Select Provider Pricing Clauses

The selection of provider pricing clauses is divided in three steps:

• Select eligible provider pricing clauses at the level of the provider pricing clause

• Select eligible provider pricing clauses at the level of the pricing rule or reimbursement method

• Evaluate the list of selected provider pricing clauses

Select Provider Pricing Clauses (Clause Level)

All the dimensions of a provider pricing clause need to be evaluated against the claim line characteristics. Each of these dimensions is explained below in detail:

Enabled Indicator

Disabled provider pricing clauses act for the selection as if they are not present.

Time Validity (Mandatory Start Date and Optional End Date)

The price input date of the claim line should lie within the time span of the provider pricing clause.

Provider

The individual provider - if specified - is matched against the Price Individual Provider.
The organization provider - if specified - is matched against the Price Organization Provider.

Age

The age of the serviced person of the claim line is matched against the age from and/or age to of the provider pricing clause. If this criterion is specified; the provider pricing clause is not selected for evaluation for a serviced object.

Provider Group

The Price Individual Provider or the Price Organization Provider should be in the provider group.

Provider Category

A provider category is a classification of a provider into different categories. A provider is categorized for a category when:

• The specialty of the provider matches one of the specialties of the provider category

• All the conditions on the provider category are met.

• The provider’s product scope matches the scope of the provider category.
  Note that this condition is only enforced if the claim line does not have an overriding funding arrangement, product family and/or product line. If the claim line has an overriding funding arrangement, product family and/or product line, the provider is categorized regardless of the scope of the provider category.

On the claim line the following provider fields for pricing purposes can be populated:

• Price Individual Provider

• Price Organization Provider

• Service Specialty (note that this value is inherited from bill or claim level if not specified on claim line level itself)

The following matrix specifies how the Provider Category is matched against the claim line for different combinations of the price provider fields:

On claim line			Applied to
Price Organization Provider	Price Individual Provider	Service Specialty	Product Scope	Specialty
Y	—	—	Is applied to the Price Organization Provider	Is matched with the specialties of the Price Organization Provider
—	Y	—	Is applied to the Price Individual Provider	Is matched with the specialties of the Price Individual Provider
Y	Y	—	Is applied to the Price Organization Provider	Is matched with the specialties of the Price Individual Provider
Y	—	Y	Is applied to the Price Organization Provider	Is matched with the specialty on the claim line
—	Y	Y	Is applied to the Price Individual Provider	Is matched with the specialty on the claim line
Y	Y	Y	Is applied to the Price Organization Provider	Is matched with the specialty on the claim line
—	—	Y	No match on provider category if the product scope is 'In'. Match on provider category if the product scope of the category is 'Out' or 'Either'.	Is matched with the specialty on the claim line
—	—	—	No match on provider category if the product scope is 'In'. Match on provider category if the product scope of the category is 'Out' or 'Either'.	Not matched

Location Type

The location type group usage specifies how the location type group should be evaluated. 'In' means that one or more of the location types in the location type group should be present; 'Not In' means that none of the location types in the location type group should be present. Present means looking at the location type of the claim line or - if no location type is attached to the claim line - at the location type of the bill or claim.

Procedure Groups and Procedure Conditions

The three claim line procedures are matched at the price Input date against the group details of all specified procedure groups and procedure conditions in combination with their usages:

• In case of a specified procedure group there is a match (when the usage is set to 'In') if at least one of the three claim line procedures is in the specified group; when the usage is set to 'Not in' there is a match if none of the claim line procedures are in the specified group (this check is performed for every specified group).

• In case of a specified procedure condition there is a match if at least one of the three claim line procedures meets the specified condition; when the usage is set to 'Not in' there is a match if none of the claim line procedures meet the specified condition (this check is performed for every specified condition).

So for example if Procedure Group 2 is specified with the usage set to 'In' then one or more claim line procedures should be part of that procedure group at the price input date. And if Procedure Group 1 and Procedure Condition 3 are specified with the usages set to 'In' then one or more claim line procedures should be part of that procedure group and also one or more claim line procedures should adhere to the procedure condition at the price input date.
If one of the procedures is marked as principal, then that procedure must match the restriction on procedure groups and/or procedure conditions - as long as there exists some restriction on procedure at all; for more detail and examples, see Price Principal Procedures.

