Components Model

The main starting point for determining the correct price, is the provider pricing clause. This points either to a reimbursement method or to a pricing rule, each of which consists of more granular pieces of configuration.

Configuration Building Blocks

Product Category

Product categories are used to dynamically categorize products during claims pricing. Product categories are referred to by provider pricing clauses. Based on the product category (or categories) in which the policy product 'fits', relevant provider pricing clauses can be selected for pricing of claim lines.

Product Category Fields

Field	Description
Code	The code of the product category
Description	The description of the product category

A product category can be made more specific by adding dynamic logic conditions to it. A policy product only fits in the product category when all of the dynamic logic conditions evaluate to true. When no dynamic logic conditions are added to a product category, the fit of products in the category is determined regardless of dynamic logic conditions.

Product Category Dynamic Logic

Field	Description
Product category	The product category to which the condition applies
Condition	A dynamic logic condition that serves as a condition that must be met by a provider pricing clause.

A product category can have one or more product category dimensions. A product fits into a product category when it satisfies at least one of the product category’s dimensions. When no dimensions are configured, the fit of products in the category is determined regardless of dimensions.

Product Category Dimension

Field	Description
Product	The executable product of the person or object.
Product line	The product line of the product, e.g. HMO.
Product family	The product family of the product
Funding arrangement	The funding arrangement of the product, e.g. Fully Insured
Brand	The brand of the product.
Payer	The payer of the product.

The following business rules apply to a product category dimension:

• A product category dimension must either refer to a product only, or to one or more of: product line, product family, funding arrangement, brand, payer.

• A product category dimension may refer to a payer or to a brand or to neither, but NOT to both.

Provider Category

Provider categories define conditions to dynamically categorize providers during claims pricing. Provider categories are referred to by provider pricing clauses. Based on the provider category (or categories) in which the pricing provider 'fits', relevant provider pricing clauses can be selected for pricing of claim lines.

In order to determine the correct provider category, the scope of the provider with regard to the provider groups of the policy products is also evaluated.

Provider Category Fields

Field	Description
Code	The code of the provider category.
Description	The description of the provider category.
Product provider group scope	The scope of the provider with regard to the provider groups of the policy products.

A provider category can be made more specific by adding dynamic logic conditions to the provider category. A pricing provider only fits in the provider category when all of the dynamic logic conditions evaluate to true. When no dynamic logic conditions are added to a provider category, the fit of providers in the category is determined regardless of dynamic logic conditions

Provider Category Dynamic Logic

Field	Description
Provider category	The provider category to which the condition applies.
Condition	A dynamic logic condition that serves as a condition that must be met by a provider pricing clause.

A provider category can be made specific to certain specialties by adding those specialties to the provider category. A pricing provider only fits in the provider category when the provider’s specialty (as specified in the claim line’s service specialty) matches with one of the provider category specialties. When no specialties are added to a provider category, the fit of providers in the category is determined regardless of specialty.

Provider Category Specialty

Field	Description
Provider category	The provider category to which the specialty applies.
Specialty	The specialty of the provider.

Pricing Priorities

Pricing priorities are referred to by provider pricing clauses. Pricing priorities are used to determine which provider pricing clause takes precedence when multiple are applicable and one must be selected.

Pricing priorities have a user friendly display name which is displayed in the setup of provider pricing clauses.

Pricing Priorities Fields Table

Field	Description
Code	The code of the pricing priority
Priority	The relative priority when evaluating pricing clauses (1 means highest priority)
Display name	The display name of the pricing priority

Adjustment Execution Phases

Adjustment execution phases are referred to by adjustment rules and combination adjustment rules. Adjustment execution phases are used to determine the order in which the adjustments should be executed. This is particularly useful when combination adjustment rules come into play, for which the allowed amount of a claim line may determine the adjustment of other claim lines.

Adjustment execution phases have a user friendly display name which is displayed in the setup of adjustment rules and combination adjustment rules.

Adjustment Execution Phases Fields Table

Field	Description
Code	The code of the adjustment execution phase
Phase	The phase in which adjustment rules are executed (1 means first phase)
Display name	The display name of the adjustment execution phase

Pricing Rules

Generic

Each pricing rule can refer to one or more modifiers:

Pricing Rule Modifiers

Field	Description
Pricing rule	The pricing rule to which the pricing rule modifier refers.
Modifier	The modifier to which the pricing rule modifier applies.

