Provider Limit Rules

Provider limit rules are used to cap the allowed number of units or the allowed amount. Below a couple of scenarios are described regarding the processing of provider limit rules.

Scenario 1

In this scenario one provider limit rule in units is set up that counts per insurable entity and organization provider.

Table 1. Scenario 1: Provider Limit Rules Configuration

Rule[1]	Category	Procedures	PPC Quantifier	Heights
PRL1	Provider level: Organization Across insurable entities: No Type: Number (before reimbursement method) Period type: Renewal Reference: Calendar Year Period: 1 year Procedure definition: Unspecified Messages: Informative	(In) Revenue Codes (range 0110 - 0159)	-	1 Jan 2010 - 31 Dec 2010: 10 units 1 Jan 2011 - 31 Dec 2011: 8 units 1 Jan 2012 - 31 Dec 2012: 5 units

Table 2. Scenario 1: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL1	MEM_001	-	ORG_PRV_001	-	-

Table 3. Scenario 1: Existing Counter Periods

Current	Max	Start Date	End Date
2	10	2010-01-01	2010-12-31

Table 4. Scenario 1: Claim

Line	Price Input Date	Procedures	Serviced Person	Price Org. Provider	Price Ind. Provider	Contract	Price Input Number Of Units
1	2010-03-03	0111	MEM_001	ORG_PRV_001	-	-	4
2	2010-03-03	0112	MEM_001	-	IND_PRV_001	-	1
3	2010-03-04	0113	MEM_001	ORG_PRV_001	-	-	3
4	2011-03-05	0114	MEM_001	ORG_PRV_001	-	-	6
5	2013-03-03	0115	MEM_001	ORG_PRV_001	-	-	1
6	2010-03-07	0115	MEM_001	ORG_PRV_001	-	-	2
7	2010-08-08	0113	MEM_001	ORG_PRV_001	-	-	1

Result

• Claim Line 1 counts towards the existing counter period of 1 Jan 2010 - 31 Dec 2010

  • The available room on the counter period is 8 units (10 minus 2)

  • The consumption on the counter for that period is 4 units

  • The limit is not met

• Claim Line 2 does not specify a price organization provider so fatal message CLA-FL-PRIC-016 is attached and the allowed number of units is set to 0

• Claim Line 3 counts towards the existing counter period of 1 Jan 2010 - 31 Dec 2010

  • The available room on the counter period is 4 units (10 minus 6)

  • The consumption on the counter for that period is 3 units

  • The limit is not met

• Claim Line 4 is set in period 1 Jan 2011 - 31 Dec 2011

  • A new counter period is created

  • The available room on the counter period is 8 units

  • The consumption on the counter for that perod is 6 units

  • The limit is not met

• Claim Line 5 is set in period 1 Jan 2013 - 31 Dec 2013

  • There is no height specified for this period so fatal message CLA-FL-PRIC-018 is attached and the allowed number of units is set to 0

• Claim Line 6 counts towards the existing counter period of 1 Jan 2010 - 31 Dec 2010

  • The available room on the counter period is 1 unit

  • The consumption on the counter for that period is 1 unit

  • The limit is met and exceeded

• Claim Line 7 counts towards the existing counter period of 1 Jan 2010 - 31 Dec 2010

  • There is no available room on the counter period

  • The limit is exceeded (the allowed number of units is set to 0)

Table 5. Scenario 1: Result

Line	Allowed Number of Units	Message
1	4	Limit not met
2	0	CLA-FL-PRIC-016
3	3	Limit not met
4	6	Limit not met
5	0	CLA-FL-PRIC-018
6	1	Limit met and exceeded
7	0	Limit exceeded

Table 6. Counter Periods After the Claim Has Been Processed

Current	Max	Start Date	End Date
10	10	2010-01-01	2010-12-31
6	8	2011-01-01	2011-12-31

Scenario 2

In this scenario one provider limit rule in amount is set up that counts per insurable entity and the combination of individual and organization provider.

