Episode Model
The system supports calculation of the price for the providers (example: hospitals and physicians) by paying for their services based on a ‘Bundled’ amount for a defined episode of care/services for a person or an object. These defined episodes of care/services are referred to as ‘Episode’ in the application.
During pricing, an Episode Definition is evaluated to identify an episode for a person or an object e.g. Hip Replacement of a person in Health Insurance, referred to as ‘Episode’ in the system. This chapter describes the model behind the configuration of an Episode Definition and Episode
The setup of Episode Definition consists of two parts:
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Episode Definition
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The evaluation of payer, provider group, contract reference and condition dynamic logic to see if the episode definition applies to the claim
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Episode Criteria The criteria for a claim line; satisfying them can lead to either of the following:
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Exclusion of the claim from being considered for that episode definition
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Starting of a new episode (as described by the episode definition) and inclusion of the claim line(s) in this new episode
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Inclusion of the claim line in an existing episode
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Episode Definition
This setup has the following fields
| Field | Description |
|---|---|
Code |
The code of the episode definition |
Description |
The description of the episode definition |
Payer |
The payer to which the episode definition belongs to |
Provider Group |
The provider group to which the episode definition belongs to |
Contract Reference |
The contract reference to which the episode definition belongs to |
Scope |
The scope of the episode definition – Claim or Claim line. Claim - All the lines on the claim, that are within the start and end date of the episode, are included if at least one line is included in the episode. Claim line - Only the lines on the claim, that are within the start and end date of the episode and satisfy the necessary criteria, are included |
Condition |
The condition dynamic logic to help drive the recognition of an episode |
Start Date |
The function dynamic logic to determine the start date for an episode |
End Date |
The function dynamic logic to determine the end date for an episode |
Initiate Internally? |
Can the system start an episode during processing or should it always be triggered externally via the Episode API? |
Result |
The claim line where the derived price for the episode should be put: on the claim line that created the episode – Existing (i.e. triggering line) or on a New line |
New Line |
The function dynamic logic to create New line |
Exclude Message |
The message that gets attached to the claim line that leads to exclusion of the claim |
Episode Identifier Function |
The function dynamic logic which returns the episode identifier |
The following list specifies the placeholder values for the message that is attached to the claim line upon applying an exclude:
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The code of the episode definition
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The description of the episode definition
Constraints:
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New line function dynamic logic must be specified when Result is opted as ‘New’.
Episode Criteria
For an episode definition, episode criteria need to be defined. This setup has the following fields
| Field | Description |
|---|---|
Type |
1) Trigger – When all the episode criteria of the type Trigger are satisfied in a claim by one or more claim lines, an episode is created and lines are included in it 2) Include - A claim line is included when it meets the criterion 3) Exclude - When a claim line meets the exclude criterion then there is no Trigger or Inclusion of any of the other lines on the claim |
Procedure Group 1 Usage |
In: When one or more of the procedures in the procedure group 1 are present on the claim line. Not In: When none of the procedures in the procedure group 1 are present on the claim line. |
Procedure Group 1 |
A claim line must have (with procedure group 1 usage specified as In) or may not have (with procedure group 1 usage specified as Not In) a procedure in the procedure group to satisfy the criterion |
Procedure Group 2 Usage |
In: When one or more of the procedures in the procedure group 2 are present on the claim line. Not In: When none of the procedures in the procedure group 2 are present on the claim line. |
Procedure Group 2 |
A claim line must have (with procedure group 2 usage specified as In) or may not have (with procedure group 2 usage specified as Not In) a procedure in the procedure group to satisfy the criterion |
Procedure Group 3 Usage |
In: When one or more of the procedures in the procedure group 3 are present on the claim line. Not In: When none of the procedures in the procedure group 3 are present on the claim line. |
Procedure Group 3 |
A claim line must have (with procedure group 3 usage specified as In) or may not have (with procedure group 3 usage specified as Not In) a procedure in the procedure group to satisfy the criterion |
Diagnosis Group Usage |
In: When one or more diagnoses in the diagnosis group are present on the claim line. Not In: When none of the diagnoses in the diagnosis group are present on the claim line. Which diagnoses are evaluated depends on 'match on'. |
Diagnosis Group |
A claim line must have (with diagnosis group usage specified as In) or may not have (with diagnosis group usage specified as Not In) a diagnosis with the sequence numbers up to and including 'Match On' in the diagnosis group to satisfy the criterion |
Match On |
The claim line diagnoses having the sequence numbers up to and including as specified in this field are applicable for evaluation in the diagnosis group Not specifying the value implies 'All' diagnoses on the claim line |
Location Type Group Usage |
In: When a location type in the location type group is present Not In: When none of the location types in the location type group is present A location type can be specified at the following levels: 1. Claim line 2. Bill 3. Claim The level claim line has highest priority, followed by bill and the claim. This implies that if a location type is specified on a claim line then that is considered for evaluation and the location type on bill and claim are ignored. |
Location Type Group |
The claim line or bill or claim level (evaluation priority in the specified order) must have (with location type group usage specified as In) or may not have (with location type group usage specified as Not In) a location type in the location type group to which this criterion applies |
Condition |
The condition dynamic logic to help drive the recognition of an episode criterion |
Episode Category |
The episode category |
Constraints:
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The procedure group 1 usage must be specified when a procedure group 1 is used and may not be specified when a procedure group 1 is not used. Same applies to procedure group 2 usage and procedure group 3 usage as well
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The diagnosis group usage must be specified when a diagnosis group is used and may not be specified when a diagnosis group is not used
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The location type group usage must be specified when a location type group is used and may not be specified when a location type group is not used
Episode Category
The episode category acts as a way of optionally distinguishing the reimbursement of parts of an episode. This is done by linking the reimbursement method 'Bundled Amount' to the episode category.
For more details on the usage of episode category and how it helps in identifying the partial payments refer to the Bundled Amount page in the Pricing Components chapter of the Configuration Guide
An episode category consist of the following fields
| Field | Description |
|---|---|
Code |
The code of an episode category |
Description |
The description of an episode category |
Episode
An episode is an umbrella entity to hold the group of claim lines that belong to the same episode of care/service.
| Field | Description |
|---|---|
Insurable Entity |
The insurable entity (person or object) for which the episode has been recognized |
Episode Definition |
The episode definition to which the episode belongs |
Episode Identifier |
This identifies the episode |
Start Date |
The date when the episode starts |
End Date |
The date when the episode ends |
Voided? |
Indicates if the episode should be recognized by the system during processing or not |
Constraints:
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Multiple episodes (irrespective of the value of indicator voided) for the same person or object, episode definition and episode identifier is prohibited
Episode Details
This entity holds the reference between the claims lines and episodes
| Field | Description |
|---|---|
Episode |
The episode to which the episode detail belongs |
Claim Line |
The claim line to which the episode detail belongs |
Type |
The type of the episode detail - Trigger, New or Include. It is derived based on the type of the episode criteria that is met by the claim line during the episode recognition process |
Priced? |
Indicates if the claim line is priced in the episode or not |
Episode category |
The episode category specified on the episode criteria that is met by the claim line during the episode recognition process |