Select and Apply Provider Limit Rules

The 'Select and Apply Before Reimbursement Provider Limit Rules in Units' level 4 flow shows how Before Reimbursement Provider Limit Rules in Units are applied.

The 'Select and Apply After Reimbursement Provider Limit Rules in Units' level 4 flow shows how After Reimbursement Provider Limit Rules in Units are applied.

The 'Select and Apply Provider Limit Rules in Amounts/Service Days' level 4 flow shows how Provider Limit Rules in Amounts and Service Days are applied.

Check Price Input Number of Units

The claim line price input number of units is required for the calculation of the allowed number of units in the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step; so the first part of this sub-step is checking if the price input number of units is specified (not null) on the claim line. Note that:

• This check is performed even if there are no before reimbursement provider limit rules selected, because the allowed number of units is required for the evaluation of the subsequent pricing method and rules.

• This check is not performed in the 'Select and Apply After Reimbursement Provider Limit Rules in Units' and 'Select and Apply Provider Limit Rules in Amounts/Service Days' sub-steps).

If the price input number of units is not specified a product independent fatal message (CLA-FL-PRIC-015) is attached to the claim line, the allowed number of units is set to 0 (the allowed amount is not set), the succeeding steps are skipped and the system goes directly to the evaluation of before reimbursement method message rules.

Code	Sev	Text
CLA-FL-PRIC-015	Fatal	The allowed number of units cannot be calculated, because the claim line does not specify a price input number of units

Select Provider Limit Rules

In this step the provider pricing clauses that reference provider limit rules are evaluated. This is described in Select Provider Pricing Clauses. In the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step only provider limit rules of type 'Number' and execution moment 'Before Method' are evaluated. In the 'Select and Apply After Reimbursement Provider Limit Rules in Units' sub-step only provider limit rules of type 'Number' and execution moment 'After Method' are evaluated. In the 'Select and Apply Provider Limit Rules in Amounts/Service Days' sub-step only provider limit rules of types 'Amount' and 'Service Days' are evaluated. If the evaluation results in the selection of one or more provider limit rules, the next step in the flow is executed: checking if all required claim line fields are specified (described in the Check Required Fields section).

Extra Checks after Selection

In the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step the following extra check is performed after provider limit rules are selected: if the price input number of units is 0, the allowed number of units is set to 0 (the allowed amount is not set), the succeeding steps are skipped and the system goes directly to the tracking of selected provider limit rules. Because later in Manual Pricing, the allowed number of units may be updated from 0, the provider limit rules will still be selected so that they are tracked; they are just not applied.

In the 'Select and Apply After Reimbursement Provider Limit Rules in Units' sub-step the following extra checks are performed after provider limit rules are selected:

• If the allowed amount was calculated by a diminishing rate, payment function or replacement rule, a product independent fatal message (CLA-FL-PRIC-024) is attached to the claim line, the succeeding steps are skipped and the system goes directly to the tracking of selected provider limit rules (note that the allowed amount and allowed number of units are not updated).

• If the allowed number of units is 0, the succeeding steps are skipped and the system goes directly to the tracking of selected provider limit rules. Because later in Manual Pricing, the allowed number of units may be updated from 0, the provider limit rules will still be selected so that they are tracked; they are just not applied.

In the 'Select and Apply Provider Limit Rules in Amounts/Service Days' sub-step the following extra checks are performed after provider limit rules are selected:

• If at least one provider limit rule in amount is selected that has a different provider limit rule currency than the allowed amount currency, a product independent fatal message (CLA-FL-PRIC-028) is attached to the claim line (once), the succeeding steps are skipped and the system goes directly to the tracking of selected provider limit rules (note that the allowed amount and allowed number of units are not updated).

• If the allowed amount is 0 are null and provider limit rules in amounts are selected, the succeeding steps are skipped and the system goes directly to the tracking of selected provider limit rules. Because later in Manual Pricing, the allowed amount may be updated from 0, the provider limit rules will still be selected so that they are tracked; they are just not applied.