Table 7. Scenario 2: Provider Limit Rules Configuration

Rule[1]	Category	Procedures	PPC Quantifier	Heights
PRL2	Provider level: Combination Across insurable entities: No Type: Amount Period type: Renewal Reference: Calendar Year Period: 6 months Procedure definition: Unspecified Messages: Informative	(In) Revenue Codes (range 0160 - 0179)	80%	1 Jan 2010 - 31 Dec 2010: $100 1 Jan 2011 - no end date: $800

Table 8. Scenario 2: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL2	MEM_001	IND_PRV_001	ORG_PRV_001	-	-

Table 9. Scenario 2: Existing Counter Periods

Current	Max	Start Date	End Date
700	800	2010-01-01	2010-06-30

Table 10. Scenario 2: Claim

Line	Price Input Date	Procedures	Serviced Person	Price Org. Provider	Price Ind. Provider	Contract	Allowed Amount[2]
1	2010-03-03	0161	MEM_001	ORG_PRV_001	-	-	$100
2	2010-02-02	0162	MEM_001	ORG_PRV_001	IND_PRV_001	-	$200
3	2010-04-03	0173	MEM_001	-	IND_PRV_001	-	$200
4	2011-05-03	0174	MEM_001	ORG_PRV_002	IND_PRV_001	-	$100

Result

• Claim Line 1 is set in period 1 Jan 2010 - 30 Jun 2010

  • The existing counter does not apply to this claim line because the price individual provider is unspecified

  • A new counter with only a reference to price organization provider and a new counter period are created

  • The available room on the counter period is $800 (80% x $1000)

  • The consumption on the counter for that period is $100

  • The limit is not met

• Claim Line 2 counts towards the existing counter period of 1 Jan 2010 - 30 Jun 2010

  • The available room on the counter period is $100 (800 minus 700)

  • The consumption on the counter for that period is $100

  • The limit is met and exceeded

• Claim Line 3 is set in period 1 Jan 2010 - 30 Jun 2010

  • The existing counter does not apply to this claim line because the price organization provider is unspecified

  • A new counter with only a reference to price individual provider and a new counter period are created

  • The consumption on the counter for that period is $200

  • The limit is not met

• Claim Line 4 is set in period 1 Jan 2011 - 30 Jun 2011

  • A new counter and counter period are created

  • The available room on the counter period is $640 (80% x $800)

  • The consumption on the counter for that period is $100

  • The limit is not met

Table 11. Scenario 2: Result

Line	Allowed Amount[3]	Message
1	$100	Limit not met
2	$100	Limit met and exceeded
3	$200	Limit not met
4	$100	Limit not met

Counters and counter periods after the claim has been processed

Table 12. Counter for Combination of IND_PRV_001 and ORG_PRV_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL2	MEM_001	IND_PRV_001	ORG_PRV_001	-	-

Table 13. Counter Period

Current	Max	Start Date	End Date
800	800	2010-01-01	2010-06-30

Table 14. Counter for ORG_PRV_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL2	MEM_001	-	ORG_PRV_001	-	-

Table 15. Counter Period

Current	Max	Start Date	End Date
100	800	2010-01-01	2010-06-30

Table 16. Counter for IND_PRV_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL2	MEM_001	IND_PRV_001	-	-	-

Table 17. Counter Period

Current	Max	Start Date	End Date
200	800	2010-01-01	2010-06-30

Table 18. Counter for Combination of IND_PRV_001 and ORG_PRV_002

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL2	MEM_001	IND_PRV_001	ORG_PRV_002	-	-

Table 19. Counter Period

Current	Max	Start Date	End Date
100	640	2011-01-01	2011-06-30

Scenario 3

In this scenario one provider limit rule in amount is set up that counts per insurable entity, per individual provider and per procedure of the revenue codes definition.

Table 20. Scenario 3: Provider Limit Rules Configuration

Rule[1]	Category	Procedures	PPC Quantifier	Heights
PRL3	Provider level: Individual Across insurable entities: No Type: Amount Period Type: Renewal Reference: Calendar Year Period: 6 months Procedure definition: REVENUE_CODES Messages: Informative	(In) Revenue Codes (range 0180 - 0189)	-	1 Jan 2010 - 31 Dec 2010: $1000 1 Jan 2011 - no end date: $800

Table 21. Scenario 3: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL3	MEM_001	IND_PRV_001	-	-	0181

