Service Options, Services, and Service Definitions
Service options are descriptive entities used for grouping services and service definitions.
Service Option
| Field | Description |
|---|---|
Short Code |
Used to generate a unique benefit specification code |
Code |
The code of the item |
Description |
The description of the item |
Default? |
Default service options are added to a product upon creation |
Services are descriptive entities used for grouping service definitions.
Service
| Field | Description |
|---|---|
Short Code |
Used to generate a unique benefit specification code |
Code |
The code of the item |
Description |
The description of the item |
Default? |
Default services are added to a product upon creation |
Active? |
Indication if new references to it can be created |
Service Option |
A reference to a service option |
Service definitions define the medical service component of a benefit specification. They specify what a claim line should look like to qualify for cost share in terms of a combination of codes - like procedure and diagnosis - that identify a specific medical service. The same service definition can be used by different products.
Service Definition
| Field | Description |
|---|---|
Short Code |
Used to generate a unique benefit specification code |
Code |
The code of the item |
Description |
The description of the item |
Default? |
Default service definitions are added to the product through an advanced editing feature |
Active? |
Indication if new references to it can be created |
Gender |
The gender a person must have for this service definition to be applicable |
Age From |
The minimum age a person can have for this service definition to be applicable |
Age To |
The maximum age a person can have for this service definition to be applicable |
Diagnosis Group Usage |
To indicate In or Not in for a diagnosis group or condition |
Diagnosis Group |
A reference to the group of diagnoses for which the service definition applies |
Diagnosis Condition |
A reference to a dynamic logic condition specifying the applicable diagnoses |
Diagnosis Type |
The type of diagnoses to which this benefit specification applies |
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 |
A reference to the group of procedures for which the service definition applies |
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 |
A reference to the second group of procedures for which the service definition applies |
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 |
A reference to the third group of procedures for which the service definition applies |
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 |
A reference to a dynamic logic condition specifying the applicable procedures |
Location Type Usage |
Determines whether the listed location types are required for or excluded from the service definition |
Claim Form Type |
A reference to the claims form type |
Modifier Usage |
Determines whether the listed modifiers are required for or excluded from the service definition |
Specialty Usage |
Determines whether the listed specialties are required for or excluded from the service definition |
Case Definition |
A reference to the case definition that applies to the service definition |
Priority |
A reference to the priority of the service definition |
Service |
A reference to the service |
Type |
Determines where the service definition will be used (Coverage, Authorization, Waiting Period , Reservation or Post Benefits) |
Indicator Consume Authorization |
Indication if this service definition (authorization) can result in consuming returned authorizations |
The following business rules are enforced for a service definition:
-
Either a diagnosis group or a diagnosis condition can be specified, but not both.
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For a service definition of type 'Coverage' without a case definition one or more procedure groups and/or procedure conditions must be specified.
-
For a service definition of type 'Authorization', 'Reservation', 'Waiting Period' or 'Post Benefits' one or more procedure groups and/or procedure conditions must be specified.
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The diagnosis group usage must be specified when a diagnosis group or diagnosis condition is used and may not be specified when these are not used.
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A diagnosis type may only be specified when a diagnosis group or a diagnosis condition is specified.
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The location type usage must be specified when a location type list is used and may not be specified when a location type list is not used.
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The modifier usage must be specified when a modifier list is used and may not be specified when a modifier list is not used.
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The specialty usage must be specified when a specialty list is used and may not be specified when a specialty list is not used.
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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).
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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.
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Only service definitions of type 'Coverage' may reference a case definition.
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A case definition, procedure group or procedure condition must be specified for each service definition.
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If benefit specifications exist that are based on the service definition, any changes on the service definition will be propagated to the benefit specifications.
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The indicator consume authorization must have a value if the service definition is of type 'Authorization' and may not have a value if the service definition is of another type.
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Age from should not be larger than age to.
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If at least one product service definition referencing the service definition has a gender specified, then the gender field on the service definition must be empty.
-
If at least one product service definition referencing the service definition has an age from or age to specified, then both the age from and the age to fields on the service definition must be empty.
One or more service definition modifiers may be added to the service definition. These are the modifiers that apply to the service definition (or do not apply).
Service Definition Modifier
| Field | Description |
|---|---|
Service Definition |
A reference to the service definition |
Modifier |
A reference to the modifier |
One or more service definition location types may be added to the service definition. These are the specific location types that apply to the service definition (or do not apply).
Service Definition Location Type
| Field | Description |
|---|---|
Service Definition |
A reference to the service definition |
Location Type |
A reference to the location type |
One or more service definition specialties may be added to the service definition. These are the specialties that apply to the service definition (or do not apply).
Service Definition Specialty
| Field | Description |
|---|---|
Service Definition |
A reference to the service definition |
Specialty |
A reference to the specialty |
One or more service definition conditions may be added to the service definition. These are the dynamic logic conditions that apply to the service definition.