Bundled Amounts
A bundled amount reimbursement method represents the contracted amount per episode for the category of the services. It is used in provider pricing clauses to calculate the allowed amount for the episode, per category (or categories.
The bundled amount has the following fields:
Bundled Amounts Fields
Field | Description |
---|---|
Code |
The code of the bundled amount |
Description |
The description of the bundled amount |
Type |
The bundled amount type to which the bundled amount belongs |
Episode Definition |
The episode definition to which the bundled amount applies |
Priced On |
The claim line that will hold the amount - Triggering or First |
Include Before Message |
The message that gets attached to the claim line that is included before the triggering line is detected |
Triggering Message |
The message that gets attached to the triggering claim line |
Include After Message |
The message that gets attached to the claim line that is included after the triggering line is detected |
Access Restriction |
Determines whether or not the access to the bundled amount is restricted |
The following list specifies the placeholder values for the message that is attached to the claim line upon applying a bundled amount:
-
The code of the bundled amount
-
The description of the bundled amount
-
The provider pricing clause quantifier and currency
-
The episode definition
-
The episode category list that applies to the bundled amount
-
The code of the claim that holds the priced claim line for the bundled amount
-
The claim line code that holds the priced claim line for the bundled amount
Bundled amount types can be referred to by bundled amounts for administrative purposes. Pricing rules can also refer to bundled amount types. If a bundled amount type is specified on a pricing rule then the rule is only applied if a bundled amount of that type has been applied (in combination with the reimbursement method type usage as 'In' ) or has not been applied (in combination with reimbursement method type usage as 'Not In' ) to calculate the price on the claim line.
Bundled Amount Types
Field | Description |
---|---|
Code |
The code of the bundled amount type |
Description |
The description of the bundled amount type |
A bundled amount can be linked to one or more episode categories. Not linking to any episode category is the equivalent of an “ALL” episode category.
Bundled Amount Categories
Field | Description |
---|---|
Bundled amount |
The bundled amount reimbursement method to which the bundled amount category applies |
Episode Category |
The episode category to which the bundled amount category applies |
This linkage of bundled amount to episode category makes it possible to setup provider pricing clauses such that for a given episode definition, one provider gets paid one lump sum amount for an episode and another provider gets paid per combination of episode categories e.g. for a Provider A, the episode gets priced as one lump sum amount for Hip Replacement and for provider B it is a) priced for preoperative treatments b) priced for surgery and c) priced for postoperative treatments separately.
In order to configure such provider pricing clauses, four bundled amounts must be set up:
Bundled Amount Code | Bundled Amount Description | Episode | Bundled Amount Categories | Priced on |
---|---|---|---|---|
HIPREP_ALL |
Hip replacement, comprehensive bundled payment |
HIPREP |
Triggering |
|
HIPREP_PREO |
Hip replacement, pre op reimbursement |
HIPREP |
PREO |
First |
HIPREP_FACSURG |
Hip replacement, facility and surgical reimbursement |
HIPREP |
FAC, SURG |
Triggering |
HIPREP_PAC |
Hip replacement, post acute reimbursement |
HIPREP |
PAC |
First |
Provider pricing clauses are then setup as:
Provider Pricing Clauses | Reimbursement Method | Quantifier |
---|---|---|
PROV_A_HIPREP_ALL → applies to Provider A |
HIPREP_ALL |
$70,000 |
PROV_B_HIPREP_PREO → applies to Provider B |
HIPREP_PREO |
$15,000 |
PROV_B_HIPREP_FACSURG → applies to Provider B |
HIPREP_FACSURG |
$35,000 |
PROV_B_HIPREP_PAC → applies to Provider B |
HIPREP_PAC |
$20,000 |
Here, the episode for provider A is priced on the triggering line at $70,000 and for Provider B it is priced at (1) $15,000 on the first included claim line of the category PREO, (2) $35,000 on the triggering claim line and (3) $20,000 on the first included claim line of the category PAC.