Table 22. Scenario 3: Existing Counter Periods

Current	Max	Start Date	End Date
300	1000	2010-01-01	2010-06-30

Table 23. Scenario 3: Claim

Line	Price Input Date	Procedures	Serviced Person	Price Org. Provider	Price Ind. Provider	Contract	Allowed Amount[2]
1	2010-03-03	0181	MEM_001	-	IND_PRV_001	-	$100
2	2010-02-02	0182	MEM_001	-	IND_PRV_001	-	$200
3	2010-04-03	0181	MEM_001	-	IND_PRV_002	-	$1200

Result

• Claim Line 1 counts towards the existing counter period of 1 Jan 2010 - 30 Jun 2010

  • The available room on the counter period is $700 (1000 minus 300)

  • The consumption on the counter for that period is $100

  • The limit is not met

• Claim Line 2 is set in period 1 Jan 2010 - 30 Jun 2010

  • The existing counter does not apply to this claim line because the procedure is different

  • A new counter with a reference to procedure 0182 and a new counter period are created

  • The available room on the counter period is $1000

  • The consumption on the counter for that period is $200

  • The limit is not met

• Claim Line 3 is set in period 1 Jan 2010 - 30 Jun 2010

  • The existing counter does not apply to this claim line because the price individual provider is different

  • A new counter with a reference to price individual provider IND_PRV_002 and a new counter period are created

  • The available room on the counter period is $1000

  • The consumption on the counter for that period is $1000

  • The limit is met and exceeded

Table 24. Scenario 3: Result

Line	Allowed Amount[3]	Message
1	$100	Limit not met
2	$200	Limit not met
3	$1000	Limit met and exceeded

Counters and counter periods after the claim has been processed

Table 25. Counter for Combination of IND_PRV_001 and Procedure 0181

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL3	MEM_001	IND_PRV_001	-	-	0181

Table 26. Counter Period

Current	Max	Start Date	End Date
400	1000	2010-01-01	2010-06-30

Table 27. Counter for Combination of IND_PRV_001 and Procedure 0182

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL3	MEM_001	IND_PRV_001	-	-	0182

Table 28. Counter Period

Current	Max	Start Date	End Date
200	1000	2010-01-01	2010-06-30

Table 29. Counter for Combination of IND_PRV_002 and Procedure 0181

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL3	MEM_001	IND_PRV_002	-	-	0181

Table 30. Counter Period

Current	Max	Start Date	End Date
1000	1000	2010-01-01	2010-06-30

Scenario 4

In this scenario a typical DME (Durable Medical Equipment) limit will be worked through. A DME rental limit will consist of a number of restrictions like:

• maximum of 1 per month

• maximum of 4 months at a stretch

  • possibility of interrupting that period because of for example, hospital admittance, say 2 months

  • possibility of starting anew after a time period that resembles the lifetime of the medical equipment, say 5 years

Provider Limit Rules Configuration

This will be configured by splitting the restrictions into two parts. The first restriction can be met by the following provider limit rule:

Table 31. Scenario 4: Provider Limit Rules Configuration

Rule[1]	Category	Procedures	PPC Quantifier	Heights
PRL4A	Provider level: Across Across insurable entities: No Type: Number Period Type: Renewal Reference: Treatment Period: 1 month Messages: Informative	IN DME	-	1 Jan 2012 - no end date: 1 unit

For most DMEs, it is likely that the rule should also work per procedure; because this is worked out in scenario 3, it is left out here. How does the Treatment reference work? The price input date of the claim line plus or minus one month is the first day where a new claim line price input date is allowed. Plus or minus one month works as follows (assuming 1 unit is claimed each time):

Table 32. Scenario 4

Price Input Date Claim Line 1	Price Input Date Claim Line 2	OK or Deny
2013-01-01	2013-01-31	Deny
2013-01-01	2012-12-01	OK
2013-01-01	2013-02-01	OK
2013-01-31	2013-02-27	Deny
2013-01-31	2013-02-28	OK
2012-01-31	2012-02-28 (leap year)	Deny
2013-01-30	2013-02-28	OK
2013-01-29	2013-02-28	OK
2013-04-30	2013-05-30	OK
2013-04-30	2013-05-31	OK
2013-04-30	2013-03-31	Deny

Second Restriction

The second restriction leads to:

Table 33. Second Restriction

Rule	Category	Procedures	PPC Quantifier	Heights
PRL4B	Provider level: Across Across insurable entities: No Type: Number Period Type: Flexible Reference: First Claim Interrupt Period: 2 months Replacement Period: 5 years Messages: Informative	IN DME	-	1 Jan 2012 - no end date: 4 units

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. 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.

