indicator. The claim is unfinalized:
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Mark Final Consumption for Reversal: The final consumption on both lines is marked for reversal.
Before the claim is resubmitted, line 2 is deleted. As a consequence, the consumption that was on line 2 moves to the claim header, and is temporarily stored there.
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Keep Benefits?
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For line 1: No
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The preliminary consumption is removed.
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New preliminary consumption is calculated
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The calculated consumption is stored
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Line 2 no longer exists
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Concurrent Use? No other claim has used the counter, so the claim can be finalized.
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Reverse Marked Final Consumption: The old final consumption (for line 1 referring to claim line code 1, for line 2 now on the claim header) is reversed.
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Finalize Preliminary Consumption: The preliminary consumption is finalized.