Each pricing rule can refer to one or more classifications:

Pricing Rule Classifications

Field	Description
Pricing rule	The pricing rule to which the pricing rule classification refers.
Classification	The classification to which the pricing rule classification applies.

Each pricing rule can refer to one or more reimbursement method types:

Pricing Rule Reimbursement Method Types

Field	Description
Pricing rule	The pricing rule to which the pricing rule reimbursement method type refers.
Reimbursement method type	The reimbursement method type to which the pricing rule reimbursement method type applies.

Lower Of Rules

A lower of rule specifies that lower of logic needs to be applied. Lower of logic means taking the lower of charged amount and allowed amount at the claim line level.

Lower Of Rules

Field	Description
Code	The code of the lower of rule.
Description	The description of the lower of rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the lower of rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the lower of rule is applied.
Other condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Execution moment	Is the rule executed before or after the adjustment rules?
Access Restriction	Determines whether or not the access to the lower of rule is restricted

Constraints:

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

The following table specifies the placeholder values for messages that are attached to claim lines when the lower of rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The descriptions of the reimbursement method types (comma separated)

Adjustment Rules

An adjustment rule specifies which combination of procedures, modifiers and diagnoses leads to an adjustment of the allowed amount. Adjustment rules are executed per claim line, regardless of other claim lines on the same claim.

Adjustment Rules

Field	Description
Code	The code of the adjustment rule.
Description	The description of the adjustment rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the adjustment rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the adjustment rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Execution phase	The phase in which the adjustment rule is executed. This can be used to chain multiple adjustment rules in a specified order of execution.
Formula	The dynamic logic that calculates the new allowed amount.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Access Restriction	Determines whether or not the access to the adjustment rule is restricted

An adjustment rule can specify the percentage for multiplying with claim line’s allowed amounts. Multiple percentages can be specified but only one percentage can be valid at a time. The percentage can be overruled by the quantifier on the provider pricing clause. If a percentage can not be found at the pricing input date, processing attaches an error message.

Adjustment Rule Percentage

Field	Description
Adjustment Rule	The adjustment rule to which the adjustment rule percentage refers.
Start Date	The start date of the time validity of the percentage.
End Date	The end date of the time validity of the percentage.
Percentage	The percentage.

Constraints:

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

• Different percentages for the same adjustment rule cannot overlap in time-validity.

The following table specifies the placeholder values for messages that are attached to claim lines when the adjustment rule is applied:

• The code of the rule

• The description of the rule

• The provider pricing clause quantifier if specified, otherwise the adjustment rule percentage

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The old allowed amount postfixed by a space and the currency display code

• The new allowed amount postfixed by a space and the currency display code Note that the currency for the old and new allowed amount is identical.

• The value of userDefinedParameters[8] (this variable can be assigned in the formula)

• The value of userDefinedParameters[9] (this variable can be assigned in the formula)

Combination Adjustment Rules

A combination adjustment rule specifies which combination of procedures, modifiers and diagnoses leads to an adjustment of the allowed amount. Combination adjustment rules take all claim lines of a claim into account.

