Pend Reasons

This section describes external intervention rules, or, as they are often referred to, pend rules. A claim can trigger an external intervention rule at four different points in the flow. As soon as the claim pends, a workflow task event may be sent out (depending on the sort of pend it is) and the claim becomes accessible through special user interface pages that allow for the claim or its processing results to be modified.

External intervention rules are evaluated in the sequence defined on the external intervention rule, within the applicable step.

An external intervention rule can pend a claim for manual change, manual pricing, manual pricing adjudication, manual benefits or for manual adjudication. If pended for pricing, the operator can modify the allowed amounts of claim lines. If pended for benefits, the operator can modify and recalculate the applied benefits. If pended to manual pricing adjudication or manual adjudication, the operator needs to manually decide to accept or deny the claim.

If the pend reason has the reprocess indicator checked, the claim in not actually pended but reprocesses automatically. All unresolved pend reasons are removed.

Claims uses two concepts to support pends; rules and reasons. The external intervention rule describes the circumstance in which a claim pends. The pend reason describes why the claim has pended. Each external intervention rule must specify the pend reason that is attached to the claim (line) should that rule trigger. This separation allows a configuration operator to have multiple rules refer to the same pend reason. This allows a configuration operator to set up disjunctive pend conditions (that imply the same sort of pend) as separate external intervention rules rather than one single (complex) rule.

Concepts

If an external intervention rule triggers, a pend reason is attached to the specified level (claim, bill or claim line). Pend reasons have to be defined first and have the following attributes:

Pend Reason

Table 1. Pend Reason
Field	Description
Code	Identifying code
Description	Description
Priority	Numeric priority of the pend reason. The priority is sent in the workflow task start message. Thus, they can be used to differentiate between tasks of different priorities by putting them in different workflow queues.
External Code	External code which is sent in the workflow task start message.
Ind Publish Message	If checked, the pend reason and the object it is attached to (claim, bill or claim line) are included in the workflow task start message.
Ind Non Clean	If checked, attaching this pend reason to a claim marks the claim as non clean.^[1]
Ind Reattach	If unchecked, this reason is not attached, that is, does not cause the claim to pend if the claim(line)'s history shows that the same pend reason has been attached in the past. If checked, then any pend history is ignored when attaching this pend reason.
Ind Adjudication Only	If checked, this pend reason is only enforced (meaning that it needs to be resolved before the claim can be re-submitted for processing) in the Pricing Manual Adjudication status (for external benefits) or the Manual Adjudication status (for internal benefits).
Ind Reprocess	If checked, the claim is reprocessed automatically without manual intervention.
Claim Fields	Dynamic function produces a list of name value pairs that are included in the workflow message. This is specific to pend reasons for claim level external intervention rules.
Bill Fields	Dynamic function produces a list of name value pairs that are included in the workflow message.
Claim Line Fields	Dynamic function produces a list of name value pairs that are included in the workflow message. This is specific to claim line level external intervention rules.
Alternative External Text	An alternative text to be in the external output. Note that the use of placeholders is not supported.
External Text Provider	The text as presented in external output for the provider. Note that the use of placeholders is not supported.
Access Restriction	The access restriction restricting access to the pend reason.

An external intervention rule configuration consists of three different sort of fields. Some identify the rule, some are used to describe the circumstance under which a claim pends and some drive what happens when the claim actually claim pends. An external intervention rule has the following fields:

External Intervention Rule

Table 2. External Intervention Rule
Field	Description
Code	The code of the external intervention rule.
Description	The description of the external intervention rule.
Level	The level that is used to check the criteria specified in this rule, and also the level where the pend reasons is attached, should the rule trigger. This can be either the claim, the bill or the claim Line.
Step	The step in the claims processing where this rule is evaluated. These are: Manual Change Manual Pricing Manual Pricing Adjudication Manual Benefits Manual Adjudication
Sequence	The sequence in which the external intervention rules are evaluated in the applicable step.
Claim Type	The claim type to which the external intervention rule applies: Provider Claim or Restitution Claim. If this field is left empty then the rule is executed for both claim types.
Payer	If specified, the payer code on the claim should match one of the codes belonging to the specified payer.^[2]
Brand	If specified, this brand should match the brand of the claim.^[2]
Message Group	For a claim level rule, one of the claim messages should match one of the messages in the group. For a bill level rule, one of the bill messages should match one of the messages in the group. For a claim line level rule, one of the claim line messages should match one of the messages in the group.
Message Group (Pend Reason)	If one or more of the messages on the claim, bill or line (depending on this rule’s level) match a message in the message group then the claim pends. For every message that causes the claim to pend in this way, the system attaches the pend reason with the same code. If no corresponding pend reason exists, the system attaches the pend reason set on this rule.
Un-finalize Reason Group	One of the claim un-finalize reasons should match one of the unfinalize reasons in the group (irrespective of the level).
Diagnosis Group	For a claim level rule, the primary claim diagnosis should match one of the diagnoses in the group. The criterion is met if the claim primary diagnosis is part of the diagnosis group on the claim date of the claim For a bill level rule, the primary bill diagnosis should match one of the diagnoses in the group. The criterion is met if the bill primary diagnosis is part of the diagnosis group on the bill date of the claim bill. For a claim line level rule, the primary claim line diagnosis should match one of the diagnoses in the group. The criterion is met if the claim line primary diagnosis is part of the diagnosis group on the start date of the claim line
Procedure Group	One of the procedures of the claim line should match one of the procedures in the group. This criterion is restricted to the claim line level. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line
Procedure Group 2	One of the procedures of the claim line should match one of the procedures in the group. This criterion is restricted to the claim line level. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line
Procedure Group 3	One of the procedures of the claim line should match one of the procedures in the group. This criterion is restricted to the claim line level. The criterion is met if one of the claim line’s procedures is part of the procedure group on the start date of the claim line
Dynamic Logic Condition	The dynamic logic condition that is used to check the claim, bill or claim line depending on the level. If the condition evaluates as true, the claim pends.
Pend Reason	The pend reason that is attached to the appropriate level (claim, bill or claim line).
Ind Suppress When Fatal	If checked and the level is "claim", then this rule does not trigger a pend (does not attach a pend reason nor lock the claim lines) if a fatal claim message exists. If checked and the level is "bill", then this rule does not trigger a pend (does not attach a pend reason) if a fatal claim or bill message exists. If checked and the level is "claim line", then this rule does not trigger a pend (does not attach a pend reason nor lock the claim line) 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: (1) for manual change, fatal messages of the following origins are taken into account: external, manual and sanity checks (2) for manual pricing, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing and pricing no recalculation (3) for manual pricing adjudication, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing, pricing limit and pricing no recalculation (4) for manual benefits, fatal messages of the following origins are taken into account: external, manual, sanity checks, pre-pricing, enrollment, pricing, pricing limit, pricing no recalculation, payment status, pre-benefits and benefits (5) for manual adjudication, all product independent fatal messages are taken into account
Ind Lock Claim Lines	If checked on a claim level rule, then the non-replaced claim lines of the claim is locked for any changes (Ind Locked checked) when the claim is pended by this external intervention rule. If checked on a claim line level rule, then the non-replaced claim line is locked for any changes (Ind Locked checked) when it is pended by this external intervention rule. This indicator can only be checked on rules for steps Manual Pricing Adjudication and Manual Adjudication. Note that the indicator is ignored on bill level rules. See Claim Line Locking Scenarios page in the Appendices chapter of the Operations Guide for more information.
Ind Enabled	This external intervention rule is only executed when this box is checked
Ind Replace Pend Messages	This can only checked (Y) if the pend reason message group is set. If this is checked it discards the message itself as soon as it finds the pend reason with the same code. If it is unchecked it keeps the message. It is set (N) by default.

External Intervention Rule Claim Form

Table 3. External Intervention Rule Claim Form
Field	Description
External Intervention Rule	The external intervention rule for which specific claim forms are defined.
Claim Form	The form of the incoming claim.