Product Category

A provider pricing clause may reference a product category. If so, the provider pricing clause is only selected if the specified product category matches with the product information associated with the claim line. A match occurs when at least one of the dimensions of the product category AND all of the product category conditions match with the product information associated with the claim line, at the price input date of the claim line.

Which product information associated with the claim line is used to evaluate the product category dimensions and conditions against, depends on the situation. The following (mutual exclusive) scenario’s are recognized:

• The enrollment callout has been executed and no overriding funding arrangement, product family or product line are specified on the claim line. In this case, the product information that is stored for the person’s or object’s policy products that have been retrieved from the enrollment is used. In case enrollment returned multiple products, the product category must match with the information of any of the returned policy products.

  • Product of the product category dimension, if specified, must equal the product of the policy product

  • Payer of the product category dimension, if specified, must equal the payer of the brand of the policy product

  • Brand of the product category dimension, if specified, must equal the brand of the policy product

  • Funding Arrangement of the product category dimension, if specified, must equal the funding arrangement of the policy product

  • Product Family of the product category dimension, if specified, must equal the product family of the policy product

  • Product Line of the product category dimension, if specified, must equal the product line of the policy product

• An overriding funding arrangement, product family and/or product line is specified on the claim line. In this scenario, it does not matter whether or not the enrollment callout has been executed. The product information to evaluate the product category against ^[1] is composed of information on the claim and claim line.

  • Product of the product category dimension, if specified, it will not be selected.

  • Payer of the product category dimension, if specified, must equal the payer of the claim or must be the payer associated with the brand of the claim

  • Brand of the product category dimension, if specified, must equal the brand of the claim

  • Funding Arrangement of the product category dimension, if specified, must equal the overriding funding arrangement of the claim line

  • Product Family of the product category dimension, if specified, must equal the overriding product family of the claim line

  • Product Line of the product category dimension, if specified, must equal the overriding product line of the claim line

Note that the use of product categories is not sensible, if neither the enrollment callout is enabled nor an overriding funding arrangement, product line and/or product family are sent in on the claim line.

Classification

During the pre pricing step a classification scheme for the claim is determined. After the call out rules for the DRG grouper - if a classification scheme has been found - each claim line may get a classification code and optionally a classification auth code. After the claim lines are classified the total claim is classified. This is done by selecting the claim line with classification code with the highest priority. This classification code is stored - together with the classification scheme - on the claim header. A provider pricing clause may reference the classification results in the following ways:

• By referencing one or more classification scheme codes (in combination with classification scheme usage)

  • If 'In' then the claim must contain one of the classification schemes in the list

  • If 'Not in' then the claim must contain none of the classification schemes in the list

• By referencing one or more classification codes for the claim (in combination with claim classification usage)

  • If 'In' then the claim must contain one of the classifications in the list

  • If 'Not in' then the claim must contain none of the classifications in the list

• By referencing one or more classification codes for the claim line (in combination with claim line classification usage)

  • If 'In' then the claim line must contain one of the classifications in the list

  • If 'Not in' then the claim line must contain none of the classifications in the list

Contract Reference

One of the contract references of the claim line should match with the contract reference of the provider pricing clause, if specified.

Restrict Pricing Rule to Reimbursement Methods in Combination with Restrict to Methods Usage

If specified, this means that the pricing rule (it can only be specified for pricing rules) is only applied if the previous reimbursement was based ('In' usage) or not based ('Not In' usage) on one of the methods that is now being referred to:

• If 'In' then one of the reimbursement methods in the list must be applied to the claim line

• If 'Not In' then none of the reimbursement methods in the list must be applied to the claim line

Condition Dynamic Logic

Multiple conditions are possible for one provider pricing clause. The provider pricing clause applies if all the conditions evaluate to true.

