Case Recognition Scenario
Sequence | Procedure | Benefits Provider | Person | Comment |
---|---|---|---|---|
1 |
A2341 |
Dr Jackson (OON) |
John Doe |
Ancillary to case ABC |
2 |
B6687 |
Dr Smith (IN) |
John Doe |
Not case related |
3 |
C9348 |
Dr Smith (IN) |
John Doe |
Primary case ABC |
4 |
D3921 |
Dr Jackson (OON) |
John Doe |
Ancillary to case ABC |
Dr Jackson is not in a product provider group. Dr Smith is.
Person John Doe is subscribed to the BASE product on all service dates in the claim.
Product Benefit Specifications
Product | Code | Proc Grp Contains | Product Netw | Case Def | Regime |
---|---|---|---|---|---|
BASE |
B1 |
A2341 and D3921 |
IN |
ABC |
Covered in Full |
BASE |
B2 |
A2341 and D3921 |
OON |
ABC |
Coinsurance 20 |
BASE |
B3 |
A2341 |
IN |
Copay 20 |
|
BASE |
B4 |
B6687 |
IN |
Covered in Full |
|
BASE |
B5 |
B6687 |
OON |
Copay 20 |
|
BASE |
B6 |
C9348 |
EITHER |
ABC |
Covered in Full |
Case Definition
Recognition rules for ABC. If the primary line is IN, then out of network ancillary lines treated as IN as well.
Type | Proc Grp Contains |
---|---|
Primary |
C9348 |
Ancillary |
A2341 and D3921 |
Benefit Selection Phase 1
The lines are processed in sequence 1,2,3,4.
Line 1: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B1, B2 and B3. Because this set contains at least one specification with a case definition (two to be exact, B1 and B2) OHI Claims continues to evaluate if line 1 qualifies as a primary line.
Before checking if line 1 qualifies as a primary line, it needs to be made sure that line 1 does not also qualify as an ancillary line to an already existing case, as this takes precedence. First, it is checked if line 1 can be attached to an existing case ABC; which it can not. Second, it is checked if line 1 is recognized as primary; again, it does not. Line 1 is marked as possible ancillary. B1, B2 and B3 are marked as possible candidates for line 1.
Line 2: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B4 and B5. Neither benefit specification refers to a case definition, so line 2 continues with the evaluation of the product provider group status. The result is that B4 remains as the only candidate for line 2.
Line 3: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B6. Since B6 refers to a case definition, so OHI Claims continues by evaluating if line 3 is a primary line.
Before checking if line 3 qualifies as a primary line, it needs to be made sure that line 3 does not also qualify as an ancillary line to an already existing case (since this takes precedence). First, it is checked if line 3 can be attached to an existing case ABC; which it can not. OHI Claims then checks to see if line 3 qualifies as primary; which it does. Line 3 creates a new case. B6 is marked as the only possible candidate for line 3.
Line 4: the selection on procedures, diagnosis, person age, person gender and dynamic conditions leaves only B1 and B2. Because this set contains at least one specification with a case definition (in fact both specifications) OHI Claims continues to evaluate if line 4 qualifies as a primary line.
Before checking if line 4 qualifies as a primary line, it needs to be made sure that line 4 does not also qualify as an ancillary line to an already existing case (since this takes precedence). First, it is checked if line 4 can be attached to an existing case ABC; which it can. Because this takes precedence, it’s no longer necessary to check if line 4 would start a case. Line 4 is marked as possible ancillary. B1 and B2 are marked as possible candidates for line 4.
On overview of the results after phase 1:
Claim | Results | ||||
---|---|---|---|---|---|
Sequence |
Procedure |
Benefits Provider |
Person |
Possible Ancillary? |
Ben Specs |
1 |
A2341 |
Dr Jackson (OON) |
John Doe |
Yes |
B1, B2 and B3 |
2 |
B6687 |
Dr Smith (IN) |
John Doe |
No |
B4 |
3 |
C9348 |
Dr Smith (IN) |
John Doe |
No |
B6 |
4 |
D3921 |
Dr Jackson (OON) |
John Doe |
Yes |
B1 and B2 |
Benefit Selection Phase 2
Phase two only processes lines that are possible ancillaries to an existing case. This means line 1 and 4.
Line 1: Line 1 starts with the selection from phase 1, that is, B1, B2 and B3. First, OHI Claims attempts to attach line 1 to an existing case. The case created by line 3 in phase 1 is found and line 1 qualifies as an ancillary line to that case.
The next step is that the remaining benefit specification is filtered in context of case definitions: because B3 does not specify a case definition, it is eliminated.
The last filter is in the context of the provider group status. Because line 1 is part of a case of definition ABC, it is treated as IN given that the primary line (line 3) is IN. Therefore, benefit specification B2 is eliminated. Only B1 remains.
Line 4: Line 4 starts with the selection from phase 1, that is, B1 and B2. First, OHI Claims attempts to attach line 4 to an existing case. The case (of definition ABC) created by line 3 in phase 1 is found and line 4 qualifies as an ancillary line to that case.
The next step is that the remaining benefit specification is filtered in context of case definitions: both B1 and B2 specify case definition ABC, neither is eliminated.
The last filter is in the context of the provider group status. Because line 1 is part of a case of definition ABC, it is treated as IN given that the primary line (line 3) is IN. Therefore, benefit specification B2 is eliminated. Only B1 remains.
On overview of the results after phase 2:
Claim | Results | |||
---|---|---|---|---|
Sequence |
Procedure |
Benefits Provider |
Person |
Ben Specs |
1 |
A2341 |
Dr Jackson (OON) |
John Doe |
B1 |
2 |
B6687 |
Dr Smith (IN) |
John Doe |
B4 |
3 |
C9348 |
Dr Smith (IN) |
John Doe |
B6 |
4 |
D3921 |
Dr Jackson (OON) |
John Doe |
B1 |
After phase 2, the evaluation of the regimes can start.