Provider Limit Counter Integration Point

The Provider Limit Counter Integration Point enables external adjudication engines to submit increments and decrements to provider limits.

Operations

This specific API supports the following operations

POST	/providerlimitconsumptions writes consumption on a counter.

Rules

Uniqueness

A provider limit counter is uniquely identified by the combination of references to the provider, the person, the procedure, the contract reference, the claim and the provider limit rule. It also has a unique technical identifier, the counter id.

Create or Update Behavior

The Counter

• If the request message specifies a counterId, the API selects that provider limit counter.

• If the request message does not specify a counterId, the API selects the provider limit counter that matches the unique combination of references.

• If the API does not find a matching counter, it creates a new counter.

The Limit Counter Periods and Limit Counter Consumptions

For a detailed explanation on how the application matches or creates counter periods, and creates provider limit consumptions, please see Evaluation of Counters and Counter Periods.

• This integration point does not set the maximum amount, the maximum number, or the maximum service days of provider limit consumptions on the consumptions it creates.

• This integration point always finalizes the provider limit consumptions it creates.That is, it sets the preliminary indicator to unchecked and sets the transaction date-time to the system date and time.

Submitting Consumption on an Oracle Health Insurance Claim

This integration point does not support submitting provider limit consumptions to an Oracle Health Insurance claim.

Information Must Match the Limit Type

• The request must contain information that matches the limit rule type of the providerLimitRule.

  • amount{} only allowed for type Amount, numberOfUnits only allowed for type Number, for type Service Days serviceDate must be filled and amount and numberOf UNits must be empty.

  • Withdrawn indicator is only allowed for type service days.

Currency

• If the request does not provide a currency code for amount type limits, it is derived.

  • If the limit counter does not exist yet, or it exists without any limit counter periods, the API creates the consumption with the default currency code.

  • If the API finds a limit counter period that the consumption counts towards (based on the search as specified here), then the API creates the consumption with the _current amount currency code of the provider limit counter period.

  • If the API does not find a limit counter period that the consumption counts towards, but other limit counter periods do exist for the applicable provider limit counter, then the the API creates the consumption with the current amount currency code of the most recent counter period.

Request Message

The system accepts the provider limit consumption request message in the following format:

Provider Limit Consumption

{

   "description" : "",
   "serviceDate" : "",
   "numberOfUnits" : "",
   "withdrawn" : "",
   "contractReferenceCode: "",
   "counterId:""
   "<insurableEntityType.usageName>" : {
      "code" : "",
   }
   "amount" : {
      "currency" : "",
      "value" : ""
   },
   "provider" : {
      "code" : "",
      "flexCodeDefinitionCode" : ""
   },
   "procedure" : {
      "code" : "",
      "flexCodeDefinitionCode" : ""
   },
    "providerLimitRule" : {
      "code" : ""
   }
}

Authorization

The IP is protected by "writeproviderconsumptiononline IP" access restriction.

Response Messages

When creating the consumption successfully, HTTP status code '201: Created' is returned. Additionally, the response will set a HTTP Location header to point to the generic HTTP API representation of the created consumption.

Batches

This integration point does not support the handling of multiple requests ('File Based Import') in one go.

Error Messages

The following error messages that are specific to the provider limit counter integration point interface may be returned in the response messages:

Table 1. Messages

Code	Severity	Message
CLA-IP-PLCN-001	Fatal	Provider Limit Rule code {code} is unknown
CLA-IP-PLCN-002	Fatal	Provider identified by code {code} and flex code definition code {code} is unknown
CLA-IP-PLCN-003	Fatal	Either amount or number should be specified unless the limit type is service days (in which case both amount and number should be left blank)
CLA-IP-PLCN-004	Fatal	It is not possible to write consumption to a limit related to a claim
CLA-IP-PLCN-006	Fatal	Withdrawn consumption only allowed if the limit type is service days
CLA-IP-PLCN-007	Fatal	Insurable entity identified by code {code} and type {code} is unknown
CLA-IP-PLCN-008	Fatal	Contract reference code {code} is unknown
CLA-IP-PLCN-009	Fatal	Procedure identified by code {code} and flex code definition code {code} is unknown
CLA-IP-PLCN-010	Fatal	Counter identified by id {id} is unknown

In addition, this integration point may return functional business rule messages as well as the standard messages related to dynamic fields and dynamic records. Refer to the Response Messages for more information.