Claims Advice Service

Claims Advice Service is a REST based API exposed by Claims to check if a specific medical service is contracted and/or covered based on the configuration in Claims, without processing an actual claim.

Claims Advice Service

The path where this service be available will be:

http://<HOST_ADDRESS>:<HOST:PORT>/<CONTEXT_ROOT>/claimsadviceservice

The service will expose a POST method. "adviceResponseDefinitionCode" can be passed in as a Accept Header parameter to specify which dynamic logic on the claims side should be picked up to create the response. If there is no header parameter passed in, a default definition is picked up. In case no defaults are defined, an error message is given back with status code 406 (Not Acceptable).

The following fields are configured to set up an advice response definition:

Field	Description
Code	Uniquely identifies the advice response definition
Description	The description of the advice response definition
Response Mapping	The dynamic logic that is executed to generate the response message for the external system
Default?	Indicates that this is the default advice response definition (only one advice response definition can be marked as default)

The contract for the service will be as follows:

Request Structure: AdviceRequest

Id	Attribute	Type	Required
1	procedure: (flexCodeDefinitionCode and code)	String/String	Yes
2	serviceDate	Date	Yes
3	insurableEntity: (code and type)	String/String	Yes
4	productCodes	List<String>	Yes, if coverage information is required
6	locationProvider: (flexCodeDefinitionCode and code)	String/String	No
7	serviceProvider: (flexCodeDefinitionCode and code)	String/String	No
8	diagnosis: (flexCodeDefinitionCode and code)	String/String	No
9	specialtyCode	String	No
10	modifierCode	String	No
11	locationTypeCode	String	No
12	contractReferenceCode	String	No
13	parameters	Map<String,String>	No

Oracle Health Insurance recommends that the code, usage name and resource name of an insurable entity type is kept similar across Oracle Health Insurance components.

Sample Structure:

{
   "procedure"         : {
                           "flexCodeDefinitionCode" : "01",
                           "code"                   : "091"
                         },
   "productCodeList"   : ["GOLD" , "DENTAL"],
   "serviceDate"       : "2017-01-01",
   "locationTypeCode"  : "14",
   "diagnosis"         : {
                           "flexCodeDefinitionCode" : "ID-SAMPLE",
                           "code"                   : "814"
                         },
   "locationProvider"  : {
                           "flexCodeDefinitionCode" : "AL",
                           "code"                   : "51233444"
                         },
   "insurableEntity"   : {
                           "code" : "19000123",
                           "type" : "servicedMember"
                         },
   "parameterList"     : [
                          {"key" : "authorizationForm",  "value" : "CHRONICMEDAUT"},
                          {"key" : "providerGroupScope", "value" : "IN"           }
                         ]

}

Response Structure

The return type of the service will be a structure returned by the dynamic logic. It can be a XML/JSON or a plain string depending upon the dynamic logic construction.

Service Details

The service logic will be to perform a basic selection based on the incoming parameters and to pass on the results to the configured dynamic logic on the advice response definition.

AdviceService Selection Logic

Benefits

The advice service will perform a fixed query based on the input parameters to fetch product benefit specifications. It will perform the selection for Coverage, Waiting Period and Authorization type of Product Benefit Specification. The following considerations will be taken:

Attribute	Selection Logic	Exclude
Product	Must match the product code (s) in the request	N
Enabled	Yes	N
Type	Types: coverage, waiting period or authorization	N
Start Date and End Date	The service date should be between the start date and end date	N
Claim Form Type	Excluded	Y
Procedure Group 1, 2, 3 + In/Not In	Must (or none may) contain the requested procedure code	N
Procedure Condition	Excluded	Y
Diagnosis Group + In/Not In	Must (or none may) contain the requested diagnosis code	N
Diagnosis Condition	Excluded	Y
Modifiers + In/Not In	One must (or none may) match the requested modifier code	N
Specialties + In/Not In	One must (or none may) match the requested specialty code	N
Location Type + In/Not In	One must (or none may) match the requested location type code	N
Age from / to	If insurableEntity is that of a person, then the person’s age on the service date should be between these parameters. If this criterion is specified; the product benefit specification is not selected for evaluation for a serviced object.	N
Gender	If insurableEntity is that of a person, then the person’s gender should be the same. If this criterion is specified; the product benefit specification is not selected for evaluation for a serviced object.	N
Product Provider Group Scope	Must include the requested provider (either location or servicing) if the Scope is IN, and must not include both of them (if provided) if the Scope is OUT.	N
Specific Provider Group Scope	Must include the requested provider (either location or servicing) if the Scope is IN, and must not include both of them (if provided) if the Scope is OUT.	N
Country Region/Country Region Group	Excluded at all levels	Y
Case Definition	Excluded	Y
Benefit Provider	Excluded: Instead use location or service provider	Y
Other conditions	Excluded	Y

No validations will be made or exceptions will be raised if multiple product benefit specifications are found with same priority.

The result of the selection will be a Map of selected ProductBenefitSpecifications based on the type of the specification:

"WaitingPeriod" : List<ProductBenefitSpecification>,
"Authorization" : List<ProductBenefitSpecification>,
"Coverage"      : List<ProductBenefitSpecification>

Pricing

The advice service will perform a fixed query based on the input parameters to fetch provider pricing clauses. Provider Pricing Clause of type Fee Schedule, Charged Amount and Simple Adjustment Rule will be picked up. The following considerations will be made for attributes on Provider Pricing Clause.