To see how this works out, consider a number of claims that come in:

Table 34. Scenario 4: Claims

Claim	Claim Line	Procedure	Serviced Person	Ind. Provider	Org. Provider	Price Input Date	Price Input Number of Units
1	1	DME_001	MEM_001		ORG_PRV_001	2012-02-01	1
2	1	DME_001	MEM_001		ORG_PRV_001	2012-04-01	1
3	1	DME_001	MEM_001		ORG_PRV_001	2012-03-01	1
4	1	DME_001	MEM_001		ORG_PRV_001	2012-05-10-	1
5	1	DME_001	MEM_001		ORG_PRV_001	2012-06-10	1

After processing claim 1, the result will be

Table 35. Scenario 4: Counter for MEM_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL4B	MEM_001	-	-	-	-

Table 36. Scenario 4: Counter Period

Current	Max	Start Date	End Date
1	4	2012-02-01	2012-04-01

After processing claim 2, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 37. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-06-01

After processing claim 3, the period will be (end date set to the most recent consumption date in the period - which did not change - plus the interrupt period)

Table 38. Scenario 4: Counter Period

Current	Max	Start Date	End Date
3	4	2012-02-01	2012-06-01

After processing claim 4, the period will be (end date set to the start date plus the replacement period minus one day)

Table 39. Scenario 4: Counter Period

Current	Max	Start Date	End Date
4	4	2012-02-01	2017-01-31

Processing claim 5 will lead to a deny.

Now consider a scenario where the claims came in in such a way that more than one period is created at first:

Table 40. Scenario 4: Claims

Claim	Claim Line	Procedure	Serviced Person	Ind. Provider	Org. Provider	Price Input Date	Price Input Number of Units
1	1	DME_001	MEM_001		ORG_PRV_001	2012-02-01	1
2	1	DME_001	MEM_001		ORG_PRV_001	2012-03-01	1
3	1	DME_001	MEM_001		ORG_PRV_001	2012-05-10	1
4	1	DME_001	MEM_001		ORG_PRV_001	2012-04-01	1

After processing claim 1, the result will be

Table 41. Scenario 4: Counter for MEM_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL4B	MEM_001	-	-	-	-

Table 42. Scenario 4: Counter Period

Current	Max	Start Date	End Date
1	4	2012-02-01	2012-04-01

After processing claim 2, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 43. Scenario 4: Counter Period After Processing Claim 2

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-05-01

After processing claim 3, the periods will be

Table 44. Scenario 4: Counter Period After Processing Claim 3

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-05-01
1	4	2012-05-10	2012-07-10

After processing claim 4, the two periods will be reevaluated into one:

Table 45. Scenario 4: Counter Period

Current	Max	Start Date	End Date
4	4	2012-02-01	2017-01-31

Now consider a similar scenario, but one that leads to an exceed:

Table 46. Scenario 4: Consider a Scenario

Claim	Claim Line	Procedure	Serviced Person	Ind. Provider	Org. Provider	Price Input Date	Price Input Number of Units
1	1	DME_001	MEM_001		ORG_PRV_001	2012-02-01	1
2	1	DME_001	MEM_001		ORG_PRV_001	2012-03-01	1
3	1	DME_001	MEM_001		ORG_PRV_001	2012-05-10	1
4	1	DME_001	MEM_001		ORG_PRV_001	2012-06-10	1
5	1	DME_001	MEM_001		ORG_PRV_001	2012-04-01	1

After processing claim 1, the result will be

Table 47. Scenario 4: Counter for MEM_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL4B	MEM_001	-	-	-	-

Table 48. Scenario 4: Counter Period

Current	Max	Start Date	End Date
1	4	2012-02-01	2012-04-01

After processing claim 2, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 49. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-05-01

After processing claim 3, the periods will be

Table 50. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-05-01
1	4	2012-05-10	2012-07-10

After processing claim 4, the periods will be

Table 51. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-02-01	2012-05-01
2	4	2012-05-10	2012-08-10

Processing claim 5 will lead to a deny because the two periods will be reevaluated into one that is already maxed:

Table 52. Scenario 4: Counter Period

Current	Max	Start Date	End Date
4	4	2012-02-01	2017-01-31

Likewise, the start date of a period may change:

Table 53. Scenario 4: Claims

Claim	Claim Line	Procedure	Serviced Person	Ind. Provider	Org. Provider	Price Input Date	Price Input Number of Units
1	1	DME_001	MEM_001		ORG_PRV_001	2012-03-01	1
2	1	DME_001	MEM_001		ORG_PRV_001	2012-04-01	1
3	1	DME_001	MEM_001		ORG_PRV_001	2012-02-01	1

After processing claim 1, the result will be

Table 54. Scenario 4: Counter for MEM_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL4B	MEM_001	-	-	-	-

Table 55. Scenario 4: Counter Period

Current	Max	Start Date	End Date
1	4	2012-03-01	2012-05-01

After processing claim 2, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 56. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-03-01	2012-06-01

After processing claim 3, the start date of the period will be adjusted:

Table 57. Scenario 4: Counter Period

Current	Max	Start Date	End Date
3	4	2012-02-01	2012-06-01

Changing the start date may also lead to an exceed:

Table 58. Scenario 4: Claims

Claim	Claim Line	Procedure	Serviced Person	Ind. Provider	Org. Provider	Price Input Date	Price Input Number of Units
1	1	DME_001	MEM_001		ORG_PRV_001	2012-03-01	1
2	1	DME_001	MEM_001		ORG_PRV_001	2012-04-01	1
3	1	DME_001	MEM_001		ORG_PRV_001	2012-05-10	1
4	1	DME_001	MEM_001		ORG_PRV_001	2012-06-10	1
5	1	DME_001	MEM_001		ORG_PRV_001	2012-02-01	1

After processing claim 1, the result will be

Table 59. Scenario 4: Counter for MEM_001

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL4B	MEM_001	-	-	-	-

Table 60. Scenario 4: Counter Period

Current	Max	Start Date	End Date
1	4	2012-03-01	2012-05-01

After processing claim 2, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 61. Scenario 4: Counter Period

Current	Max	Start Date	End Date
2	4	2012-03-01	2012-06-01

After processing claim 3, the period will be (end date set to the most recent consumption date in the period plus the interrupt period)

Table 62. Scenario 4: Counter Period

Current	Max	Start Date	End Date
3	4	2012-03-01	2012-07-10

After processing claim 4, the period will be (end date set to the start date plus the replacement period minus one day)

Table 63. Scenario 4: Counter Period

Current	Max	Start Date	End Date
4	4	2012-03-01	2017-02-28

Processing claim 5 will lead to a deny but the period will also be reevaluated:

Table 64. Scenario 4: Counter Period

Current	Max	Start Date	End Date
4	4	2012-02-01	2017-01-31

Scenario 5

In this scenario one provider limit rule in units is set up that counts across insurable entities and per organization provider. When the maximum is reached, the limit keeps on counting.

Table 65. Scenario 5: Provider Limit Rules Configuration

Rule[4]	Category	Procedures	PPC Quantifier	Heights
PRL5	Provider level: Organization Across insurable entities: Yes Type: Number (before reimbursement method) Period type: Renewal Reference: Calendar Year Period: 1 year Procedure definition: Unspecified Messages: Informative	IN CARDIOLOGY	-	1 Jan 2017 - 31 Dec 2017: 10 units

Table 66. Scenario 5: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL5	-	-	ORG_PRV_001	-	-

Table 67. Scenario 5: Existing Counter Periods

Current	Max	Start Date	End Date
9	10	2017-01-01	2017-12-31

Table 68. Scenario 5: Claims

Claim	Line	Price Input Date	Procedure	Serviced Person	Price Org. Provider	Price Ind. Provider	Price Input Number Of Units
1	1	2017-03-03	CRD1	MEM_001	ORG_PRV_001	IND_PRV_002	1
2	1	2017-09-12	CRD1	MEM_002	ORG_PRV_001	IND_PRV_001	1

Result

• The claim line of Claim 1 counts towards the existing counter period of 1 Jan 2017 - 31 Dec 2017

  • The available room on the counter period is 1 unit (10 minus 9)