Select Provider Pricing Clauses (Rule or Method Level)

A reimbursement method and/or pricing rule can have dimensions that need to be evaluated against the claim line characteristics.

Reimbursement Methods

Bundled Amount

A bundled amount can add the following restrictions that need to be applied:

Existence of Episode Detail

The bundled amount references a episode definition. The claim line needs to have a episode detail corresponding an unvoided episode for that same episode definition.

Bundled Amount Categories

If no bundled amount categories are defined, then the bundled amount is applicable to all categories, so no additional evaluation is necessary.

If one or more bundled amount categories are defined, then the episode detail needs to reference one of those categories.

Charged Amount

A charged amount can add the following restrictions that need to be applied:

Classifications in Combination with Classification Usage

• If 'In' then the claim line must contain one of the classifications in the list

• If 'Not in' then the claim line must contain none of the classifications in the list

Procedure Groups and Procedure Conditions

• See section Procedures Groups and Procedure Conditions

Modifiers in Combination with Modifier Usage

• If 'In' then claim line must at least contain one or more of the modifiers in the list

• If 'Not in' then claim line must not contain that modifier (or modifiers if more than one is specified)

Fee Schedule

A fee schedule can add the following restrictions that need to be applied:

Condition Dynamic Logic

Reference to condition dynamic logic in which it is specified how the dynamic fields on the fee schedule line are compared to the fields of the claim line or claim. This dynamic logic condition is evaluated per claim line and per fee schedule line; in effect, it can filter a couple of possibly applicable fee schedule lines to just one.

Modifiers in Combination with Modifier Usage

Only evaluated when a fee schedule line without modifiers is selected (see evaluation of fee schedule line modifiers).

A fee schedule consists of fee schedule lines; the selection needs to find the fee schedule line that should be applied. A fee schedule line can add the following restrictions that need to be applied:

Enabled Indicator

Disabled fee schedule lines act for the selection as if they are not present.

Time Validity (Mandatory Start Date and Optional End Date)

The price input date of the claim line should lie within the time span of the fee schedule line.

Classifications in Combination with Classification Usage

• If 'In' then the claim line must contain one of the classifications in the list

• If 'Not in' then the claim line must contain none of the classifications in the list

Procedures and Procedure Groups

The three claim line procedures are matched at the price Input date against the specified procedures and the group details of all specified procedure groups. There is a match if at least one of the three claim line procedures is the same as the specified procedure or is in the specified procedure group at the price Input date (this check is performed for every specified procedure and procedure group). So for example if the first two procedures are specified then one or more claim line procedures should be the same as the first procedure and one or more claim line procedures should be the same as the second procedure.

If one of the procedures is marked as principal, then that procedure must match the restriction on procedures and/or procedure groups; for more detail and examples, see Price Principal Procedures.

Modifiers

• If containing one modifier, the claim line must at least contain that modifier

• If containing more than one modifier, the claim line must at least have those modifiers

• If empty then the modifier list in combination with modifier usage of the fee schedule header is evaluated

  • If that list is also empty, then no restriction on modifier is imposed

  • If 'In' then claim line must at least contain one or more of the modifiers in the list

  • If 'Not in' then claim line must not contain that modifier (or modifiers if more than one is specified)

Contract Reference

If a contract reference is specified on the fee schedule line, the claim line must refer to at least that contract reference.

Provider Group

The Price Individual Provider or the Price Organization Provider of the claim line should be in the provider group specified on the fee schedule line.

Provider

The individual provider - if specified - of the fee schedule line is matched against the Price Individual Provider.

The organization provider - if specified - of the fee schedule line is matched against the Price Organization Provider.

Pricing Rules

Generic

A pricing rule can add the following restrictions (generic for all pricing rules) that need to be applied:

Procedure Groups and Procedure Conditions

See section Procedures Groups and Procedure Conditions.