Code	Sev	Text
CLA-FL-PRIC-024	Fatal	After reimbursement provider limit rule(s) in units cannot be applied, because the allowed amount was calculated by a diminishing rate, payment function or replacement rule
CLA-FL-PRIC-028	Fatal	The allowed amount currency and the provider limit rule currency must be equal

No Provider Limit Rules Selected

If in the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step the evaluation does not result in the selection of one or more provider limit rules because none are found, the allowed number of units is set to the price input number of units (the allowed amount is not set) and the system goes directly to the evaluation of before reimbursement method message rules. If the evaluation does not result in the selection of one or more provider limit rules because a fatal message is attached during selection, the allowed number of units is set to 0 (the allowed amount is not set) and the system goes directly to the evaluation of before reimbursement method message rules.

If in the 'Select and Apply After Reimbursement Provider Limit Rules in Units' sub-step the evaluation does not result in the selection of one or more provider limit rules (none found or a fatal message attached during selection) the system goes directly to the evaluation of after reimbursement method message rules (the allowed amount and allowed number of units are not updated).

If in the 'Select and Apply Provider Limit Rules in Amounts and Service Days' sub-step the evaluation does not result in the selection of one or more provider limit rules (none found or a fatal message attached during selection) the system goes directly to the evaluation of encounter rules (the allowed amount and allowed number of units are not updated).

Sub-step	Selection Result	Allowed Values
Before Reimbursement Units	No provider limits found	Allowed number of units = price input number of units Allowed amount = untouched
Before Reimbursement Units	Fatal message attached during selection	Allowed number of units = 0 Allowed amount = untouched
After Reimbursement Units	No provider limits found	Allowed number of units = untouched Allowed amount = untouched
After Reimbursement Units	Fatal message attached during selection	Allowed number of units = untouched Allowed amount = untouched
Amounts/Service Days	No provider limits found	Allowed number of units = untouched Allowed amount = untouched
Amounts/Service Days	Fatal message attached during selection	Allowed number of units = untouched Allowed amount = untouched

Check Required Fields

In this step the system checks if all claim line fields that are required for the calculation of the selected provider limit rules are specified. If all required fields are specified the next step in the flow is executed: determining the heights of the selected provider limit rules. If not all required fields are specified, one or more product independent fatal messages are attached to the claim line (see below) after which the system goes directly to the Track Provider Pricing Clauses step (the selected provider pricing clauses are still tracked). Note that in the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step in this scenario the allowed number of units is set to 0 (the allowed amount is not set); in the 'Select and Apply After Reimbursement Provider Limit Rules in Units' and 'Select and Apply Provider Limit Rules in Amounts and Service Days' sub-steps the allowed amount and allowed number of units are not updated.

Provider limits operate at different levels (specified on the provider limit category):

• Per individual provider (required field: price individual provider)

• Per organization provider (required field: price organization provider)

• Per combination of individual and organization provider (required field: one of price individual provider or price organization provider)

• Per provider contract (required field: contract reference)

• Across all providers and provider contracts (required field: none)

• Per procedure (required field: procedure specified by the flex code definition/set)

For every selected provider limit rule it is checked if all required fields are specified on the claim line. So for example for a provider limit rule that counts per individual provider, the claim line price individual provider needs to be specified; for a provider limit rule that counts per combination of individual and organization provider, one of price individual provider or price organization provider needs to be specified, because it counts towards a counter of either individual plus organization provider or individual provider or organization provider depending on what is on the claim line. If the required fields are not specified, a product independent fatal message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-016	Fatal	Provider limit rule {code} cannot be applied because the claim line does not specify {unspecified fields}

In this step the system also performs another check: if a provider limit rule is selected that has a calendar year reference and a period larger than one year, the enrollment subscription date is needed to plot the counter periods. If the subscription date is not received from enrollment (in a pricer only scenario where the enrollment callout is disabled), the counter periods cannot be plotted so a product independent fatal message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-017	Fatal	Provider limit rule {code} cannot be applied because the subscription date is needed for this type of limit

Determine Heights

A provider limit rule can have heights (time valid) which specify the maximum amount, number of units or service days (depending on the type of the provider limit rule). In this step the provider limit heights of the selected provider limit rules are determined based on the price input date. If for every selected provider limit rule a height or provider pricing clause quantifier (depending on the type of the provider limit rule) is found, the next step in the flow is executed: determining the applicable counter periods and available room in those periods (described in the Determine Periods and Available Room section).