Attribute	Selection Logic	Excluded
Individual Provider	Match either the location or the service provider parameter	N
Organization Provider	Match either the location or the service provider parameter	N
Provider Group	Contain either the location or the service provider parameter	N
Procedure Group 1,2,3 + in / not in	One (or none) must contain the procedure code parameter	N
Product Category	Evaluate all fixed product dimensions (product family, funding arrangement, product line etc)	N
Age from/to	If insurableEntity is that of a person, then the person’s age on the service date should be between these parameters. If this criterion is specified; the provider pricing clause is not selected for evaluation for a serviced object.	N
Enabled	Yes	N
Location Type Group + In/Not In	One must (or none may) match the requested location type code	N
Procedure Condition 1,2,3	Excluded	Y
Classification Scheme	Excluded	Y
Claim Classification	Excluded	Y
Claim Line Classification	Excluded	Y
Restrict to Method Usage	ChargedAmount and FeeSchedule.	N
Ind Exempt	Excluded	Y
Contract Reference	Must match the contract reference	N
Priority	Excluded	Y
Start Date and End Date	The service date should be between the start date and end date	N
Case Definition	Excluded	Y
Provider Category	Excluded	Y
Specificity of Provider	The dimensions that are included in the selection are also evaluated based on specificity of the provider	N

Further restrictions on ReimbursementMethod types and PricingRules will be applied as under:

Fee Schedule and Fee Schedule Line

Attribute	Selection Logic	Exclude
Header Line condition	Excluded	Y
Header Modifiers + In/Not In	One must (or none may) match the requested modifier code	N
Enabled	Yes	N
Procedure 1, 2, 3	One must match the procedure code parameter	N
Procedure group 1, 2, 3	One must include the procedure with matching code	N
Modifiers	One must match the requested modifier code	N
Classifications	Excluded	Y
Ind provider	Match or the location or the service provider parameter	N
Org provider	Match or the location or the service provider parameter	N
Contract Reference	Must match the contract reference	N
Provider group	Contain or the location or the service provider parameter	N
Start Date and End Date	The service date should be between the start date and end date	N
Specificity	Excluded	Y

Charged Amount

Attribute	Selection Logic	Exclude
Procedure group 1,2,3 + In/Not In	One (or none) must contain the procedure code parameter	N
Procedure condition 1,2,3	Excluded	Y
Modifiers + In/Not in	One (or none) must match the modifier code parameter	N
Classification	Excluded	Y

Simple Adjustment Rules

	Selection or Application Logic	Exclude
Procedure group 1, 2, 3 + In/Not In	One must (or none may) match the procedure code parameter	N
Diagnosis group + In/Not In	One must (or none may) match the requested diagnosis code	N
Modifiers + In/Not In	One must (or none may) match the requested modifier code	N
Reimbursement Method Type	Charged Amount or Fee Schedule	N
Classification	Excluded	Y

In case location and service provider are both provided in the request, the following applies:

• If both are of type Individual Provider, then only the service provider will be used to match the Provider Pricing Clause/Fee Schedule individual provider value.

• If both are of type Organisation Provider, then only the location provider will be used to match the Provider Pricing Clause/Fee Schedule organisation provider value.

The result of the selection will be a Map of selected Provider Pricing Clause based on the type of the Reimbursement Method or Pricing Rule:

"FeeSchedule"   : List<ProviderPricingClauseData>,
"ChargedAmount" : List<ProviderPricingClauseData>,
"Adjustment"    : List<ProviderPricingClauseData>

ProviderPricingClauseData

This structure will contain the following attributes:

• providerPricingClause

• pricingRule: This will point to SimpleAdjustmentRule, if the selected ProviderPricingClause is pointing to SimpleAdjustmentRule, else will be null.

• reimbursementMethod: This will point to ChargedAmount or FeeSchedule, if the selected ProviderPricingClause is pointing to ChangedAmount or FeeSchedule, else will be null.

• feeScheduleLineList: This will contain the selected fee schedule lines based on the above selection logic, if the selected ProviderPricingClause is pointing to FeeSchedule, else will be an empty list.

Errors

Error	Message
CLA-IP-ADVI-001	Procedure with code {code} and flex code definition {code} is unknown
CLA-IP-ADVI-002	Insurable entity {usageName} with code {code} is unknown
CLA-IP-ADVI-003	Product code {code} is unknown
CLA-IP-ADVI-004	Location provider with code {code} and flex code definition {code} is unknown
CLA-IP-ADVI-005	Service provider with code {code} and flex code definition {code} is unknown
CLA-IP-ADVI-006	Diagnosis with code {code} and flex code definition {code} is unknown
CLA-IP-ADVI-007	Specialty code {code} is unknown
CLA-IP-ADVI-008	Modifier code {code} is unknown
CLA-IP-ADVI-009	Location type code {code} is unknown
CLA-IP-ADVI-010	Contract reference code {code} is unknown
CLA-IP-ADVI-011	The request is missing one or more of the required attributes

Examples

End to end examples of interactions between Authorizations and Claims can be found in the "Authorizations" page in the Authorizations chapter of the Operations Guide (see scenarios for more information).

Authorization

The operation in this section is protected by access restriction "claims.adviceservice IP".