Diagnosis Group and Diagnosis Condition in Combination with Diagnosis Usage

• If 'In' then the claim line primary diagnosis must be present in the diagnoses group or condition on the price input date

• If 'Not In' then the claim line primary diagnosis must not be present in the diagnoses group or condition on the price input date

• Note that the diagnoses are inherited from bill or claim level if not specified on the claim line

Modifiers In Combination with Modifier Usage

• If 'In' then claim line must at least contain one or more of the modifiers in the list

• If 'Not in' then claim line must not contain that modifier (or modifiers if more than one is specified)

Reimbursement Method Types in Combination With Reimbursement Method Type Usage

• If 'In' then the pricing rule is only applied if the previous reimbursement was based on a reimbursement method of one of the types that is now being referred to

• If 'Not In' then the pricing rule is only applied if the previous reimbursement was not based on a reimbursement method of one of the types that is now being referred to

Classifications in Combination With Classification Usage

• If 'In' then the claim line must contain one of the classifications in the list

• If 'Not in' then the claim line must contain none of the classifications in the list

Condition Dynamic Logic

The condition should evaluate to true.

Combination Adjustment Rule

A combination adjustment rule specifies a determinant (the determinant of a claim line for being primary, secondary or tertiary):

• Allowed Amount

• Procedure List

Allowed Amount

All claim lines of a claim are evaluated together^[2]. The claim lines that meet all dimensions of the combination adjustment rule are evaluated per serviced person or object, provider and price input date. This may lead to different sets of claim lines that are to be evaluated.

Each set of combination of claim lines may then be extended with approved claim lines from other finalized claims that have the same serviced person or object, provider and price input date to which the same combination adjustment rule was previously applied. This is controlled by the ignore history indicator of the claim being processed:

• if checked, then the combination of claim lines is not extended with claim lines from other claims

• if unchecked, then the combination of claim lines is extended with approved claim lines from other finalized claims with indicator ignore history unchecked that have the same serviced person or object, provider and price input date to which the same combination adjustment rule was previously applied

To be able to compare the allowed amounts of the claim lines in a set, all claim lines in the set must have the same allowed amount currency. If the claim lines have different allowed amount currencies, the following product independent fatal message is attached to all claim lines from the current claim that are in the set (note that the provider pricing clause is still tracked):

Code	Sev	Text
CLA-FL-PRIC-027	Fatal	The claim lines in the evaluation set have different allowed amount currencies

If the set only contains claim lines from the current claim, then:

• If the combination adjustment rule does not have a tertiary line formula dynamic logic or a percentage for tertiary line category that is valid at the price input date, then:

  • If multiple claim lines within the combination have the highest allowed amount per allowed unit, then:

    • The claim line with the highest allowed amount and the lowest sequence number is recognized as primary

    • Other claim lines are recognized as secondary (meaning that only one claim line can be recognized as the primary claim line)

  • If only one claim line has the highest allowed amount per allowed unit, then:

    • That claim line is recognized as primary

    • Other claim lines are recognized as secondary

• If the combination adjustment rule does have a tertiary line formula dynamic logic or a percentage for tertiary line category that is valid at the price input date, then:

  • If multiple claim lines within the combination have the highest allowed amount per allowed unit, then:

    • The claim line with the highest allowed amount and the lowest sequence number is recognized as primary

    • The claim line with the highest allowed amount and second lowest sequence number is recognized as secondary

    • Other claim lines are recognized as tertiary (meaning that only one claim line can be recognized as the primary claim line and only one claim line as the secondary claim line)

  • If only one claim line has the highest allowed amount per allowed unit, then:

    • That claim line is recognized as primary

    • If multiple claim lines within the combination have the second highest allowed amount, then:

      • The claim line with the second highest amount and the lowest sequence number is recognized as secondary

      • Other claim lines are recognized as tertiary

    • If only one claim line has the second highest allowed amount per allowed unit, then:

      • That claim line is recognized as secondary

      • Other claim lines are recognized as tertiary

If the set contains at least one claim line from a finalized claim, then:

• If only a claim line from a finalized claim exists that is tagged as 'Primary', then one of the current claim lines will become secondary and others tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if a current claim line has the highest allowed amount informative message CLA-FL-PRIC-020 will be attached to the current claim line (if multiple candidates exist having the same highest allowed amount, then the one with the lowest sequence number is chosen to attach the message to).

