Provider Limit Counters Model

Provider Limit Counters keep track of the quantity of reimbursed services with the purpose of capping the reimbursement as soon as the specified maximum has been reached. For example, a physical therapist may be limited to a maximum reimbursement of $80 dollars per person, per day. Thus, if a physical therapist charges $100 for a person on one day, the allowed amount is capped to $80.

Provider Limits are applied during the pricing of claim lines. Provider Limits calculation is not influenced by benefits calculation. However, because Provider Limits cap the allowed amount and allowed number of units, they work through to benefits calculation, as the input amount for the benefit calculation is typically the allowed amount and the allowed number of units as determined by the pricing calculation.

Each limit consists of two parts: a limit category and a limit rule. The limit category defines the behavior of a limit, such as whether it operates on the amount, number of units or number of service days. The limit rule, a type of pricing rule, points to a limit category and can be used as a building block for provider pricing clauses. The limit rule also represents the actual "bucket" for a limit’s increments, that is, limit consumption is counted per applied limit rule.

The limit’s maximum, that is, the $ 80 of the example above, is specified in the limit heights or on the provider pricing clause which points to the limit rule.

Provider Limit Category

A provider limit category has the following fields:

Table 1. Provider Limit Category
Field	Description
Code	The unique code of the provider limit category.
Level	The level at which the limit operates: Per individual provider Per organization provider Per combination of individual and organization provider Per provider contract (i.e. per contract reference) Across all providers and provider contracts
Across insurable entities indicator	Do the provider limit rules of this category count across insurable entities?
Type	The unit on which the limit operates: amount, number of units, number of service days.
Reference	Specifies the as-of date that is used to determine which period applies. The following as-of dates can be specified: After Start of Calendar Year - in short: Calendar Year. The first period starts at January 1st of the year of the pricing date. After Date of Insurable Entity- in short: Insurable Entity. For serviced person - The first period starts at the date of birth of the person. For serviced object - The first period starts as of the reference date of the object Around Treatment - in short: Treatment The first period starts at (the price input date minus the provider limit category period) plus one day and ends at the price input date. The second period starts at the (price input date minus the provider limit category period) plus two days and ends at the price input date plus one day. So forth, periods are set out until the last period that ranges from the price input date unto and including (the price input date plus the provider limit category period) minus one day. However, if at any point the end date surpasses the system date, the setting out of periods stops right there. This limit actually has no fixed period and therefore the counter period for such a limit doesn’t refer to a time period: it just acts as a placeholder for all consumption. Example: Price input date is August 10th 2008 and the length of the provider limit category period is a month. Periods are then set out, the first being July 11th 2008 up to and including August 10th 2008, the last being August 10th 2008 up to and including September 9th 2008. Example: Price input date is August 10th 2009, the length of the provider limit category period is a month and today is August 17th 2009. Periods are then set out, the first being July 11th 2009 up to and including August 10th 2009, the last being July 18th 2009 up to and including August 17th 2009. After First Claim - in short: First Claim The first time the period starts at the price input date and ends at either the price input date plus the interrupt period if the limit is not maxed out by the consumption or the price input date plus the replacement period minus one day if the limit is maxed out by the consumption Then, every time a consumption is registered in an existing period that is not maxed out by the consumption, the end date is set to the latest price input date plus the interrupt period. And every time the limit is maxed out by the consumption, the end date is set to the start date of the period plus the replacement period minus one day. Because claims need not come in the logical order (oldest first), the period possibly needs to be rearranged as more claims come in. For examples, see the Provider Limit Rules Examples section of the Claims Flow chapter of the Operations Guide.
Period type	The way the limit counter periods are set out: Per renewal period This implies that the period can be set out looking at the configuration and is in that way fixed. This choice is valid in combination with reference Calendar Year, Date of Insurable Entity or Treatment. Per flexible period This implies that the period cannot be set out looking at the configuration only, but may vary when more claims come in. This choice is valid only in combination with reference First Claim.
Period length	The length of the period.
Period unit of measure	The unit of measure for the period length: days, months, years.
Interrupt period length	The length of the interrupt period.
Interrupt period unit of measure	The unit of measure for the interrupt period length: days, months, years.
Replacement period length	The length of the replacement period.
Replacement period unit of measure	The unit of measure for the replacement period length: days, months, years.
Procedure definition	Flex Code System that defines for which procedures counters should be kept. If specified, then a different counter is kept for each procedure of the specified flex code definition or for each procedure of a flex code definition within the specified flex code set. Note that if a claim line has a procedure of the specified flex code definition, a counter for that procedure will be kept regardless if the procedure was used for the selection of the provider pricing clause and provider limit rule.
Limit not met message	The message that is attached to the claim line when the limit has not been exceeded.
Limit met message	The message that is attached to the claim line when the limit has been met.
Limit met and exceeded message	The message that is attached to the claim line when the limit has been met and exceeded.
Limit exceeded message	The message that is attached to the claim line when the limit has already been exceeded.