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

Note that a rule can specify multiple fields of the claim(line) to be checked, for example, a single rule can check for the diagnoses, the procedure, the messages and the unfinalize reasons. If a single rule configures multiple fields to be checked, then the claim(line) needs to match all of them in order for that rule to trigger and the claim to pend.

Use Cases

Consider the following configuration, all for manual adjudication (MA):

Table 4. Use Cases
Step	Level	Message group	Diagnosis group	Procedure group	Condition dynamic logic	Pend reason	When fatal?
MA	Line			Reconstructive surgery procedures		Plastic surgery	No
MA	Line	Messages indicating partial auth match				Partial auth	Yes
MA	Line	Messages from the auth indicating external intervention				Auth intervention	No
MA	Claim				Covered amount over $ 10,000.00	High dollar amount	No
MA	Line		Neuromotor injury related diagnoses	PT visits		Rare diags	No

When the claims processing reaches the step to evaluate the external intervention rules for manual adjudication, each of these five rules is of the right step.

Now first all the claim level rules are evaluated (in the example the one for the high dollar amount): if the total covered amount of the claim exceeds $ 10,000.00, the pend reason 'High dollar amount' is attached to the claim.

Next all the bill level rules are evaluated (in the example none) for each bill. If all conditions hold true, then a pend reason is attached to the bill.

Then all the claim line level rules are evaluated for each claim line. The second rule (partial auth) is only evaluated when no fatal messages are attached to the claim line in question. If all conditions hold true, then a pend reason is attached to the claim line. In the example, a maximum of 4 pend reasons could thus be attached to a single claim line.

After all the rules have been evaluated, a start task message may have to be sent. If at least one pend reason with the publish message indicator checked, is attached to any of the levels, then such a message for Manual Adjudication is sent out (for more details, see the chapter on Workflow Integration Point in the Developer Guide). This message includes information about the pend reasons and the priority that has been configured.

Pend Reason Message Group Use Case

When the external intervention rule is evaluated, if the claim or claim line has one or more messages that are included in pend reason message group, then the system retrieves the pend reasons with a matching code and attaches those pend reasons and pends the claim. If the system cannot find a pend reason with a matching code, instead it attaches the pend reason that is directly attached on the external intervention rule by default. If the replace pend messages indicator is checked then the system removes all the claim or claim line messages that it successfully matched to a pend reason. This can be exemplified in the below use case:

Table 5. Pend Reason Message Group Use Case
Pend Reason Message Group	A
Messages:	X	Y
Pend Reason	X		Z (default)
Replace Pend Messages?	Yes

If the claim line comes in with message X and message Y, the claim pends because at least one message is on group A, then the pend reason X is attached. Pend reason Y cannot be found, so pend reason Z is attached instead. Message X is removed because replace indicator = Y, Message Y is not removed because it could not be matched to a pend reason.

Pend Reasons for Reprocessing

The system executes External intervention rules in the specified sequence. Whenever an external intervention rule is evaluated with a pend reason that has the reprocess indicator set to Yes, the claim is reprocessed automatically. External intervention rules with a higher sequence, or the same sequence but not evaluated yet, are skipped.

When reprocessing a claim, external intervention rules with a pend reason that has the reprocess indicator set to Yes, are ignored.

Example

Table 6. Initial Claim Processing
Sequence	Reprocess Pend Reason	Action
1	No	Evaluate and proceed to the next rule
2	Yes	Set claim status back to Initial and reprocess the claim Remove the pend reason from external intervention rule 1
3	Yes	Skip
4	No	Skip

Table 7. Reprocessing of the Claim
Sequence	Reprocess Pend Reason	Action
1	No	Evaluate and proceed to the next rule
2	Yes	Ignore
3	Yes	Ignore
4	No	Evaluate the rule

1. This indicator is not tied to any hard coded logic in the application. This indicator can be used in dynamic logic, such as a dynamic check that determines whether a claim line is within the filing limit.

2. It is not allowed to specify both a payer and a brand. Claims have a similar restriction. As a consequence, an external intervention rule that would specify both a payer and brand would never trigger.