Provider Limit Rules in Units

The heights of provider limit rules in units are overruled by the quantifier on the related provider pricing clauses (if specified). If a provider limit height cannot be found for one or more selected provider limit rules at the price input date and there is no quantifier specified on the related provider pricing clause, a product independent fatal message (one for every provider limit rule) is attached to the claim line and the system goes directly to the 'Track Provider Pricing Clauses' step (the selected provider pricing clauses are still tracked):

Code	Sev	Text
CLA-FL-PRIC-018	Fatal	No provider limit height found for provider limit rule {code} on date {price input date}

Note that in the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step in this scenario the allowed number of units is set to 0 (the allowed amount is not set); in the 'Select and Apply After Reimbursement Provider Limit Rules in Units' sub-step the allowed amount and allowed number of units are not updated.

Provider Limit Rules in Amounts

The heights of provider limit rules in amounts are multiplied by the quantifier (percentage) on the related provider pricing clauses (if specified). If a provider limit height cannot be found for one or more selected provider limit rules at the price input date product independent fatal message CLA-FL-PRIC-017 (one for every provider limit rule) is attached to the claim line and the system goes directly to the 'Track Provider Pricing Clauses' step (the selected provider pricing clauses are still tracked). Note that in this scenario the allowed amount and allowed number of units are not updated.

Provider Limit Rules in Service Days

The heights of provider limit rules in service days are evaluated in the same way as the heights of provider limit rules in units. Note that in the scenario where fatal message CLA-FL-PRIC-018 is attached, the allowed amount and allowed number of units are not updated.

Claim Line referring a Reservation Line

The reservation regime may specify reserved consumptions as 'maximum height'. Checked ceiling indicators for amount and number of units on the reservation regime mean that the height available to the claim line, cannot exceed what has been reserved by the reservation line. The reserved consumption for the number of service days can never exceed what has been reserved by the reservation line.

Determine Periods and Available Room

Periods

For every selected provider limit rule the counter period is determined based on the price input date, the provider limit category reference, the period type, period length, period unit of measure, interrupt period, interrupt period unit of measure, replacement period and replacement period unit of measure.

For period type Renewal, the provider limit counters and provider limit counter periods are set out analogous to benefits. Elaborate examples can be found in the (Benefit) Limit Counters Model in the "Benefit Rules" chapter of the Configuration Guide.

For period type Flexible, the provider limit counters periods may change as new claim lines are being processed. Examples are described in Provider Limit Rules Examples.

Note that there is a restriction in case of provider limit rules that count per provider contract. If a provider limit rule that counts per provider contract is selected and the claim line has multiple contract references the following applies:

• If on the related provider pricing clause there is no restriction on contract reference (no contract reference specified), the periods and available room for all claim line contract references are determined (so in the next step multiple counters can be created for the selected provider limit rule but for different contract references).

• If on the related provider pricing clause there is a restriction on contract reference (a contract reference specified), the period and available room is determined only for that specific contract reference (so in the next step only one counter can be created for the selected provider limit rule).

Whether or not a counter period is restricted to claim lines within the claim of the triggering claim line depends on the setting of the ignore history indicator:

• If the ignore history indicator is checked, then the maximum of the provider limit rule only takes into account claim lines within the same claim as the triggering claim line. As a consequence this will lead to a different counter for each different claim; in other words, consumption on such a counter can only come from claim lines within the same claim.

• If the ignore history indicator is unchecked, then the maximum of the provider limit rule is applied across claims. As a consequence, consumption on such a counter can come from claim lines of different claims.

Available Room

After the periods have been set out, the available room (unconsumed amount, number of units or number of service days) within those periods is determined based on the current count ^[1] of the counter periods (if existing), the heights determined in the previous step and the reached action specified on the rule. Note that if the reached action on the rule is set to continue there is always available room (unlimited) on the applicable period, even if the maximum has been reached.

For a claim line referring to a reservation line the available room is calculated depending on the setting of the ceiling for amount and the ceiling for the number of units on the reservation regime:

Ceiling set to Y(es)

The sum of the non expired consumption reserved by the reservation line and non expired offset consumption(s) (negative consumption) taken by the claim lines (referring the same reservation line) under the counter period delivers the available room. A consumption is considered 'expired' for the claim line when the receipt date of the claim is after the expiration date of the consumption. If the receipt date is not specified on the claim; the entry date of the claim is used as the as-of date.