Constraints:

Steering attributes (all except the code and the messages of the provider limit category) can no longer be changed once a counter exists that refers to a limit of that category.
Renewal provider limit categories may not have reference First Claim and the interrupt period as well as the replacement period must be unspecified; the period must be specified.
Flexible provider limit categories must have reference First Claim and the interrupt period as well as the replacement period must be specified; the period may not be specified.

Interruption periods should typically be shorter than replacement periods.

Provider limits that count per insurable entity are always counted per serviced person or object, not per family. Provider limits are counted regardless of the person’s or object’s product(s). E.g. when a person switches products, this has no influence on the balance of any provider limits that exist for the person (nor are new limit counters created).

The provider limit category allows a user to configure messages that will be attached to the claim line if the specific condition applies. The text fields of these message may contain the following placeholders:

The amount, number or service days counted under the provider limit rule (if an amount, then postfixed by a space and the currency display code of the amount)
The amount, number or service days of the provider limit rule as specified in the provider pricing clause subsequently provider limit height (if an amount, then postfixed by a space and the currency display code of the amount)
The code of the provider limit rule
The start date of the provider limit counter period
The end date of the provider limit counter period
The current count on the provider limit counter period, including consumption of the current claim line (if an amount, then postfixed by a space and the currency display code of the amount)
The limit minus the current count, including consumption of the current claim line (if an amount, then postfixed by a space and the currency display code of the amount)
- Only populated for 'not met' messages.
The amount, number of units or number of service days on the claim line with which the limit is exceeded (if an amount, then postfixed by a space and the currency display code of the amount)
- Only populated for 'met and exceeded' and 'exceeded' messages
The description of the provider limit rule

To get a clear understanding of how place holders are populated, consider the following examples:

The provider limit category is linked to a $1000 provider limit rule. The set up message text of the "Limit not met" message reads: "An amount of {0} has been counted towards the limit of {1} for the period of {3} to {4}. Currently {5} of this limit has been used and {6} is remaining." The message attached to a claim line, that counts towards (but does not exceed) the limit, reads:

"An Amount of 125.00$ has been counted towards the limit of 1000.00$ for the period of 2009-01-01 to 2009-12-31. Currently, 650.00$ of this limit has been used and 350.00$ is remaining"

The provider limit category is linked to a 10 unit limit. The setup message text of the "Limit not met" message reads: "The number of {0} units have been counted towards the {2} limit of {1} units for the period of {3} to {4}. Currently, {5} units of this limit has been used and {6} are remaining." The message attached to a claim line, that counts towards (but does not exceed) the limit, reads:

"The number of 3 units have been counted towards the HOUSE VISIT limit of 10 units for the period 2009-04-15 to 2009-06-13. Currently, 7 units have been used and 3 units are remaining"

Provider Limit Rule

A provider limit category may be referred to by one or more provider limit rules. This allows for configuration efficiency, where a provider limit category is set up once, but used in many limit rules - provided the dimensions on the rule like procedure groups and/or procedure conditions act as a differentiator. A provider limit rule has the following fields:

Table 2. Provider Limit Rule
Field	Description
Code	The code of the provider limit.
Description	The description of the provider limit.
Provider limit category	The provider limit category this provider limit refers to.
Execution moment	Is the rule executed before the reimbursement method or after the reimbursement method?
Reached action	Specifies what should happen when the limit is reached: stop or continue applying the rule.
Procedure group usage	How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group	The group with the procedures to which the rule is applied.
Procedure condition usage	How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition	The procedure condition that defines the procedures to which the rule is applied.
Procedure group 2 usage	How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 2	The second group with the procedures to which the rule is applied.
Procedure condition 2 usage	How should the second procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 2	The second procedure condition that defines the procedures to which the rule is applied.
Procedure group 3 usage	How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line.
Procedure group 3	The third group with the procedures to which the rule is applied.
Procedure condition 3 usage	How should the third procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition.
Procedure condition 3	The third procedure condition that defines the procedures to which the rule is applied.
Modifier usage	How should the modifier list be evaluated? In: When one or more of the modifiers in the list is present on the claim line. Not In: When none of the modifiers in the list are present on the claim line.
Diagnosis usage	How should the diagnosis group or condition be evaluated? In: When one or more of the diagnoses in the group or condition are present on the claim line. Not In: When none of the diagnoses in the group or condition are present on the claim line.
Diagnosis group	The group with the diagnoses to which the provider limit rule is applied.
Diagnosis condition	The diagnosis condition that defines the diagnoses to which the provider limit rule is applied.
Other condition	The condition for refinement.
Reimbursement method type usage	How should the reimbursement method type list be evaluated? In: When one of the reimbursement method types in the list is present on the claim line Not In: When none of the reimbursement method types in the list are present on the claim line.
Classification usage	How should the classification list be evaluated? In: When one of the classifications in the list is present on the claim line Not In: When none of the classifications in the list are present on the claim line.
Currency	The currency for amount fields in provider limit heights.
Message	The message that is attached to the claim line if the rule is applied.

A provider limit rule can refer to one or more modifiers:

Table 3. Modifiers
Field	Description
Provider limit rule	The provider limit rule to which the provider limit rule modifier refers.
Modifier	The modifier to which the provider limit rule modifier applies.

A provider limit rule can refer to one or more classifications:

Table 4. Classifications
Field	Description
Provider limit rule	The provider limit rule to which the provider limit rule classification refers.
Classification	The classification to which the provider limit rule classification applies.

A provider limit rule can refer to one or more reimbursement method types:

Table 5. Reimbursement Method Types
Field	Description
Provider limit rule	The provider limit rule to which the provider limit rule reimbursement method type refers.
Reimbursement method type	The reimbursement method type to which the provider limit rule reimbursement method type applies.

A provider limit rule can have heights which specify the maximum amount, number of units or service days. These heights can be overruled by the quantifier on the provider pricing clause.

Table 6. Provider Pricing Clause
Field	Description
Provider limit rule	The provider limit rule to which the provider limit height refers.
Start date	The start date of the time validity of the height.
End date	The end date of the time validity of the height.
Maximum amount	The maximum amount of the provider limit.
Maximum amount currency	The currency of the maximum amount (derived from the provider limit rule currency).
Maximum number	The maximum number of units of the provider limit.
Maximum service days	The maximum number of service days of the provider limit.

Constraints:

Either a diagnosis group or a diagnosis condition can be specified, but not both.
The diagnosis usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.
The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.
The provider limit height must specify a maximum that complies with the provider limit rule category.
The classification usage must be specified when a classification list is used and may not be specified when a classification list is not used.
The reimbursement method type usage must be specified when a reimbursement method type list is used and may not be specified when a reimbursement method type list is not used.
A reimbursement method type cannot be specified for provider limit rules that are evaluated before reimbursement method.
The procedure group usage must be specified when a procedure group is used and may not be specified when a procedure group is not used (this applies to all three procedure groups).
The procedure condition usage must be specified when a procedure condition is used and may not be specified when a procedure condition is not used (this applies to all three procedure conditions).
The execution moment must be specified for provider limit rules in units and may not be specified for provider limit rules in amounts and service days.
Provider limit height amount fields inherit the currency at provider limit level.
The provider limit rule currency can no longer be changed once a counter exists that refers to that provider limit rule.
A provider limit rule currency must be specified for type amount and may not be specified for other types.