• If only claim lines from finalized claims exist that are tagged as 'Secondary', then one of the current claim lines will become primary and others tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if the current claim line that is recognized as primary does not have the highest allowed amount informative message CLA-FL-PRIC-021 will be attached to the current claim line.

  • In addition if a current claim line that is recognized as tertiary has a higher allowed amount than the existing secondary claim line informative message CLA-FL-PRIC-022 will be attached to the current claim line (if multiple candidates exist, then the one with the highest allowed amount and lowest sequence number is chosen to attach the message to).

• If only claim lines from finalized claims exist that are tagged as 'Tertiary', then one of the current claim lines will become primary, one of them will become secondary and others tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if the current claim line that is recognized as primary does not have the highest allowed amount informative message CLA-FL-PRIC-023 will be attached to the current claim line.

  • In addition if the current claim line that is recognized as secondary does not have a higher allowed amount than the existing tertiary lines informative message CLA-FL-PRIC-023 will be attached to the current claim line.

• If claim lines from finalized claims exist that are tagged as 'Primary' and 'Secondary', then the current claim lines will become tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if a current claim line has the highest allowed amount informative message CLA-FL-PRIC-020 will be attached to the current claim line (if multiple candidates exist having the same highest allowed amount, then the one with the lowest sequence number is chosen to attach the message to).

  • In addition if a current claim line has a higher allowed amount than the existing secondary claim line informative message CLA-FL-PRIC-022 will be attached to the current claim line (if multiple candidates exist, then the one with the highest allowed amount and lowest sequence number is chosen to attach the message to).

• If claim lines from finalized claims exist that are tagged as 'Primary', 'Secondary' and 'Tertiary', then the current claim lines will become tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if a current claim line has the highest allowed amount informative message CLA-FL-PRIC-020 will be attached to the current claim line (if multiple candidates exist having the same highest allowed amount, then the one with the lowest sequence number is chosen to attach the message to).

  • In addition if a current claim line has a higher allowed amount than the existing secondary claim line informative message CLA-FL-PRIC-022 will be attached to the current claim line (if multiple candidates exist, then the one with the highest allowed amount and lowest sequence number is chosen to attach the message to).

• If claim lines from finalized claims exist that are tagged as 'Secondary' and 'Tertiary', then one of the current claim lines will become primary and others tertiary following the same algorithm as if there were no claim lines in history.

  • In addition if the current claim line that is recognized as primary does not have the highest allowed amount informative message CLA-FL-PRIC-021 will be attached to the current claim line.

  • In addition if a current claim line that is recognized as tertiary has a higher allowed amount than the existing secondary claim line informative message CLA-FL-PRIC-022 will be attached to the current claim line (if multiple candidates exist, then the one with the highest allowed amount and lowest sequence number is chosen to attach the message to).

Note that tertiary claim lines are only recognized if one or more primary and secondary claim lines have been recognized without system generated errors.

Code	Sev	Text
CLA-FL-PRIC-020	Informative	The current allowed amount is the highest allowed amount, but claim line {claim line code} within claim {claim code} is marked as primary
CLA-FL-PRIC-021	Informative	Claim line {claim line code} within claim {claim code} has a higher allowed amount but is marked as secondary
CLA-FL-PRIC-022	Informative	Claim line {claim line code} within claim {claim code} is marked as secondary but the current allowed amount is higher
CLA-FL-PRIC-023	Informative	Claim line {claim line code} within claim {claim code} has a higher allowed amount but is marked as tertiary

Procedure List

All claim lines of a claim are evaluated together^[2]. The claim lines that meet all dimensions (there is a difference in which procedure group/condition has to be met; see below) of the combination adjustment rule are evaluated per serviced person or object, provider and price input date. This may lead to different sets of claim lines that are to be evaluated.