Ceiling set to N(o)

The available room is the sum of the 1) available room within the period (unconsumed amount or number of units) . This is the difference of the current count of the counter period (if existing) and the height (on the limit rule or quantifier) determined in the previous step and 2) available room on the reservation. This is the sum of the non expired consumption reserved by the reservation line and non expired offset consumption (negative consumption) taken by the claim lines referring the same reservation line under the counter period.

The reservation regime holds no setting for the ceiling for the number of service days. For the number of service days the reservation is always considered to be the ceiling.

For a claim line referring to a reservation line, it is always guaranteed to have access to the reserved consumption even if the limit maximum has been reached.

In the 'Select and Apply Before Reimbursement Provider Limit Rules in Units' sub-step:

• If there is no available room in one or more periods that have been set out, the system skips the Create Counters, Periods and Consumptions step and goes to the Set Allowed Number of Units step where the allowed number of units is set to 0.

• If there is available room in every period that has been set out, an extra check is performed:

  • If one or more Provider Limit Category and/or Reservation Regime messages that will be attached in the Attach Messages step are fatal, the system skips the Create Counters, Periods and Consumptions step and goes to the Set Allowed Number of Units step where the allowed number of units is set to 0.

  • If no fatal Provider Limit Category and/or Reservation Regime messages will be attached in the Attach Messages step (no messages attached or only informative messages attached), the counters (if not existing), counter periods and consumptions are created (described in the next section).

In the 'Select and Apply After Reimbursement Provider Limit Rules in Units' sub-step:

• If there is no available room in one or more periods that have been set out, the system skips the Create Counters, Periods and Consumptions step and an extra check is performed:

  • If one or more 'exceeded' Provider Limit Category and/or Reservation Regime messages that will be attached in the Attach Messages step are fatal, the system skips the Set Allowed Value(s) step and goes to the Attach Messages step where the message(s) will be attached to the claim line. This means that the allowed amount and the allowed number of units are not updated.

  • If no fatal 'exceeded' Provider Limit Category and/or Reservation Regime messages will be attached in the Attach Messages step (no messages attached or only informative messages attached), the system goes to the Set Allowed Value(s) step where the allowed number of units and the allowed amount are set to 0.

• If there is available room in every period that has been set out, an extra check is performed:

  • If one or more Provider Limit Category and/or Reservation Regime messages that will be attached in the Attach Messages step are fatal, the system skips the Create Counters, Periods and Consumptions and Set Allowed Value(s) steps and goes to the Attach Messages step where the message(s) will be attached to the claim line. This means that the allowed amount and the allowed number of units are not updated.

  • If no fatal Provider Limit Category messages will be attached in the Attach Messages step (no messages attached or only informative messages attached), the counters (if not existing), counter periods and consumptions are created (described in the next section).

In the 'Select and Apply Provider Limit Rules in Amounts and Service Days' sub-step:

• If there is no available room in one or more periods that have been set out, the system skips the Create Counters, Periods and Consumptions step and an extra check is performed:

  • If one or more 'exceeded' Provider Limit Category and/or Reservation Regime messages that will be attached in the Attach Messages step are fatal, the system skips the Set Allowed Amount step and goes to the Attach Messages step where the message(s) will be attached to the claim line. This means that the allowed amount and the allowed number of units are not updated.

  • If no fatal 'exceeded' Provider Limit Category and/or Reservation Regime messages will be attached in the Attach Messages step (no messages attached or only informative messages attached), the system goes to the Set Allowed Amount step where the allowed amount is set to 0.

• If there is available room in every period that has been set out, an extra check is performed:

  • If one or more Provider Limit Category and/or Reservation Regime messages that will be attached in the Attach Messages step are fatal, the system skips the Create Counters, Periods and Consumptions and Set Allowed Amount steps and goes to the Attach Messages step where the message(s) will be attached to the claim line. This means that the allowed amount and the allowed number of units are not updated.

  • If no fatal Provider Limit Category and/or Reservation Regime message will be attached in the Attach Messages step (no messages attached or only informative messages attached), the counters (if not existing), counter periods and consumptions are created (described in the next section).

Create Counters, Periods, and Consumptions

First the counters and counter periods (if not already existing) are created for the periods determined in the previous step. For the situation where the ignore history indicator is checked, a counter is created that has a reference to the claim being processed. For the situation where the ignore history indicator is unchecked, a counter is created that has no reference to a claim.