The following table specifies the placeholder values for messages that are attached to claim lines when the provider limit rule is applied:

The code of the rule
The description of the rule
The descriptions of the procedure groups/conditions (comma separated)
The description of the diagnosis group or diagnosis condition
Modifier list
The descriptions of the reimbursement method types (comma separated)

Besides this general message, a situation specific message, as specified in the provider limit category, is also attached to the claim line.

Provider Limit Counter

A provider limit counter acts as an umbrella for both all of the consumption on a provider limit and the periods of time for a provider limit.

Table 7. Provider Limit Counter
Field	Description
Provider limit rule	The provider limit rule for which this counter is used.
Insurable entity	The insurable entity (person or object) to which this counter applies. This field is populated when the limit counts per insurable entity.
Individual provider	The individual provider to which this counter applies. This field is populated when the limit is counted per individual provider or per the combination of individual and organization provider.
Organization provider	The organization provider to which this counter applies. This field is populated when the limit is counted per organization provider or per the combination of individual and organization provider.
Contract reference	The contract reference to which this counter applies. This field is populated when the limit counts per contract reference.
Procedure	The procedure to which this counter applies. This field is populated when the limit counts per procedure.
Claim	The claim to which this counter applies. This will only be specified for claims with ignore history indicator checked, in essence leading to a counter per claim.
Version	The version of the counter (to detect concurrent use). The version is incremented when: Consumption belonging to the counter is finalized Consumption belonging to the counter is reversed Counter periods belonging to the counter are changed

Provider Limit Counter Period

A provider limit counter period shows the periods of time that are set out for a provider limit counter.

A provider limit category of period type 'Renewal' will always result in periods that can be set out just by looking at the configuration and are in that way fixed. The start date and end date for such a provider limit counter are determined based on the provider limit category period length, unit of measure and reference (date). Consider a provider limit, based on the calendar year. When a claim line counts towards such a limit, a period can be set out from January 1st up to and including December 31st of the year of the price input date. When a claim line comes in with a price input date in another calendar year, another period is created.

A provider limit category of period type 'Flexible' will lead to a period that might change when more claims come in and is in that way not fixed. For examples, see the Provider Limit Rules Examples section of the Claims Flow chapter of the Operations Guide.

Table 8. Provider Limit Counter Period
Field	Description
Provider limit counter	The provider limit counter for which this period is set out.
Start date	The start date of the period.
End date	The end date of the period.
Current amount	The current counted amount. This equals the sum of all (finalized) consumption amounts for this counter period.
Current amount currency	The currency of the current amount.
Maximum amount	The maximum amount (1) as specified in the provider pricing clause subsequently provider limit height) against which was counted on the last (finalized) consumption.
Maximum amount currency	The currency of the maximum amount.
Current number	The current counted number of units. This equals the sum of all (finalized) consumption numbers for this counter period.
Maximum number	The maximum number of units (as specified in the provider pricing clause subsequently provider limit height) against which was counted on the last (finalized) consumption.
Current service days	The current counted number of service days. This equals the sum of all (finalized) consumption service days for this counter period.
Maximum service days	The maximum number of distinct service days (as specified in the provider pricing clause subsequently provider limit height) against which was counted on the last (finalized) consumption.

Provider Limit Consumption

Provider limit counters keep track of the amount, number of units or number of service days used on a limit. A provider limit consumption represents a single increment to that counter. Consumption can originate from a pricing finalized claim, from a finalized claim or it can be entered in the 'Provider Limit Counters' page. Consumption originating from a claim line is referred to as internal consumption, consumption registered through the 'Provider Limit Counters' page is referred to as external consumption.

