Bundled Amounts

A bundled amount reimbursement method represents the contracted amount per episode for the category of the services. It is used in provider pricing clauses to calculate the allowed amount for the episode, per category (or categories.

The bundled amount has the following fields:

Bundled Amounts Fields

Field	Description
Code	The code of the bundled amount
Description	The description of the bundled amount
Type	The bundled amount type to which the bundled amount belongs
Episode Definition	The episode definition to which the bundled amount applies
Priced On	The claim line that will hold the amount - Triggering or First
Include Before Message	The message that gets attached to the claim line that is included before the triggering line is detected
Triggering Message	The message that gets attached to the triggering claim line
Include After Message	The message that gets attached to the claim line that is included after the triggering line is detected
Access Restriction	Determines whether or not the access to the bundled amount is restricted

The following list specifies the placeholder values for the message that is attached to the claim line upon applying a bundled amount:

0. The code of the bundled amount

1. The description of the bundled amount

2. The provider pricing clause quantifier and currency

3. The episode definition

4. The episode category list that applies to the bundled amount

5. The code of the claim that holds the priced claim line for the bundled amount

6. The claim line code that holds the priced claim line for the bundled amount

Bundled amount types can be referred to by bundled amounts for administrative purposes. Pricing rules can also refer to bundled amount types. If a bundled amount type is specified on a pricing rule then the rule is only applied if a bundled amount of that type has been applied (in combination with the reimbursement method type usage as 'In' ) or has not been applied (in combination with reimbursement method type usage as 'Not In' ) to calculate the price on the claim line.

Bundled Amount Types

Field	Description
Code	The code of the bundled amount type
Description	The description of the bundled amount type

A bundled amount can be linked to one or more episode categories. Not linking to any episode category is the equivalent of an “ALL” episode category.

Bundled Amount Categories

Field	Description
Bundled amount	The bundled amount reimbursement method to which the bundled amount category applies
Episode Category	The episode category to which the bundled amount category applies

This linkage of bundled amount to episode category makes it possible to setup provider pricing clauses such that for a given episode definition, one provider gets paid one lump sum amount for an episode and another provider gets paid per combination of episode categories e.g. for a Provider A, the episode gets priced as one lump sum amount for Hip Replacement and for provider B it is a) priced for preoperative treatments b) priced for surgery and c) priced for postoperative treatments separately.

In order to configure such provider pricing clauses, four bundled amounts must be set up:

Bundled Amount Code	Bundled Amount Description	Episode	Bundled Amount Categories	Priced on
HIPREP_ALL	Hip replacement, comprehensive bundled payment	HIPREP		Triggering
HIPREP_PREO	Hip replacement, pre op reimbursement	HIPREP	PREO	First
HIPREP_FACSURG	Hip replacement, facility and surgical reimbursement	HIPREP	FAC, SURG	Triggering
HIPREP_PAC	Hip replacement, post acute reimbursement	HIPREP	PAC	First

Provider pricing clauses are then setup as:

Provider Pricing Clauses	Reimbursement Method	Quantifier
PROV_A_HIPREP_ALL → applies to Provider A	HIPREP_ALL	$70,000
PROV_B_HIPREP_PREO → applies to Provider B	HIPREP_PREO	$15,000
PROV_B_HIPREP_FACSURG → applies to Provider B	HIPREP_FACSURG	$35,000
PROV_B_HIPREP_PAC → applies to Provider B	HIPREP_PAC	$20,000

Here, the episode for provider A is priced on the triggering line at $70,000 and for Provider B it is priced at (1) $15,000 on the first included claim line of the category PREO, (2) $35,000 on the triggering claim line and (3) $20,000 on the first included claim line of the category PAC.