Combination Adjustment Rules Fields Table

Field	Description
Code	The code of the combination adjustment rule.
Description	The description of the combination adjustment rule.
Line Determinant	The determinant (allowed amount or procedure list) of a claim line for being primary, secondary or tertiary. Allowed amount: the claim line with the highest allowed amount per allowed unit is recognized as primary, the claim line with the second highest allowed amount is recognized as secondary and others as tertiary (or secondary if no tertiary combination adjustment rule percentage can be found). Procedure list: primary claim lines are recognized by the supplied procedure groups/conditions, secondary claim lines are recognized by the supplied secondary procedure groups/conditions and tertiary claim lines are recognized by the supplied tertiary procedure groups/conditions.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the combination adjustment rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the combination adjustment rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Secondary procedure group usage	How should the secondary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Secondary procedure group	The group of procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Secondary procedure condition usage	How should the secondary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Secondary procedure condition	The procedure condition that defines the secondary procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Secondary procedure group 2 usage	How should the second secondary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Secondary procedure group 2	The second group of procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Secondary procedure condition 2 usage	How should the second secondary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Secondary procedure condition 2	The second procedure condition that defines the secondary procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Secondary procedure group 3 usage	How should the third secondary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Secondary procedure group 3	The third group of procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Secondary procedure condition 3 usage	How should the third secondary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Secondary procedure condition 3	The third procedure condition that defines the secondary procedures, by which secondary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure group usage	How should the tertiary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Tertiary procedure group	The group of procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure condition usage	How should the tertiary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Tertiary procedure condition	The procedure condition that defines the tertiary procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure group 2 usage	How should the second tertiary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Tertiary procedure group 2	The second group of procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure condition 2 usage	How should the second tertiary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Tertiary procedure condition 2	The second procedure condition that defines the tertiary procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure group 3 usage	How should the third tertiary procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Tertiary procedure group 3	The third group of procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Tertiary procedure condition 3 usage	How should the third tertiary procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Tertiary procedure condition 3	The third procedure condition that defines the tertiary procedures, by which tertiary claim lines can be recognized. This field is only available for combination adjustment rules with determinant 'Procedure list'.
Execution phase	The phase in which the combination adjustment rule is executed. This can be used to chain multiple (combination) adjustment rules in a specified order of execution.
Primary line formula	The dynamic logic that calculates the new allowed amount. This formula is executed for primary claim lines.
Secondary line formula	The dynamic logic that calculates the new allowed amount. This formula is executed for secondary claim lines.
Tertiary line formula	The dynamic logic that calculates the new allowed amount. This formula is executed for tertiary claim lines.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Access Restriction	Determines whether or not the access to the combination adjustment rule is restricted

A combination adjustment rule can specify the percentages for multiplying with secondary and tertiary claim line’s allowed amounts. Multiple percentages can be specified but only one percentage can be valid at a time. The percentage for secondary claim lines can be overruled by the quantifier on the provider pricing clause.

Adjustment Rule Percentage

Field	Description
Combination Adjustment Rule	The combination adjustment rule to which the adjustment rule percentage refers.
Line Category	The category of claim lines (secondary or tertiary) to which the adjustment rule percentage is applicable.
Start Date	The start date of the time validity of the percentage.
End Date	The end date of the time validity of the percentage.
Percentage	The percentage.

Constraints:

• One or more procedure groups and/or procedure conditions must be specified.

• For line determinant 'Procedure list' one or more secondary procedure groups and/or procedure conditions must be specified.

• For line determinant 'Allowed amount' no secondary and tertiary procedure groups or conditions may be specified.

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all nine procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all nine procedure conditions).

• Different percentages for the same combination adjustment rule and line category cannot overlap in time-validity.

• The line category must be specified for combination adjustment rules and may not be specified for 'simple' adjustment rules.

The following table specifies the placeholder values for messages that are attached to claim lines when the combination adjustment rule is applied:

• 0. The code of the rule

• 1. The description of the rule

• 2. The provider pricing clause quantifier if specified, otherwise the adjustment rule percentage

• 3. The descriptions of the procedure groups/conditions (comma separated)

• 4. The description of the diagnosis group or diagnosis condition

• 5. The descriptions of the secondary procedure groups/conditions (comma separated)

• 6. Modifier list

• 7. The old allowed amount postfixed by a space and the currency display code

• 8. The new allowed amount postfixed by a space and the currency display code Note that the currency for the old and new allowed amount is identical.

• 9. The value of userDefinedParameters[9] (this variable can be assigned in the formula)

Message Rules

A message rule specifies which combination of procedure, diagnosis and/or modifiers leads to attaching a message to the claim line.

Message Rules Table

Field	Description
Code	The code of the message rule.
Description	The description of the message rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the message rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the message rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Message	The message that is attached to the claim, bill or claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Execution moment	Is the rule executed before the reimbursement method, after the reimbursement method or after the encounter rule?
Claim Level	The level at which the message should be attached (Claim or Claim Line).
Access Restriction	Determines whether or not the access to the message rule is restricted

Constraints:

• Specifying a message is mandatory.

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• A reimbursement method type cannot be specified for a message rule that is evaluated before reimbursement method.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

The following table specifies the placeholder values for messages that are attached to the claim line when the message rule is applied:

• 0. The code of the rule

• 1. The description of the rule

• 2. The descriptions of the procedure groups/conditions (comma separated)

• 3. The description of the diagnosis group or diagnosis condition

• 4. Modifier list

• 5. The descriptions of the reimbursement method types (comma separated)

Pricing External Intervention Rules

Pricing external intervention rules are evaluated in deciding if a claim line should pend for manual pricing. They differ from 'normal' external intervention rules in that they can trigger on contract references through provider pricing clauses.