A provider limit consumption can represent a negative number of units or amount. Negative consumption can be registered through the 'Provider Limit Counters' page. The internal consumptions that are created to offset the reserved consumption are also negative.

If a claim should be reprocessed and denied, the corresponding consumption is marked as reversed, i.e., the reversal date is set. An offset consumption (to offset reserved consumption) if created is also marked as reversed.

A provider limit consumption under a service day counter specifies a single date. Service day counters are different this way because they accumulate only the distinct consumption. For example, if the counter should have two consumptions for the service date 2012-04-02, it still only counts as a single service day.

It is impossible to send in a negative date, so in order to decrement a service day counter through the 'Provider Limit Counters' page, a provider limit consumption has an indicator specifically for this purpose. If the withdrawn indicator is checked, the consumption represents a decrement of the number of service days (provided that the specified date was counted in the first place).

A provider limit consumption belongs to a single provider limit counter and is never removed; consumption can be reversed or offset by a negative counterpart, but never removed.

A provider limit consumption created by a reservation claim has indicator reserved set to Y(es) and the expiration date is set to the reservation expiration date. The offset consumption (negative) that is created by the claim line that consumes the reservation also inherits the indicator reserved and expiration date from the reserved consumption.

A claim line’s provider limit consumption becomes finalized, when the claim status becomes PRICING FINALIZED or FINALIZED. Only then will the consequent increment to the provider limit counter become visible to the processing of other claim lines.

If a claim line is denied after pricing (for example in manual adjudication) then the ignored indicator on the claim line’s provider limit consumptions is checked. These consumptions will be ignored by other claim lines when the claim is recalculated in manual adjudication, and they will not finalize when the claim status becomes PRICING FINALIZED or FINALIZED. This mechanism ensures that the consumptions are not lost when a claim is reprocessed without doing the pricing step again.

For details on how the provider limit rules are selected and applied; and how the consumptions are created, refer to chapter 'Select and Apply Provider Limit Rules' in the pricing section of the Claims Flow chapter of Operations Guide.

A provider limit consumption has the following fields:

Table 9. Provider Limit Consumption
Field	Description
Provider limit counter	The limit counter towards which this consumption counts.
Counter version	The version of the counter at the time of writing this consumption.
Claim line	The claim line that generated this consumption.
Claim	The claim that the claim line that generated this consumption belongs to.
Amount	The amount by which this consumption increments the counter.
Amount currency	The currency of the amount.
Maximum amount	The maximum amount ( as specified in the provider pricing clause subsequently provider limit height or the reserved amount) against which was counted upon creation of this consumption.
Maximum amount currency	The currency of the maximum amount.
Number of units	The number of units by which this consumption increments the counter.
Maximum number of units	The maximum number of units (as specified in the provider pricing clause subsequently provider limit height or the reserved number of units) against which was counted upon creation of this consumption.
Service date	The service date for which this consumption is registered.
Maximum service days	The maximum number of distinct service days (as specified in the provider pricing clause subsequently provider limit height or the number of reserved service days; this will be always 1) against which was counted upon creation of this consumption.
Reversal date-time	The date and time on which this consumption was logically deleted (due to reprocessing).
Transaction date-time	The date and time on which this consumption became finalized.
Description	The description of the consumption. Used in case this consumption is created through the 'view provider limit counters' UI page, instead of internal claims processing.
Withdrawn indicator	If checked, this consumption decrements a service day based counter.
Preliminary indicator	Is this consumption linked to a non-finalized claim line?
Marked for reversal indicator	Is this consumption marked for reversal (through unfinalize)?
Reversed indicator	Is this consumption reversed?
Ignored indicator	If checked, this consumption will be ignored by other claim lines and it will remain preliminary when the claim is finalized.
Expiration Date	The date after which the consumption expires. The claim receipt date is used as the as-of date. If the receipt date is not specified on the claim; the entry date of the claim is used as the as-of date
Reserved Indicator	Is this consumption reserved ?

Scenarios

To get a clear understanding of how provider limit counters are set out, please refer to the Provider Limit Rules Examples section of the Claims Flow chapter of Operations Guide.