Procedures

Oracle Health Insurance applications store each procedure in a two layer structure, that is, a procedure record and one or more procedure setting records. The reason is that the properties of a procedure may change over time. However, from a set up point of view, it is still the same procedure. Having the two layers precludes the configuration users from having to update / add procedure codes to the configuration that relies on the procedure codes (e.g. benefit specifications) every time a procedure property changes.

It is possible to group procedures in procedure groups and baskets.

Procedure

Procedure

Field	Description
Code	The code for this procedure
Description	The description of the procedure
Flex Code Definition Code	The definition to which the procedure belongs.
Start Date	The first day that this procedure can be used
End Date	The last day that this procedure can be used
Display Access Restriction	The access restriction restricting access to this procedure. See the chapter on data access restriction features in the User Access chapter in the Security Guide.

The flex code definition code is the qualifier of the procedure code. The available definitions can be part of the seeded configuration or can be setup by a configuration user. An example: a procedure with the code '30.22', the description 'Excision of vocal cords' and the procedure 'ICD-09-CM'

The combination of a procedure code and flex code definition is unique. The start date is not part of this unique key: it is not possible to have two procedure with the same code and definition, even if they are specified for different non-overlapping periods in time. The start and end data represent a condition on the usage of the procedure. For example, a claim line can only refer to a procedure if the service date is between the procedure start and end date.

Even though there can exist only a single combination of code and definition for each procedure entity, the actual attributes of the procedure that the entity represents may change over time. For this reason all attributes (with the exception of the description) are stored in a detail entity named procedure Setting. A procedure setting has the following attributes:

Procedure Settings

Field	Description
Procedure	The procedure to which this setting belongs
Age From	Minimum age for the serviced person to which this procedure may be rendered.
Age To	Maximum age for the serviced person to which this procedure may be rendered.
Gender	This procedure may only be rendered to serviced person of this gender.
Start Date	The first day that this is setting is valid
End Date	The last day that this setting is valid. If not specified, this setting is valid indefinitely as of the specified start date.

The start and end date on a procedure setting record are bounded by the start and end data on the procedure record. Exactly one setting must be time valid on each day between the start and end date of the procedure.

Whenever another record refers to a procedure, like a claim or claim line, this reference is always to a procedure record; not to a setting record. This makes it possible to change the attributes of a procedure over time, without breaking referential integrity or creating overhead setup maintenance.

Procedure Group

A procedure group represents a number of bundled procedures. The purpose of a procedure group is to support re-usability in the context of benefit and adjudication related setup. A procedure group has the following attributes:

Procedure Group

Field	Description
Code	The unique code for this group.
Description	The description for this group

The procedure group detail keeps track of which procedure belongs to which procedure group at which period in time. Procedure group details can specify a single procedure, a fixed procedure range or a free format procedure range:

• Single procedure. Specifying a single procedure means that that procedure is part of the procedure group.

• Fixed procedure range. A range can be specified by specifying a start procedure and an end procedure of the same procedure definition. This means both the start and the end procedure are part of the procedure group, as well as any other procedure with the same procedure definition and a code greater than the code of start procedure and smaller than the code of the end procedure^[1]

• Free format procedure range. A free format range can be specified by the combination of a start range, an end range and a reference to a flex code definition code^[1].

Procedure Group Detail

Field	Description
Procedure Group	The procedure group to which the specified procedure belongs.
Procedure	The procedure that belongs to the specified group. This procedure is the start procedure of the procedure range if an end range procedure is also specified.
End Range Procedure	The last procedure in the procedure range that belongs to the specified group. If not specified, only the specified (start) procedure is part of the specified group.
Start Range	The start of the free format procedure range
End Range	The end of the free format procedure range
Flex Code Definition	The flex code definition for the free format procedure range
Start Date	The first day that the procedure or procedure range belongs to the procedure group.
End Date	The last day that the procedure or procedure range belongs to the procedure group.

Notes:

• The time validity of a procedure group detail must lie within the time validity of a procedure, to preclude the possibility of illogical configuration. An update of the end date of a procedure automatically leads to an update of a procedure group detail for that procedure, if, and only if, not updating would lead to violation of the business rule. The same automatic update should take place for combination check procedures, when updating the end date of a procedure.

• The code of the "End Range Procedure" must be greater than the code of the (start) "Procedure". Otherwise, an invalid range would be specified.

• The value of the "End Range" must be greater than the value of the "Start Range". Otherwise, an invalid range would be specified.

• Either free format style is used within a single record or fixed style, but not a hybrid combination.

Examples

Consider the following procedure group:

Procedure Group

Code	Description
R_B_PRIVATE_ROOM	Room and Board Revenue Codes for Private Rooms (Medical/General and Deluxe)

Procedure Group Details

Procedure	End Range Procedure	Definition	Start Date	End Date
0110 - General		REVENUE_CODES	01/01/2012
0111 - Medical/Surgical/Gyn		REVENUE_CODES	01/01/2012
0112 - OB	0119 - Other	REVENUE_CODES	01/01/2012
0140 - General	0149 - Other	REVENUE_CODES	01/01/2012

The following table lists several procedures and whether or not they are considered to be 'in' the procedure group:

Procedure	Definition	Date[2]	In procedure group 'R_B_PRIVATE_ROOM' ?
0110 - General	REVENUE_CODES	10/12/2013	Yes, match on 1st procedure group detail.
0112 - Medical/Surgical/Gyn	REVENUE_CODES	10/12/2013	Yes, match on 3rd procedure group detail; start of range
0113 - Medical/Surgical/Gyn	REVENUE_CODES	10/12/2013	Yes, match on 3rd procedure group detail; part of range.
0149 - Other	REVENUE_CODES	10/12/2013	Yes, match on 4th procedure group detail; end of range.
0110 - General	REVENUE_CODES	01/01/2011	No, because of time validity.
0112 - Medical/Surgical/Gyn	NON_EXISTING_DEF	10/12/2013	No, definition does not match.
0120 - General	REVENUE_CODES	10/12/2013	No, not defined as single procedure nor part of any procedure range.
99201 - New patient visit	CPT_CODES	10/12/2013	No, not defined as single procedure nor part of any procedure range.

The following example contains ICD-10 examples as well as several theoretical examples, intended to demonstrate how the alphanumeric nature of procedure codes plays out for procedure ranges:

Procedure Group

Code	Description
EXAMPLE_PROC_GRP	Procedure Group to demonstrate ICD-10 and theoretical examples

Procedure Group Details

Procedure	End Range Procedure	Definition	Start Date	End Date
0210093	021009W	ICD10_PROCEDURES	01/01/2012
02100J	02104K	ICD10_PROCEDURES	01/01/2012
1	2	A_DEFINITION	01/01/2012
X0	X2	B_DEFINITION	01/01/2012

This would mean:

Procedure	Definition	Date	In procedure group 'EXAMPLE_PROC_GRP' ?
0210098	ICD10_PROCEDURES	10/12/2013	Yes, match on 1st procedure group detail; part of range.
02100A3	ICD10_PROCEDURES	10/12/2013	No, not defined as single procedure nor part of any procedure range.
021009	ICD10_PROCEDURES	10/12/2013	No, not defined as single procedure nor part of any procedure range.
02100JF	ICD10_PROCEDURES	10/12/2013	Yes, match on 2nd procedure group detail; part of range.
02104K3	ICD10_PROCEDURES	10/12/2013	No, not defined as single procedure nor part of any procedure range.
01	A_DEFINITION	10/12/2013	No, not defined as single procedure nor part of any procedure range.
1000	A_DEFINITION	10/12/2013	Yes, match on 3rd procedure group detail; part of group.
2000	A_DEFINITION	10/12/2013	No, not defined as single procedure nor part of any procedure range.
X10	B_DEFINITION	10/12/2013	Yes, match on 4th procedure group detail; part of group.
X10.1	B_DEFINITION	10/12/2013	Yes, match on 4th procedure group detail; part of group.
X	B_DEFINITION	10/12/2013	No, not defined as single procedure nor part of any procedure range.

Evaluation of a free format range instead of a fixed range works in similar vein: all procedures that have a flex code definition code as specified with a procedure code that is greater than or equal to the start range and less than or equal to the end range, evaluate to true.

Basket

Baskets are pre-configured templates that are used to authorize certain medical procedures. A basket has the following attributes:

Field	Description
Code	The unique code for this basket
Description	The description for this basket
Currency	The currency for all amount fields in the basket details

A basket has details representing time valid existences of procedures in a basket. A basket detail has the following attributes:

Field	Description
Procedure	The procedure that is authorized
Renewal Reference	Specifies the as-of date that is used to determine which period applies for the basket detail limit. The following as-of dates can be specified: After Start of Calendar Year - in short: Calendar Year. The first period starts at January 1st of the year of the service. After First Claim - in short: First Claim. The first time the period starts at the service date (claim line start date). Because claims need not come in the logical order (oldest first), the periods possibly need to be rearranged as more claims come in. After First Claim (irregular periods) - in short: First Claim Irregular. Same as the First Claim reference, with the difference that the periods are irregular. If no renewal reference is specified, this means that the basket detail limit actually has no fixed period and therefore the counter period for such a basket detail limit doesn’t refer to a time period: it just acts as a placeholder for all consumption.
Renewal Period	The length of the renewal period (must be specified in combination with a renewal reference)
Renewal Period Unit of Measure	The unit of measure (Day, Month or Year) for the renewal period length (must be specified in combination with a renewal reference)
Authorized Amount	The authorized amount for the procedure
Authorized Amount Currency	The currency of the authorized amount; it will automatically be set to the currency that is specified on the basket
Authorized Units	The authorized units for the procedure
Authorized Service Days	The authorized service days for the procedure
Start Date	The start date of the basket detail
End Date	The end date of the basket detail

Note that basket details have no unique key. This makes it possible to create multiple basket details for the same basket and procedure that have time overlap, for example when wanting to specify that a certain drug is authorized for 12 units per year, but with a maximum of 1 unit per month. In this scenario the Authorization Detail Matching dynamic logic function (see Dynamic Logic implementation guide for more information) should return both authorization basket details, which will result in both of them being evaluated to check if they can be consumed.

---

1. Note that procedure code is a text field, not a numeric field. Determining whether a procedure code is greater than the start procedure and smaller than the end procedure of a range, is done by character string comparison. See examples below.

2. Note that the date that is used to determine whether a procedure is part of a procedure group is context dependent. E.g. in pricing the price input date is (mostly) used but for benefits the claim line start date is used.