Inclusion Rules

Inclusion rules are used to price one or more claim lines in a claim and deny the others as included. This functionality can be used in the following scenarios:

  • Pricing a Diagnosis Related Group (DRG) claim: one ore more claim lines regarding specific DRG codes are paid and the others are denied

  • Pricing a surgical claim: only the claim line with the highest allowed amount regarding specific surgical codes is paid and the others are denied

  • Pricing a Skilled Nursing Facility (SNF) per diem claim: one or more claim lines regarding specific revenue codes are paid and the others (with the exception of pharmacy claim lines) are denied

The following Inclusion Rules are configured:

Inclusion Rules Configuration

Rule[1] Pay Only One Global? Global Procedures Not Included Procedures Message

IR1

N

(In) DRG Codes (range 0350 - 0399)

N/A

F-098 (Paid at global DRG rate)

IR2

Y

(In) Surgical Codes (range 20000- 29999)

N/A

F-559 (Paid highest allowed)

IR3

N

(In) Revenue Codes (range 0110 - 0159)

(In) Pharmacy Procedure (0250)

F-345 (Paid per diem for Skilled Nursing Facility)

Scenario 1 (DRG)

Claim 1

Line Service Date Procedure Serviced Person Price Org. Provider Price Ind. provider Allowed Number Of Units Allowed Amount[2]

1

03-03-2012

10021

MEM_001

ORG_PRV_001

-

1

$50

2

03-03-2012

0374

MEM_001

ORG_PRV_001

-

1

$200

3

04-03-2012

11721

MEM_001

ORG_PRV_001

-

3

$180

4

05-03-2012

17004

MEM_001

ORG_PRV_001

-

2

$160

5

03-03-2012

0350

MEM_001

ORG_PRV_001

-

1

$40

Result

  • Claim Lines 2 and 5 are part of the DRG Codes range so they are recognized as global claim lines, meaning that the claim lines will be paid (fatal message F-098 is not attached)

  • Claim Lines 1, 3 and 4 are not part of the DRG Codes range so they are recognized as included claim lines, resulting in denying the claim lines by attaching fatal message F-098

Line Global or Included Allowed Amount and Number of Units[3] Message

1

Included

$50 / 1 unit

F-098

2

Global

$200 / 1 unit

-

3

Included

$180 / 3 units

F-098

4

Included

$160 / 2 units

F-098

5

Global

$40 / 1 unit

-

Claim 2

Line Service Date Procedure Serviced Person Price Org. Provider Price Ind. provider Allowed Number Of Units Allowed Amount[2]

1

03-03-2012

10021

MEM_002

ORG_PRV_001

IND_PRV_001

1

$50

2

03-03-2012

0374

MEM_002

ORG_PRV_001

IND_PRV_002

1

$200

3

04-03-2012

11721

MEM_002

-

-

3

$180

4

05-03-2012

0388

MEM_002

-

IND_PRV_002

2

$160

5

03-03-2012

0350

MEM_002

ORG_PRV_002

IND_PRV_001

1

$40

6

04-03-2012

0387

MEM_002

ORG_PRV_002

-

1

$50

7

03-03-2012

0379

MEM_002

-

-

1

$50

8

02-03-2012

16543

MEM_002

ORG_PRV_003

-

1

$50

Result

  • Inclusion rules are evaluated per serviced person or object, per price organization provider (per price individual if price organization provider is unspecified) so the following claim lines are evaluated together:

    • Claim Lines 1 and 2

      • Claim Line 2 is part of the DRG Codes range so it is recognized as a global claim line

      • Claim Line 1 is not part of the DRG Codes range so it is recognized as an included claim line

    • Claim Lines 3 and 7

      • Claim Line 7 is part of the DRG Codes range so it is recognized as a global claim line

      • Claim Line 3 is not part of the DRG Codes range so it is recognized as an included claim line

    • Claim Line 4

      • Claim Line 4 is part of the DRG Codes range so it is recognized as a global claim line

    • Claim Lines 5 and 6

      • Both claim lines are part of the DRG Codes so they are both recognized as a global claim lines

    • Claim Line 8

      • Claim Line 8 is not part of the DRG Codes range; there are no global claim lines in this case so the inclusion rule is not applied to CLaim Line 8

Line Global or Included Allowed Amount and Number of Units[3] Message

1

Included

$50 / 1 unit

F-098

2

Global

$200 / 1 unit

-

3

Included

$180 / 3 units

F-098

4

Global

$160 / 2 units

-

5

Global

$40 / 1 unit

-

6

Global

$50 / 1 unit

-

7

Global

$50 / 1 unit

-

8

-

$50 / 1 unit

-

Scenario 2 (Surgery)