  • The consumption on the counter for that period is 1 unit

  • The limit is met

• The claim line of Claim 2 counts towards the existing counter period of 1 Jan 2017 - 31 Dec 2017

  • There is no available room on the counter period

  • The consumption on the counter for that period is 1 unit, because the Reached Action is set to Continue

  • The limit is exceeded

Table 69. Scenario 5: Result

Claim	Line	Allowed Number of Units	Message
1	1	1	Limit met
2	1	1	Limit exceeded

Table 70. Counter Periods After the Claim has been Processed

Current	Max	Start Date	End Date
11	10	2017-01-01	2017-12-31

Scenario 6

In this scenario one provider limit rule in units is set up that counts per insurable entity and organization provider. Reservation regime is configured with ceiling indicator set to Y(es)

Table 71. Scenario 6: Reservation Regime Configuration

Code	Indication Number of Units Ceiling	Messages
REV001	Y	Informative

Table 72. Scenario 6: Provider Limit Rules Configuration

Rule[4]	Category	Procedures	PPC Quantifier	Heights
PRL1	Provider level: Organization Across insurable entities: No Type: Number (before reimbursement method) Period type: Renewal Reference: Calendar Year Period: 1 year Procedure definition: Unspecified Messages: Informative	(In) Revenue Codes (range 0110 - 0159)	-	1 Jan 2017 - 31 Dec 2017:10 units

Table 73. Scenario 6: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL1	MEM_001	-	ORG_PRV_001	-	-

Table 74. Scenario 6: Existing Counter Periods

Current	Max	Start Date	End Date
2	10	2017-01-01	2017-12-31

Table 75. Scenario 6: Claim

Processing Seq .	Process Type	Res. Regime and Reservation Line	Claim Line Code	Receipt Date	Expiration Date	Price Input Date	Serviced Person	Price Org. Provider	Price Input Number Of Units
1	Reservation	-	RES001	2017-03-10	2017-06-30	2017-03-03	MEM_001	ORG_PRV_001	6
2	Claim	REV001/RES001	CL001	2017-03-23	-	2017-03-03	MEM_001	ORG_PRV_001	1
3	Claim	REV001/RES001	CL002	2017-05-03	-	2017-04-14	MEM_001	ORG_PRV_001	2
4	Claim	-	CL003	2017-05-07	-	2017-05-09	MEM_001	ORG_PRV_001	2
5	Claim	REV001/RES001	CL004	2017-07-11	-	2017-07-05	MEM_001	ORG_PRV_001	3
6	Claim	REV001/RES001	CL005	2017-06-01	-	2017-06-01	MEM_001	ORG_PRV_001	4

Result

• Reservation Line RES001 counts towards the existing counter period of 1 Jan 2017 - 31 Dec 2017

  • The available room on the counter period is 8 units (10 minus 2). The consumption on the counter for that period is 2 units

  • The provider limit rule message - limit is not met

  • The current on the counter period is updated to 8 (2+6).

  • The following consumption is created

Table 76. Scenario 6: Result

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
6	10	2017-06-30	Y

• Claim Line CL001 refers to the reservation regime REV001 and reservation line RES001.

  • The available room on the counter period for this claim line is 6 (6 minus 0; as there are no consumptions using the reserved consumption) plus 0 (as the reservation regime is configured to be ceiling for the number of units)

  • The claim line takes consumption of 1 from the reserved consumption

  • The provider limit rule message - not applicable

  • The reservation regime message - limit not met

  • The current on the counter period does not change (that is, sum of all the non expired consumptions under the counter period: 2+6+1-1)

  • The following consumptions are created

Table 77. Scenario 6: Consumptions

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
1	10	-	-
-1	10	2017-06-30	Y

• Claim Line CL002 refers to the reservation regime REV001 and reservation line RES001.

  • The available room on the counter period for this claim line is 5 (6 minus 1; as there is a consumption using the reserved consumption) plus 0 (as the reservation regime is configured to be ceiling for the number of units)

  • The claim line takes consumption of 2 from the reserved consumption

  • The provider limit rule message - not applicable

  • The reservation regime message - limit not met

  • The current on the counter period does not change

  • The following consumptions are created

Table 78. Scenario 6: Consumptions for Claim Line CL002

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
2	10	-	-
-2	10	2017-06-30	Y

• Claim Line CL003

  • The available room on the counter period is 2 (that is, height minus sum of all the non expired consumptions:10 - (2+6+1-1+2-2))

  • The line registers a consumption of 2 units

  • The provider limit rule message - limit met

  • The reservation regime message - not applicable

• Claim Line CL004 refers to the reservation regime REV001 and reservation line RES001.