After that consumptions are created for the counters. The value of the consumptions is determined by the input value (price input number of units for the Before Reimbursement Provider Limit Rules in Units, allowed number of units for the After Reimbursement Provider Limit Rules in Units or allowed amount for the Provider Limit Rules in Amounts) and the most restrictive limit (note that the value of consumptions for Provider limit Rules in Service Days is always 1). For example when two provider limit rules (both with the reached action set to stop) are selected for a claim line with a price input number of units of 4 and the first provider limit rule has 5 units available room on the counter period and the second provider limit rule has 2 units available room on the counter period, the second limit is most restrictive, meaning that the consumption on both provider limit rules will be 2 units. Note that provider limit rules with the reached action set to continue, are not restrictive at all. So if in the previous example the second provider limit rule would have the reached action set to continue, the consumption on both provider limit rules would be 4 units instead of 2 units.

Because the system calculated consumption can be manually overruled later, it is marked as preliminary. Preliminary consumption is not written to the counter (yet). In other words, only the claim that wrote the preliminary consumption can actually see the consumption when calculating other lines; other claims ignore this preliminary consumption. Later, during the (pricing) finalize step, the consumption is either removed or made final, with the exception of consumptions with a checked Ignored indicator (see below).

The consumption created by a reservation line (claim line) is marked as 'Reserved' by setting the indicator reserved to Y(es). They also inherit the value of the expiration date from the reservation. When a consumption (by a claim line) is taken from a reserved consumption an offset negative consumption is also created. The indicator reserved is set to Y(es) and the expiration date is set to the expiration date of the reservation on the offset consumption. For the limit in service days the offset consumption is created with the service date as on the reserved consumption and the withdraw indicator is set to Y(es).

The absolute value of the offset consumption (for amount and units) depends on the available reserved room. It is possible that the claim line takes a consumption of a higher value than what is reserved for it. This is possible when the ceiling indicator is set to N(o) and the limit maximum has not been reached. In this case the absolute value of the offset consumption will be less (but equal to the reserved room present) than the consumption taken by the claim line. The offset’s absolute value also depends on the indicator release (on the reservation regime). If it is set to Y(es); then the offset consumption offsets the entire reserved value. In this case it is possible that the absolute value of the offset is more than the consumption taken by the claim line. For more detail examples on reserved consumptions and offsets refer to the Provider Limit Rules.

Note that when the released indicator is configured to Y(es) the excess reserved consumption is only released from the counter period where the actual consumption is being registered.

If a claim line is denied after pricing (for example in manual adjudication) then the ignored indicator on the claim line’s provider limit consumptions is checked. These consumptions will be ignored by other claim lines when the claim is recalculated in manual adjudication and they will not finalize when the claim status becomes PRICING FINALIZED or FINALIZED. This mechanism ensures that the consumptions are not lost when a claim is reprocessed without doing the pricing step again.

Because separate claims ignore each other’s results during the pricing calculation, there is always the risk that a counter period exceeds the configured limit. This happens when the consumption of the individual claims remains under the limit, but the sum of both exceeds it. To prevent two or more claims writing to the same counter without seeing each other’s consumption, the following mechanism applies. During the pricing step, when reading a counter, the version number of the counter is retrieved and stored. During the (pricing) finalize step, before finalizing the claim, the version number of the counter is retrieved again and compared to the stored version number. If they match, the result becomes final and the version number of the counter is increased; if they don’t, the pricing step is repeated with the current version of the counters.

Note that this optimistic locking stratagem is not necessary for a claim with a checked ignore history indicator, because there is no risk of two claims addressing the same counter.

Note that the created consumptions are removed if in any of the succeeding steps in pricing a product independent fatal message of origin PRICING is attached to the claim line. The created counter periods are removed if the removed consumptions were the only consumptions related to those counter periods (note that this is an indirect relation, not a direct reference). The created counters are removed if the removed consumptions were the only consumptions related to those counters.