Each set of combination of claim lines may then be extended with approved claim lines from other finalized claims that have the same serviced person or object, provider and price input date to which the same combination adjustment rule was previously applied. This is controlled by the ignore history indicator of the claim being processed:

• if checked, then the combination of claim lines is not extended with claim lines from other claims

• if unchecked, then the combination of claim lines is extended with approved claim lines from other finalized claims with indicator ignore history unchecked that have the same serviced person or object, provider and price input date to which the same combination adjustment rule was previously applied

This set of claim lines is then evaluated as follows:

• Primary claim lines are recognized by the supplied procedure groups/conditions (meaning that multiple claim lines can be recognized as primary claim lines)

• Secondary claim lines are recognized by the supplied secondary procedure groups/conditions (note that this only happens if one or more primary claim lines have been recognized without system generated errors)

• Tertiary claim lines are recognized by the supplied tertiary procedure groups/conditions (note that this only happens if one or more primary and secondary claim lines have been recognized without system generated errors)

Whether or not one of the claim line procedures satisfies a procedure group and/or procedure condition is evaluated in the same way as described in the section Procedures Groups and Procedure Conditions.

See Adjustment Rules for examples how adjustment rules and combination adjustment rules are evaluated.

Inclusion Rule

• All claim lines of a claim are evaluated together^[3]

• The evaluation is done per serviced person or object, per price organization provider (per price individual provider if price organization provider is unspecified)

• The inclusion rule is triggered if one or more claim lines meet all dimensions of the rule, with the exception of the Not Included Procedure Groups/Conditions:

  • These claim lines are recognized as global claim lines or included claim lines based on the 'Pay Only One Global?' indicator:

    • If set to 'Yes' then the claim line with the highest allowed amount per allowed unit is recognized as global, others as included. If multiple claim lines have the highest allowed amount, the claim line with the lowest sequence number is recognized as global, others as included (meaning that only one claim line can be recognized as the global claim line).

    • If set to 'No' then all claim lines that meet the dimensions are recognized as global.

  • All other claim lines that meet all dimensions of the rule, with the exception of the Global Procedure Groups/Conditions, are recognized as included claim lines unless they are excluded through the excluded (a.k.a. not included) Procedure Groups/Conditions. A claim line is recognized as an excluded claim line by matching the three claim line procedures at the price input date against the group details of all specified procedure groups and/or procedure conditions in the same way as described in Procedure Groups and Procedure Conditions.

To be able to compare the allowed amounts of the claim lines in a set, all claim lines in the set must have the same allowed amount currency. If the claim lines have different allowed amount currencies, product independent fatal message CLA-FL-PRIC-027 (see 'Combination Adjustment Rule' section) is attached to all claim lines that are in the set. Note that the provider pricing clause is still tracked.

See Inclusion Rules for examples how inclusion rules are evaluated.

Replacement Rule

• All claim lines of a claim are evaluated together ^[4]

• The evaluation is limited to claim lines that meet all dimensions of the rule

• The evaluation is done per serviced person or object, per price organization provider (per price individual provider if price organization provider is unspecified)

• The evaluation may be partitioned further by price input date, depending on the indicator 'Per Price Date?':

  • If set to 'No' then one evaluation is done for all applicable claim lines together. Together with the above, this means there is one 'evaluation set' for each distinct combination of serviced person or object and price provider on the claim.

  • If set to 'Yes' then a separate evaluation is done for each distinct price input date of the applicable claim lines. Together with the above, this means there is a separate 'evaluation set' for each distinct combination of price input date, person or object and price provider on the claim.

• Each evaluation set may trigger one replacement, depending on the indicator 'Replace Single Line?':

  • If 'Replace Single Line?' is set to 'No' then the evaluation set only triggers a replacement if it contains more than one claim line

  • If 'Replace Single Line?' is set to 'Yes' then the evaluation set always triggers a replacement, that is, also if it contains only one claim line

See Replacement Rules for examples how replacement rules are evaluated.

Pricing External Intervention Rule

A pricing external intervention rule can add the following restrictions that need to be applied:

Claim Type

If specified, this means that the pricing external intervention rule is only applied for claims of that type.

Payer

If specified, the payer code on the claim should match one of the codes belonging to the specified payer.