Claim

Line Service Date Procedure Serviced Person Price Org. Provider Price Ind. Provider Allowed Number Of Units Allowed Amount[2]

1

03-03-2012

10021

MEM_003

ORG_PRV_001

-

1

$50

2

03-03-2012

12322

MEM_003

ORG_PRV_001

-

1

$200

3

04-03-2012

23456

MEM_003

ORG_PRV_001

-

3

$240

4

05-03-2012

27004

MEM_003

ORG_PRV_001

-

2

$160

5

03-03-2012

11350

MEM_003

ORG_PRV_001

-

1

$100

6

03-03-2012

28004

MEM_003

ORG_PRV_001

-

1

$30

Result

  • Claim Lines 3, 4 and 6 are part of the Surgical Codes range

    • Claim Lines 3 and 4 both have the highest allowed amount per allowed unit ($80); claim line 3 is recognized as the global claim line because it has a lower sequence number, meaning that the claim line will be paid (fatal message F-559 is not attached)

    • Claim Lines 4 and 6 are recognized as included claim lines, resulting in denying the claim lines by attaching fatal message F-559

  • Claim Lines 1, 2 and 5 are not part of the Surgical Codes range so they are recognized as included claim lines, resulting in denying the claim lines by attaching fatal message F-559

Line Global or Included Allowed Amount and Number of Units[3] Message

1

Included

$50 / 1 unit

F-559

2

Included

$200 / 1 unit

F-559

3

Global

$240 / 3 units

-

4

Included

$160 / 2 units

F-559

5

Included

$100 / 1 unit

F-559

6

Included

$30 / 1 unit

F-559

Scenario 3 (SNF Per Diem)

Claim

Line Service Date Procedure Serviced Person Price Org. Provider Price Ind. provider Allowed Number Of Units Allowed Amount[2]

1

03-03-2012

0110

MEM_004

ORG_PRV_001

-

1

$50

2

03-03-2012

18005

MEM_004

ORG_PRV_001

-

1

$200

3

03-03-2012

11721

MEM_004

ORG_PRV_001

-

3

$180

4

03-03-2012

0119

MEM_004

ORG_PRV_001

-

2

$160

5

03-03-2012

13333

MEM_004

ORG_PRV_001

-

1

$40

6

03-03-2012

0250

MEM_004

ORG_PRV_001

-

1

$50

Result

  • Claim Lines 1 and 4 are part of the Revenue Codes range so they are recognized as global claim lines, meaning that the claim lines will be paid (fatal message F-345 is not attached)

  • Claim Lines 2, 3, 5 and 6 are not part of the Revenue Codes range

    • Claim Lines 2, 3 and 5 are not part of the Not Included Procedures, so they are recognized as included claim lines, resulting in denying the claim lines by attaching fatal message F-345

    • Claim Line 6 is part of the Not Included Procedures, so the inclusion rule is not applied to Claim Line 6

Line Global or Included Allowed Amount and Number of Units[3] Message

1

Global

$50 / 1 unit

-

2

Included

$200 / 1 unit

F-345

3

Included

$180 / 3 units

F-345

4

Global

$160 / 2 units

-

5

Included

$40 / 1 unit

F-345

6

-

$50 / 1 unit

-

Scenario 4 (Exemptions)

It is possible to use exemption provider pricing clauses to exclude specific procedures from being included for a specific contract and/or provider. Consider the first scenario (DRG) of this document. There is an extra provider pricing clause created for organization provider ORG_PRV_001 which has a higher priority than the existing one:

Rule Organization Provider Procedures Exempt Start Date Priority

IR1

ORG_PRV_001

17004

Y

01-01-2012

1

In this scenario claim line 4 of claim 1 would no longer be included, because the exemption provider pricing clause will prevent that the inclusion rule is applied to that claim line.

It is also possible to use exemption provider pricing clauses to exclude specific procedures from being global procedures for a specific contract and/or provider. Consider the first scenario (DRG) in this document. There is an extra provider pricing clause created for organization provider ORG_PRV_001 which has a higher priority than the existing one:

Rule Organization Provider Procedures Exempt Start Date Priority

IR1

ORG_PRV_001

0350

Y

01-01-2012

1

In this scenario claim line 5 of claim 1 would no longer be global, because the exemption provider pricing clause will prevent that the inclusion rule is applied to that claim line.

1. The rules are referenced by a provider pricing clause with only a start date filled. The other dimensions of the inclusion rule (modifiers, diagnoses, classification, fee schedule type and other condition) are unspecified.
2. The allowed amount before the evaluation of the inclusion rule (calculated using a fee schedule reimbursement method; which is out of the scope of this example)
3. The allowed amount and number of units after the evaluation of the inclusion rule