Validate Selection

The result of the preceding steps is a list of eligible benefit specifications. At this point the claim line messages with origin BENEFITS that are specific to a product that is not in the list are discarded.

Per product and per benefit specification type, only one product benefit specification can be applied. The one exception is where a product has two coverage benefit specifications, one that applies if there is an authorization, one that applies if there is not. This covers the situation where a claim line exceeds the remaining space on an authorization, and the part that exceeds is adjudicated based on a different benefit specification.

If more than one benefit specification is found for a certain product and type, the list is ordered by the benefit priority of the benefit specification. The lower the priority field value, the higher the priority. If a benefit specification has no priority value, then this is interpreted as the lowest possible priority. This way, only a single benefit specification should have the highest priority for a certain product and type. If not, the following product dependent fatal message is attached to the claim line:

Code	Sev	Text
CLA-FL-BENS-003	Fatal	{number of found benefit specs} {type} benefit specifications have been found with the same priority for this claim line: {code1},{code2}, {code3}, {code4}, {code5}

Subsequently, the coverage specifications are listed in order of product priority. The priority is derived from the priority value that is configured on the product. The lower the priority field value, the higher the priority. If a product has no priority value, then the product is handled as having lowest priority. In the event that two different products in the list have the same priority, or if both have a null priority, the following product independent fatal message is generated:

Code	Sev	Text
CLA-FL-BENS-004	Fatal	Policy products found with same priority for insurable entity {code} on date {date}

Adjudication Cases

Adjudication cases are created during the benefit specification selection. Quite possibly more than one. This happens when a claim qualifies for two adjudication cases that have different priorities of applicability, and the requirements for starting the lower priority case are a subset of the requirements for starting the higher priority case.

In the context of the given scenario, the case evaluation step starts a new case for both case definitions. It is only at the end of the benefit specification selection (the validation step) that the applicable coverage benefit specification is determined. At this point, all adjudication cases that have been started during the selection are removed, except for the one that was started by the applicable benefit specification.

If the benefit specification selection fails due to message CLA-FL-BENS-003 or 004 the adjudication case details and any other benefits messages are removed. In other words, the benefit selection produces an adjudication case only if the selection is successful, and only one adjudication case per policy product.

Overriding Benefit

If the claim line specifies an overriding coverage regime, the list of eligible benefit specifications will be empty here except for post-benefit specs (if any). If post-benefit specifications exist they are validated.

If the claim line specifies an overriding coverage specification, the list of eligible benefit specifications will hold one coverage benefit specification and zero or more post-benefit specifications. The validation steps and the No Benefit Found step for the coverage specification are skipped. If post-benefit specifications exist they are validated.

No Benefit Found

It is possible that the benefit selection process does not yield any coverage benefit specifications at all. This happens when the line is not denied (for example due to a processing rule), while at the same time there are no applicable benefit specifications.

If this happens, the application starts a second benefit selection (for each policy product). The goal of the second selection is not to get an applicable benefit specification, but to determine per product what criteria eliminated the last potential coverage benefit specification. Once that criteria is known, the system attaches the appropriate message to the claim line, and the second selection is complete for the applicable product. Upon completion, any remaining adjudication case details and benefits messages are removed, excluding the fatal message that explains why no coverage was found.

The first step is to list all product benefit specifications active on the claim line benefits input date. Only benefit specifications of type coverage are included. If this is an empty list, the following message is applied and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-017	Fatal	There are no active benefits on benefits input date {date}

The next step is to eliminate all benefit specifications from the list that require or preclude a procedure on the line. If this eliminates all benefit specifications on the list, the following message is applied and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-018	Fatal	The claimed service is not covered due to procedure requirements

If any benefit specifications remain, the next step is to eliminate those that require or preclude a diagnosis on the line. If this eliminates all benefit specifications on the list, the following message is applied and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-019	Fatal	The claimed service is not covered due to diagnosis requirements

If any benefit specifications remain, the next step is to eliminate those that require the person’s age on the benefits age input date to be in a particular range. This step is only applicable if the serviced entity is a Person. If this eliminates all remaining benefit specifications on the list, the following message is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-021	Fatal	The claimed service is not covered for person of age {person's age}

If any benefit specifications remain, the next step is to eliminate those that have a gender requirement. This step is only applicable if the serviced entity is a Person. If this eliminates all remaining benefit specifications on the list, the following message is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-022	Fatal	The claimed service is not covered for person having gender {male/female}