Brand

If specified, this brand should match the brand of the claim.

Message Group

If specified, one of the claim line messages should match one of the messages in the group. Note that this evaluation takes place during the selection of provider pricing clauses wholesale which cannot be influenced by the execution of a specific pricing external intervention rule.

An example to clarify: Rule1 is triggered (amongst other dimensions) on a message group which contains message with code 'ABC". Rule 2 is triggered (among other conditions) on brand 'B' and adds message 'ABC' to the claim line if triggered. If a claim line comes in of brand 'B', but not having message 'ABC' attached, rule 1 is not triggered and rule 2 is.

Un-finalize Reason Group

If specified, one of the claim unfinalize reasons should match one of the unfinalize reasons in the group.

Claim Forms

The form of the claim must either match one of the defined external intervention rule claim forms, or no external intervention rule claims forms should be specified. In the latter case, the external intervention rule applies to all claims, irrespective of the claim form.

Evaluate Selected Provider Pricing Clauses

At this point in the flow, we have a list of selected provider pricing clauses that are meant for the reimbursement method or pricing rule at hand and that also match all the criteria that have been evaluated. It is still possible, however, that more than one provider pricing clause is in the list. Which one should we use? That depends on subsequent evaluations, based on four dimensions.

Dimensions

Specificity of Provider

If for one claim line multiple provider pricing clauses with the same type and the same priority apply then an implicit order is derived from the specificity of the provider pricing clause. This means that for example, a provider pricing clause for an individual provider is ranked over the pricing clause for a provider group. The order from high to low is:

1. Individual and Organization

2. Individual

3. Organization

4. Contract Reference

5. Provider Group

6. Provider Category

7. None of the above

If we apply this to all possible combinations the outcome is:

Individual	Organization	Contract Reference	Provider Group	Provider Category	Order
X	X				1
X	X	X			1
X	X		X		1
X	X			X	1
X	X	X	X		1
X	X	X		X	1
X	X		X	X	1
X	X	X	X	X	1
X					2
X		X			2
X			X		2
X				X	2
X		X	X		2
X		X		X	2
X			X	X	2
X		X	X	X	2
	X				3
	X	X			3
	X		X		3
	X			X	3
	X	X	X		3
	X	X		X	3
	X		X	X	3
	X	X	X	X	3
		X			4
		X	X		4
		X		X	4
		X	X	X	4
			X		5
			X	X	5
				X	6
					7

Exemption

When a pricing rule with the same identifying code is found more than once but with a different priority and the highest priority is marked as exempt then the pricing rule with that code is not applied (note that if only one pricing rule for a code is found marked as exempt, the pricing rule is not applied). If one of the following situations arise a product independent message is attached to the claim line:

• The exempted provider pricing clause and the not exempted provider pricing clause have the same (highest) priority

• More than one exempted provider pricing clause exists for the same pricing rule with the same (highest) priority

Code	Sev	Text
CLA-FL-PRIC-006	Fatal	{number of found provider pricing clauses} provider pricing clauses for substep {substep} and code {code} have been found with the same priority: {list of (Contract Reference.code, Provider Pricing Clause.description)}

Provider Pricing Clause Priority

Highest priority equals the lowest number that is attached to the priority; if a priority is not specified, then this counts as the lowest priority.

Fee Schedule Line Dynamic Priority

In case multiple fee schedule lines are applicable, a piece of function dynamic logic (if defined) is executed to filter the list of applicable fee schedule lines, ideally to just one line. Refer to the text on fee schedule line priority for a description of this functionality.