Set Allowed Values

In this step the allowed number of units and/or the allowed amount is/are set:

Type	Available Room [2]	Fatal Message	Allowed Values
Before Reimbursement Units	Yes	No	Allowed number of units = consumption value Allowed amount = untouched
Before Reimbursement Units	Yes	Yes	Allowed number of units = 0 Allowed amount = untouched
Before Reimbursement Units	No	Yes/No	Allowed number of units = 0 Allowed amount = untouched
After Reimbursement Units	Yes	No	Allowed number of units = consumption value Allowed amount: If a fee schedule of calculation type Amount per Unit was applied: allowed amount = (consumption value / previous allowed number of units) * previous allowed amount If a fee schedule of calculation type Amount for all Units was applied: allowed amount = untouched If a charged amount was applied: allowed amount = untouched If no reimbursement method was applied: allowed amount = untouched
After Reimbursement Units	Yes	Yes	Allowed number of units = untouched Allowed amount = untouched
After Reimbursement Units	No	No	Allowed number of units = 0 Allowed amount = 0
After Reimbursement Units	No	Yes	Allowed number of units = untouched Allowed amount = untouched
Amount	Yes	No	Allowed number of units = untouched Allowed amount = consumption value
Amount	Yes	Yes	Allowed number of units = untouched Allowed amount = untouched
Amount	No	No	Allowed number of units = untouched Allowed amount = 0
Amount	No	Yes	Allowed number of units = untouched Allowed amount = untouched
Service Days	Yes	Yes/No	Allowed number of units = untouched Allowed amount = untouched
Service Days	No	No	Allowed number of units = untouched Allowed amount = 0
Service Days	No	Yes	Allowed number of units = untouched Allowed amount = untouched

Attach Messages

In this step the messages specified (if any) on the provider limit categories of the applied provider limit rules, reservation regime and the messages specified (if any) on the applied provider limit rules themselves are attached to the claim line.

Provider Limit Categories Messages

The following messages can be configured on provider limit categories:

• 'not met message'
  Not met means that there is still room on the counter period after the consumption of the claim line in question.

• 'met message'
  Met means that there was sufficient room on the counter period for the claim line in question, but after this consumption no room is left.

• 'met and exceeded message'
  Met and exceeded means there was some room on the counter period for the claim line in question, but not enough.

• 'exceeded message'
  Exceeded means there was no room at all on the counter period for the claim line in question.

Note that in case of a claim line that refers to a reservation line, these messages are attached only when there is not enough room within the reserved consumption and the claim line is allowed to consume more that what is reserved for it. This is when the indicator ceiling on the reservation regime is set to N(o).

Reservation Regime Messages

• 'not met message'
  The message that is attached to the actual claim line when a reservation line is used and the total reserved quantity (consumption) after processing the actual claim line still leaves room.

• 'met message'
  The message that is attached to the actual claim line when a reservation line is used and the total reserved quantity (consumption) after processing the actual claim line exactly matches the reserved quantity.

• 'met and exceeded message'
  The message that is attached to the actual claim line when a reservation line is used but its reserved quantity (consumption) was insufficient for the consumption of the actual claim line.

• 'exceeded message'
  The message that is attached to the actual claim line when a reservation line is found, but cannot be used at all because the reserved quanity (consumption) is already used up fully.

For every applied provider limit rule the above message(s) (if specified) is attached (product independent) to the claim line based on the specific situation as described above (the allowed amount and allowed number of units are not updated; even if the messages are fatal). Note that these messages also apply to provider limit rules with the reached action set to continue, so for example the 'exceeded message' on the provider limit rule will for those rules also be attached to the claim line if there was no room on the counter period (regardless of consuming the limit). The origin of the attached messages is PRICING LIMIT. The text fields of these messages may contain placeholders. These placeholders and some examples on how they are populated are described in the "Provider Limit Counters Model" page of the Pricing Configuration chapter of the Configuration Guide.

Note that these messages are removed if in any of the succeeding steps in pricing a product independent fatal message of origin PRICING or PRICING NO RECALC is attached to the claim line. The reason is that these messages clarify calculation results that have been removed, and can therefore be removed themselves.

Provider Limit Rules Messages

A provider limit rule can also specify a message. This message is used to illustrate that a specific provider limit rule has been applied. The messages specified (if any) on the applied provider limit rules are attached (product independent) to the claim line with populated placeholders (see the "Provider Limit Counters Model" page of the Pricing Configuration chapter of the Configuration Guide). The origin of the attached messages is PRICING. Note that the allowed amount and allowed number of units are not updated; even if the messages are fatal.

Track Provider Pricing Clauses

The selected provider pricing clauses and their impact on the allowed amount are tracked. This is described in Track Provider Pricing Clauses.

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1. The current on the counter period takes into account all the non-expired final consumptions under the counter period.

2. The available room is determined in the previous step based on the current count of the counter periods, the heights and the reached action specified on the rule