Pricing External Intervention Rules Fields Table

Field	Description
Code	The code of the pricing external intervention rule.
Description	The description of the pricing external intervention rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the pricing external intervention rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the pricing external intervention rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Claim type	The claim type to which the external intervention rule applies: Provider Claim or Restitution Claim
Payer	The payer code on the claim should match one of the codes belonging to the specified payer.
Brand	The brand should match the brand of the claim.
Message group	One of the claim line messages should match one of the messages in the group.
Unfinalize reason group	One of the claim unfinalize reasons should match one of the unfinalize reasons in the group.
Pend reason	The pend reason that is attached to the claim line.
Suppress when fatal indicator	If checked, then this rule does not trigger a pend (will not attach a pend reason) if a fatal claim, bill or non-product specific claim line message exists. When checking for the presence of fatal messages, messages that have been added in a previous iteration in the processing flow are ignored. In other words only the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing, pricing limit and pricing no recalculation.
Access Restriction	Determines whether or not the access to the pricing external intervention rule is restricted

A pricing external intervention rule can refer to one or more claim forms:

Pricing External Intervention Rule Claims Forms

Field	Description
Pricing External Intervention Rule	The pricing external intervention rule to which the pricing external intervention rule claim form refers.
Claim Form	The claim form to which the pricing external intervention rule claim form applies.

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

Constraints:

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• Either a payer or a brand can be specified, but not both.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

The following table specifies the placeholder values for messages that are attached to claim lines when the pricing external intervention rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The descriptions of the reimbursement method types (comma separated)

Encounter Rules

An encounter rule specifies which combination of procedure, diagnosis and/or modifiers leads to identifying a claim line as an encounter claim line by setting the encounter indicator on the claim line to 'Yes'.

Encounter Rules Fields Table

Field	Description
Code	The code of the encounter rule.
Description	The description of the encounter rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the encounter rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the encounter rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Access Restriction	Determines whether or not the access to the encounter rule is restricted

Constraints:

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

The following table specifies the placeholder values for messages that are attached to claim lines when the encounter rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The descriptions of the reimbursement method types (comma separated)

Dynamic Field Rules

A dynamic field rule specifies which combination of procedure, diagnosis and/or modifiers leads to setting the value or the values of one or more dynamic fields on the claim, bill or claim line.

Dynamic Field Rules Fields Table

Field	Description
Code	The code of the dynamic field rule.
Description	The description of the dynamic field rule.
Level	Claim, Bill or Claim line. The value for this field pre filters the dynamic fields that can be set in the dynamic logic function, e.g., if the value is "claim line", then the dynamic logic function can only set values for dynamic fields that are on the claim line.
Quantifier type	The type of the provider pricing clause quantifier that must be used in combination with this rule: Amount Number Percentage Service Days If a quantifier type is specified, this means that a quantifier of this type must be specified for any provider pricing clause that refers to this dynamic field rule. If quantifier type is left empty, this means that a quantifier may not be specified for any provider pricing clause that refers to this dynamic field rule. The provider pricing clause, including its quantifier, is input to the dynamic logic function this dynamic field rule refers to.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the dynamic field rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the dynamic field rule is applied.
Condition	The condition for refinement.
Function	The function that holds the calculation for the dynamic field values. The dynamic field values are set within the function.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Message	The message that is attached to the claim line if the rule is applied.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Access Restriction	Determines whether or not the access to the encounter rule is restricted

Constraints:

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

The following table specifies the placeholder values for messages that are attached to claim lines when the dynamic field rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The descriptions of the reimbursement method types (comma separated)

Inclusion Rules

An inclusion rule defines which procedures are included in a compound procedure like a DRG.