  • The available room on the counter period for this claim line is 0 as the reservation has expired for this line (claim receipt date is after expiration date)

  • The provider limit rule message - not applicable

  • The reservation regime message - limit exceeded

  • No consumptions are created

• Claim Line CL005 (a late claim) is processed

  • The available room on the counter period is 3 (the room on reservation that is, 6-1-2).

  • The claim line registers a consumption of 3 units. This is because a reservation can never be compromised and the claim is guaranteed to have access to the reserved consumption

  • The provider limit rule message - not applicable

  • The reservation regime message - limit met and exceeded

  • The following consumptions are created

Table 79. Scenario 6: Claim Line CL005

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
3	10	-	-
-3	10	2017-06-30	Y

Scenario 7

In this scenario one provider limit rule in units is set up that counts per insurable entity and organization provider. Reservation regime is configured with ceiling indicator set to N(o).

Table 80. Scenario 7: Reservation Regime Configuration

Code	Indication Number of Units Ceiling	Messages
REV002	N	Informative

Table 81. Scenario 7: Provider Limit Rules Configuration

Rule[4]	Category	Procedures	PPC Quantifier	Heights
PRL1	Provider level: Organization Across insurable entities: No Type: Number (before reimbursement method) Period type: Renewal Reference: Calendar Year Period: 1 year Procedure definition: Unspecified Messages: Informative	(In) Revenue Codes (range 0110 - 0159)	-	1 Jan 2017 - 31 Dec 2017:10 units

Table 82. Scenario 7: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL1	MEM_001	-	ORG_PRV_001	-	-

Table 83. Scenario 7: Existing Counter Periods

Current	Max	Start Date	End Date
2	10	2017-01-01	2017-12-31

Table 84. Scenario 7: Claim

Processing Seq.	Process Type	Res. Regime and Reservation Line	Claim Line Code	Receipt Date	Expiration Date	Price Input Date	Procedures	Serviced Person	Price Org. Provider	Price Input Number Of Units
1	Reservation	-	RES001	2017-03-10	2017-06-30	2017-03-03	0111	MEM_001	ORG_PRV_001	6
2	Claim	REV002/RES001	CL001	2017-03-23	-	2017-03-03	0111	MEM_001	ORG_PRV_001	3
3	Claim	REV002/RES001	CL003	2017-06-13	-	2017-05-04	0111	MEM_001	ORG_PRV_001	4
4	Claim	REV002/RES001	CL004	2017-07-11	-	2017-07-05	0111	MEM_001	ORG_PRV_001	1

Result

• Reservation Line RES001 counts towards the existing counter period of 1 Jan 2017 - 31 Dec 2017

  • The available room on the counter period is 8 units (10 minus 2). The consumption on the counter for that period is 2 units

  • The provider limit rule message - limit not met

  • The current on the counter period is updated to 8

  • The following consumption is created:

Table 85. Scenario 7: Result

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
6	10	2017-06-30	Y

• Claim Line CL001 refers to the reservation regime REV002 and reservation line RES001.

  • The available room on the counter period for this claim line is 8

    • 6 (6 minus 0; as there are no consumptions using the reserved consumption) plus 2 (the available room for the limit)

  • The claim line takes consumption of 3 from the reserved consumption

  • The provider limit rule message - not applicable

  • The reservation regime message - limit not met

  • The current on the counter period does not change

  • The following consumptions are created

Table 86. Scenario 7: Claim Line CL001

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
3	10	-	-
-3	10	2017-06-30	Y

• Claim Line CL002 refers to the reservation regime REV002 and reservation line RES001.

  • The available room on the counter period for this claim line is 5

    • 6 (6 minus 3; as there is a consumption using the reserved consumption) plus 2 (the available room for the limit)

  • The claim line takes consumption of 3 from the reserved consumption and 1 from the room on the limit

  • The reservation regime message - limit met and exceeded

  • The provider limit rule message - limit not met

  • The current on the counter period is updated to 9

  • The following consumptions are created

Table 87. Scenario 7: Claim Line CL002

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
4	10	-	-
-3	10	2017-06-30	Y

• Claim Line CL003 refers to the reservation regime REV002 and reservation line RES001.