If any benefit specifications remain, the next step is to eliminate those that have a claim form type requirement. If this eliminates all remaining benefit specifications on the list, one of the two following messages is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-043	Fatal	The claimed service is not covered for {claim form type display name} claims
CLA-FL-BENS-051	Fatal	The claimed service is not covered for claims with no claim form type

If any benefit specifications remain, the next step is to eliminate those that require or preclude a location type on the line. If this eliminates all remaining benefit specifications on the list, one of the following messages is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-039	Fatal	The claimed service is not covered due to a location type missing on the claim line
CLA-FL-BENS-040	Fatal	The claimed service is not covered due to a location type present on the claim line
CLA-FL-BENS-050	Fatal	The claimed service is not covered due to location type requirements

If any benefit specifications remain, the next step is to eliminate those that require or preclude a modifier on the line. If this eliminates all remaining benefit specifications on the list, one of the following messages is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-044	Fatal	The claimed service is not covered due to modifiers missing on the claim line
CLA-FL-BENS-045	Fatal	The claimed service is not covered due to modifiers present on the claim line
CLA-FL-BENS-046	Fatal	The claimed service is not covered due to modifier requirements

If any benefit specifications remain, the next step is to eliminate those that require or preclude a specialty on the line. If this eliminates all remaining benefit specifications on the list, one of the following messages is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-047	Fatal	The claimed service is not covered due to specialties missing on the claim line
CLA-FL-BENS-048	Fatal	The claimed service is not covered due to specialties present on the claim line
CLA-FL-BENS-049	Fatal	The claimed service is not covered due to specialties requirements

If any benefit specifications remain, the next step is to eliminate those that have a country region requirement that is not met by the claim line. The check on person’s country region is only applicable if the serviced entity is a Person. If this eliminates all remaining benefit specifications on the list, one or more of the following three messages are applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-023	Fatal	The claimed service is not covered given the person’s country region
CLA-FL-BENS-024	Fatal	The claimed service is not covered given the provider’s country region
CLA-FL-BENS-025	Fatal	The claimed service is not covered given the employer’s country region

If any benefit specifications remain, the next step is to eliminate those for which not all benefit specification conditions are met. If this eliminates all remaining benefit specifications on the list, the following message is applied separately for each dynamic logic condition that was evaluated, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-026	Fatal	The claimed service does not meet condition {dynamic logic code} for {benefit specification code}

If the dynamic logic condition specifies a fatal message, that message is applied to the line instead of the CLA-FL-BENS-023. These messages are ignored in the initial benefit specification selection.

If any benefit specifications remain, the next step is to eliminate those that apply to an adjudication case definition that is not relevant for the claim line. If this eliminates all remaining benefit specifications on the list, the following message is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-027	Fatal	The claimed service is not covered outside the context of an adjudication case

If any benefit specifications remain, the next step is to eliminate those that require a provider network status not in accordance with the benefits provider, case inherited status or manual override on the claim line. This check tests the network status for the product (as opposed to benefit specific networks). If this eliminates all remaining benefit specifications on the list, one of the following three messages is applied, and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-028	Fatal	The claimed service is not covered inside the product provider network
CLA-FL-BENS-029	Fatal	The claimed service is not covered outside of the product provider network
CLA-FL-BENS-036	Fatal	The claimed service is not covered due to product network status requirements

If any benefit specifications remain, the next step is to eliminate those that require a benefit specific network status not in accordance with the benefits provider on the claim line. Since this is the last criteria in the benefit selection, this will eliminate the last benefit specification(s) on the list. One of the following three messages is applied and the second selection for this product is complete:

Code	Sev	Text
CLA-FL-BENS-030	Fatal	The claimed service is not covered inside the benefit specific provider network
CLA-FL-BENS-031	Fatal	The claimed service is not covered outside of the benefit specific provider network
CLA-FL-BENS-032	Fatal	The claimed service is not covered due to benefit specific network status requirements

Message CLA-FL-BENS-032 is attached in the situation where more than one benefit specification is eliminated due to the benefit specific network criteria AND not all benefit specification have the same specific provider group scope value. Although this is a theoretical possibility, it implies a configuration error.

To clarify, consider the following scenario: two benefit specifications are eliminated. The first requires the provider to be in the network TIER1 and the second benefit specification requires the provider to not be in TIER2. Both benefit specifications are eliminated if the provider is in TIER2 (and not in TIER1). This is a configuration error because, if the provider had been in TIER1, there would be conflict of the two benefit specifications (as both would apply).