Inclusion Rules Fields Table

Field	Description
Code	The code of the inclusion rule.
Description	The description of the inclusion rule.
Pay only one global?	The indicator that is used to define if more than one global procedure is reimbursed. No - If more than one global procedure claim line is present on a claim, each global procedure claim line will be reimbursed. Yes - If more than one global procedure claim line is present on a claim, the claim line with the highest allowed amount per allowed unit will be reimbursed. The subsequent global claim lines will receive the Included Procedure Message.
Global procedure group usage	How should the global procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Global procedure group	The procedure group that specifies which procedures trigger the rule.
Global procedure condition usage	How should the global procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Global procedure condition	The procedure condition that specifies which procedures trigger the rule.
Global procedure group 2 usage	How should the second global procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Global procedure group 2	The second procedure group that specifies which procedures trigger the rule.
Global procedure condition 2 usage	How should the second global procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Global procedure condition 2	The second procedure condition that specifies which procedures trigger the rule.
Global procedure group 3 usage	How should the third global procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Global procedure group 3	The third procedure group that specifies which procedures trigger the rule.
Global procedure condition3 usage	How should the third global procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Global procedure condition 3	The third procedure condition that specifies which procedures trigger the rule.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the inclusion rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the inclusion rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Not included procedure group usage	How should the not included procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Not included procedure group	The procedure group that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Not included procedure condition usage	How should the not included procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Not included procedure condition	The procedure condition that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Not included procedure group 2 usage	How should the second not included procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Not included procedure group 2	The second procedure group that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Not included procedure condition 2 usage	How should the second not included procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Not included procedure condition 2	The second procedure condition that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Not included procedure group 3 usage	How should the third not included procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Not included procedure group 3	The third procedure group that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Not included procedure condition 3 usage	How should the third not included procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Not included procedure condition 3	The third procedure condition that specifies the procedures that are not included in the global procedure. If empty, all non-global procedures will be included.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Included procedure message	The message that is attached to the included claim lines.
Access Restriction	Determines whether or not the access to the inclusion rule is restricted

Constraints:

• One or more global procedure groups and/or procedure conditions must be specified.

• Specifying an included procedure message is mandatory.

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all six procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all six procedure conditions).

The following table specifies the placeholder values for messages that are attached to claim lines when the inclusion rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the global procedure groups/conditions (comma separated)

• The descriptions of the not included procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

• The descriptions of the reimbursement method types (comma separated)

Replacement Rules

A replacement rule defines the execution of the replacements of one or more existing claim lines by one new claim line.

Replacement Rules Fields Table

Field	Description
Code	The code of the replacement rule.
Description	The description of the replacement rule.
Per price date?	Execute a separate replacement for each distinct price input date involved?: Yes - a separate replacement is executed for each distinct price input date for which there exists (a) claim line(s) on the claim to which the replacement rule applies. For each distinct price input date one new claim line will be created, to replace the existing applicable claim lines with that price input date. No - one replacement is executed which may replace claim lines with different price input dates. Only one new claim line is created to replace the existing applicable claim lines.
Replace single line?	Execute a replacement also if it replaces only one existing claim line?: Yes - even if a replacement only applies to a single claim line on a claim, that claim line will be replaced by one new claim line No - only execute a replacement if it concerns the replacement of multiple existing claim lines (i.e. a bundling).
Field Value Function	The dynamic logic function that is executed to set field values of the newly created claim line(s), i.e. the replacement claim line(s). This can also be used to override the seeded default values of fields.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The procedure group that specifies which procedures trigger the rule and will upon execution be replaced.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that specifies which procedures trigger the rule and will upon execution be replaced.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second procedure group that specifies which procedures trigger the rule and will upon execution be replaced.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that specifies which procedures trigger the rule and will upon execution be replaced.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third procedure group that specifies which procedures trigger the rule and will upon execution be replaced.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that specifies which procedures trigger the rule and will upon execution be replaced.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the replacement rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the replacement rule is applied.
Condition	The condition for refinement.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Replaced procedure message	The message that is attached to the replaced claim lines.
Skip tag	The skip tag that will be attached to claim lines and messages as a result of the replacement rule
Access Restriction	Determines whether or not the access to the replacement rule is restricted

Constraints:

• One or more procedure groups and/or procedure conditions must be specified.

• Either a diagnosis group or a diagnosis condition can be specified, but not both.

• The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.

• The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.

• The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.

• The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).

• The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).

Note that a replacement rule, unlike other pricing rules, cannot refer to a list of 'Reimbursement method types', as replacement rules are evaluated before reimbursement methods. Upon evaluating a replacement rule, the type of any subsequently selected reimbursement method is not yet known.

The following table specifies the placeholder values for messages that are attached to replaced claim lines when the replacement rule is applied:

• The code of the rule

• The description of the rule

• The descriptions of the procedure groups/conditions (comma separated)

• The description of the diagnosis group or diagnosis condition

• Modifier list

Provider Limit Rules

Provider Limit Rules are described separately, please refer to the Provider Limit Counters Model.