Interpretation of Dimensions

How to handle the interpretation of these four dimensions (provider specificity, exemption, provider pricing clause priority, fee schedule line dynamic priority)? That actually depends on the substep. To give an example: it is possible to apply more than one message rule to a claim line, but it is not possible to apply more than one reimbursement method to a claim line. In effect, there only is a limited number of algorithms to be applied:

Sub-step Reimbursement Method

Seek the one with the highest provider pricing clause priority. If multiple remain, seek the one within the remaining set with the highest provider specificity. If still multiple remain, a product independent message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-003	Fatal	{number of found provider pricing clauses} provider pricing clauses for substep Reimbursement Method have been found with the same priority: {list of (Reimbursement Method.code, Contract Reference.code, Provider Pricing Clause.description)}

If one provider pricing clause referencing a fee schedule is selected but multiple fee schedule lines remain, the fee schedule line dynamic priority is applied to find the fee schedule line with the highest dynamic priority. If multiple fee schedule lines remain, the following product independent message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-009	Fatal	Multiple fee schedule lines on fee schedule {code} are applicable for this claim line

If during the selection of provider pricing clauses for type reimbursement method no provider pricing clauses have been found, the following product independent message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-004	Informative	No provider pricing clauses for substep Reimbursement Method have been found

Sub-steps Provider Limit Rule (units), Before Reimbursement Message Rule, After Reimbursement Message Rule, Dynamic Field Rule, and Pricing External Intervention Rule

Seek the one with the highest priority per code of the rule. If multiple remain, seek the one within the remaining set with the highest provider specificity. If still multiple remain, message CLA-FL-PRIC-006 is attached to the claim line. This method is handled for each code, so that multiple rules can be executed.

Sub-step Provider Limit Rule (Amount or Service days)

The same method as the previous one. In the execution of multiple rules there is an extension: when the final result is a mix of amount and service days, a product independent message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-007	Fatal	{number of found provider pricing clauses} provider pricing clauses for substep Provider Limit Rule (amount/service days) have been found that differ in type of limit (amount versus service days)

Sub-steps Before Adjustment Lower of Rule, After Adjustment Lower of Rule, Inclusion Rule, Replacement Rule, and Encounter Rule

Seek the one with the highest priority. If multiple remain, seek the one within the remaining set with the highest provider specificity. If still multiple remain, the following product independent message is attached to the claim line:

Code	Sev	Text
CLA-FL-PRIC-019	Fatal	{number of found provider pricing clauses} provider pricing clauses for substep {substep} have been found with the same priority: {list of (Pricing Rule.code, Contract Reference.code, Provider Pricing Clause.description)}

Sub-step Adjustment Rule

This substep is divided into execution phases. The adjustment rules that have an adjustment execution phase with the lowest phase number are evaluated first. The adjustment rules that have no adjustment execution phase are evaluated last (this is seen as the last execution phase):

Seek the one with the highest priority per code of the rule per type of the rule (adjustment rules and combination adjustment rules can have the same code; they are evaluated as different rules). If multiple remain, seek the one within the remaining set with the highest provider specificity. If still multiple remain, product independent message CLA-FL-PRIC-006 is attached to the claim line. This method is handled for each code, so that multiple rules can be executed.

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1. Any dynamic logic conditions of the product category will in this case receive as input an empty list of products.

2. Note that claim lines with a product independent fatal message of the following origins: MANUAL, EXTERNAL, SANITY CHECKS, PRE PRICING, ENROLLMENT, RESERVATION, PRICING LIMIT, PRICING or PRICING NO RECALCULATION are not evaluated; claim lines with a checked locked, keep pricing or keep benefits indicator are evaluated to determine the primary, secondary and tertiary claim lines (only within the same claim, see examples section)

3. Note that claim lines with a product independent fatal message of the following origins: MANUAL, EXTERNAL, SANITY CHECKS, PRE PRICING, ENROLLMENT,RESERVATION, PRICING LIMIT, PRICING or PRICING NO RECALCULATION are not evaluated; claim lines with a checked locked, keep pricing or keep benefits indicator are evaluated to determine the global and included claim lines but the inclusion rule is not applied to these claim lines

4. Note that claim lines with a product independent fatal message of the following origins: MANUAL, EXTERNAL, SANITY CHECKS, PRE PRICING, ENROLLMENT, RESERVATION, PRICING LIMIT, PRICING or PRICING NO RECALCULATION are not evaluated. Claim lines with a checked locked, keep pricing or keep benefits indicator are not evaluated. Replacement claim lines are not evaluated; replacing a replacement claim line is not supported.