Reservation Regimes

Sometimes the provider has to obtain upfront approval. Such an approval (referred to as a reservation) is very much like the actual claim, that is, the same level of specificity. To configure the need for this upfront approval, benefit specifications referencing a reservation regime must be used.

A reservation regime specifies the function that is used to match a claim line to a reservation line plus messages that are applied to a claim line to clarify what happened, for example, in case no reservation line is found, or when the found reservation line is denied.

Reservation Regime

A reservation regime has the following fields:

Table 1. Reservation Regime
Field	Description
Code	Identifier for this regime.
Description	Descriptor of this regime.
Indication active	If unchecked, no more references to this regime may be made.
Indication amount ceiling	If checked, then the mutual amount consumptions of the actual claim lines that use a reservation line cannot exceed the amount on that reservation line: the reserved amount consumption acts as a ceiling. If unchecked, the mutual amount consumptions of the actual claim lines can exceed the amount on the reservation line up to the maximum of the limit. The ceiling indicator applies to provider limit rules and cover withhold rules of type cover; it does not apply to cover withhold rules of type withhold and in the evaluation of regime counters.
Indication (number of units) ceiling	If checked, then the mutual number of units consumptions of the actual claim lines that use a reservation line cannot exceed the number of units on that reservation line: the reserved number of units consumption acts as a ceiling. If unchecked, the mutual number of units consumptions of the actual claim lines can exceed the number of units on the reservation line up to the maximum of the limit. The ceiling indicator applies to provider limit rules and cover withhold rules of type cover; it does not apply to cover withhold rules of type withhold and in the evaluation of regime counters.
Indication release	If checked, the application releases the remainder (if any) of the reserved limit consumption after matched claim line has been processed If unchecked, the application retains the remainder (if any) of the reserved limit consumption after matched claim line has been processed, so that it remains reserved for future claim lines
Reservation Line Matching Function	The function dynamic logic that is applied when a claim line requires a reservation line. It returns one reservation line or none at all.
Not Met Message	The message that is attached to the actual claim line when a reservation line is used, and the total consumption after processing the actual claim line still leaves room.
Met Message	The message that is attached to the actual claim line when a reservation line is used and the total consumption after processing the actual claim line exactly matches the reserved quantity.
Met And Exceeded Message	The message that is attached to the actual claim line when a reservation line is used but its reserved quantity was insufficient for the consumption of the actual claim line.
Exceeded Message	The message that is attached to the actual claim line when a reservation line is found, but cannot be used at all because it is already used up fully.
Not Found Message	The message that is attached to the actual claim line when a reservation line is not found.
Denied Message	The message that is attached to the actual claim line when a reservation line is found, but its status is Denied.
Exceeded Label	The label that is used when the reservation acts as the most restrictive in capping a consumption for the actual claim line.

Reservation Regime Messages

The messages attached to a reservation regime can access the following placeholder values:

The amount or number counted under the reservation line
The amount or number of the reservation line
The code of the reservation
The code of the reservation line
The start date of the reservation line
The consumed count on the reservation line after the claim line
The unconsumed count on the reservation line after the claim line
The amount or number by which the claim line exceeds the reservation line
The code of the reservation regime

The following applies to placeholders 1, 2, 6, 7 and 8: whenever an amount is shown, it is postfixed by a space and the appropriate currency display code

Note that for some messages these placeholder values may be empty as they do not apply in the situation where the message is attached. For example, when no reservation line is found at all, placeholder values 1 through 8 are not available.

Reservation Regime Coverage Label

The coverage label for exceed must have the action value 'withhold'. Its usage depends on the setting of the ceiling indicator:

if Yes, then only the reservation line acts as a maximum and the exceed label will be used in case of an exceed.
if No, then only the adjudication limit acts as a maximum and the withhold label of the cover withhold category will be used in case of an exceed.

Reservation Line Matching

In the Reservation Line Matching dynamic logic function the payer specifies the criteria Claims has to use to search for matching reservation lines, that is, the time validity of the reservation line.

The signature of the dynamic logic function is such, that the list of possible reservation lines is already pre-filtered so that the serviced member on the reservation line and the services member on the claim line match.

Only one (or none) reservation line can be returned.