Clean Up Pricing Results

If the claim line has been processed before, the old results may need to be discarded before a new calculation takes place.

Claim lines that are processed a second time still have (old) calculation results attached. This step cleans up the results of claim lines that are to be re-calculated. The Locked indicator, Keep Pricing indicator, Keep Benefits indicator, the Skip Tag for Allowed and fatal messages of specific origins allows for specific lines to be excluded from re-calculation.

The clean up pricing results flow is schematically depicted by the following figure.

Clean Up Pricing Results

The first step is to check per line whether that line’s pricing results remain untouched or whether they are going to be re-calculated.

Lines That Are Not Re-Calculated

Fatal Messages

Claim lines with a product independent fatal message of origin MANUAL, EXTERNAL, SANITY CHECKS, PRE-PRICING, ENROLLMENT or RESERVATION (attached to the line itself, the bill or claim to which the line belongs) are not going to be re-calculated. The pricing results on the claim lines are kept.

Locked, Keep Pricing, Keep Benefits, or Skip Tag for Allowed

Claim lines with a checked Locked indicator, checked Keep Pricing indicator, checked Keep Benefits indicator and/or a Skip Tag for Allowed are not going to be re-calculated. The pricing results on the claim lines are kept.

Lines That Are Re-Calculated

The results from an earlier pricing calculation are removed:

  • Claim, bill and claim line pricing messages (that is, messages with origin PRICING, PRICING LIMIT or PRICING NO RE-CALCULATION)

    • Note that claim and bill messages are only removed if at least one non-replaced and non-locked claim line has unchecked 'Keep Pricing' and 'Keep Benefits' indicators

  • The allowed amount (including the currency) of the claim line is cleared (set to null)

  • The allowed number of units of the claim line is cleared (set to null)

  • The claim line provider pricing clauses are removed

  • The indicator "Manual Pricing" on the claim line is unchecked

  • The preliminary provider limit consumption is removed [1][2]

1. It is possible that preliminary consumption exists if the claim has been rerouted from the status MANUAL PRICING ADJUDICATION, MANUAL BENEFITS or MANUAL ADJUDICATION to the status CHANGE or MANUAL PRICING. Note that when a preliminary provider limit consumption is deleted, the counter period is also removed if no consumption remains under that period and the counter is also removed if no consumptions exist at all under that counter.
2. Preliminary consumption for a quote claim that is unfinalized and being re-processed