  • The available room on the counter period for this claim line is 1 (10 - 9)

    • The reservation (and the offset consumption(s)) has expired

    • The claim line looks at the available room with the limit on the counter period (as ceiling for number of units is set to N(o))

  • The claim line takes consumption of 1 from the room on the limit

  • The reservation regime message - limit exceeded

  • The provider limit rule message - limit met

  • The current on the counter period is updated to 10 (that is, sum of all the non expired consumption under the counter period: 2+3+4+1)

  • The following consumption is created

Table 88. Scenario 7: Claim Line CL003

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
1	10	-	-

Scenario 8

In this scenario one provider limit rule in units is set up that counts per insurable entity and organization provider. Reservation regime is configured with ceiling indicator set to Y(es) and release indicator set to Y.

Table 89. Scenario 8: Reservation Regime Configuration

Code	Indication Number of Units Ceiling	Indication Release	Messages
REV003	Y	Y	Informative

Table 90. Scenario 8: Provider Limit Rules Configuration

Rule[4]	Category	Procedures	PPC Quantifier	Heights
PRL1	Provider level: Organization Across insurable entities: No Type: Number (before reimbursement method) Period type: Renewal Reference: Calendar Year Period: 1 year Procedure definition: Unspecified Messages: Informative	(In) Revenue Codes (range 0110 - 0159)	-	1 Jan 2017 - 31 Dec 2017:10 units

Table 91. Scenario 8: Existing Counters

Rule	Person	Ind. Provider	Org. Provider	Contract	Procedure
PRL1	MEM_001	-	ORG_PRV_001	-	-

Table 92. Scenario 8: Existing Counter Periods

Current	Max	Start Date	End Date
2	10	2017-01-01	2017-12-31

Claim

Processing Seq.	Process Type	Res. Regime and Reservation Line	Claim Line Code	Receipt Date	Expiration Date	Price Input Date	Procedures	Serviced Person	Price Org. Provider	Price Input Number Of Units
1	Reservation	-	RES001	2017-03-10	2017-12-31	2017-03-03	0111	MEM_001	ORG_PRV_001	6
2	Claim	REV003/RES001	CL001	2017-03-23	-	2017-03-03	0111	MEM_001	ORG_PRV_001	3
3	Claim	REV003/RES001	CL002	2017-06-13	-	2017-05-04	0111	MEM_001	ORG_PRV_001	2

Result

• Reservation Line RES001 counts towards the existing counter period of 1 Jan 2017 - 31 Dec 2017

  • The available room on the counter period is 8 units (10 minus 2). The consumption on the counter for that period is 2 units

  • The provider limit rule message - limit not met

  • The following consumption is created

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
6	10	2017-12-31	Y

• Claim Line CL001 refers to the reservation regime REV003 and reservation line RES001.

  • The available room on the counter period for this claim line is 6 (6 minus 0; as there are no consumptions using the reserved consumption)

  • The claim line takes consumption of 3 from the reserved consumption

  • The provider limit rule message - not applicable

  • The reservation regime message - limit not met

  • The following consumptions are created

No of Units	Maximum Number of Units	Expiration Date	Indicator Reserved
3	10	-	-
-6	10	2017-12-31	Y

• Claim Line CL002 refers to the reservation regime REV003 and reservation line RES001.

  • The available room on the counter period for this claim line is 0 (6 minus 6)

  • The provider limit rule message - not applicable

  • The reservation regime message - limit exceeded

  • No consumption is created

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1. The rules are referenced by a provider pricing clause with only a start date filled. The other dimensions of the provider limit rule (modifiers, diagnoses, classification, fee schedule type and other condition) are unspecified. The reached action is set to Stop.

2. The allowed amount before the evaluation of provider limit rules (calculated using a fee schedule reimbursement method; which is out of the scope of this example)

3. The allowed amount after the evaluation of provider limit rules

4. The rules are referenced by a provider pricing clause with only a start date filled. The other dimensions of the provider limit rule (modifiers, diagnoses, classification, fee schedule type and other condition) are unspecified. The reached action is set to Continue.