Scenario 3
In this capitation scenario a payment arrangement for calendar year 2018 is made between the healthcare payer and primary care providers that are part of a specific provider network (provider group). Only the provider who was the member’s PCP on the 15th day of the month is paid a monthly rate amount. Which rate amount is paid depends on whether or not the member has hit his/her out of pocket max or deductible. This scenario takes place over a period of three months in calendar year 2018.
Configuration
In the sections below the default time periods, rates, adjustments and capitation contract that are needed for the above specified scenario are described.
Default Time Periods
The payment arrangement is made for calendar year 2018, so a default time period is configured for calendar year 2018. The rates and adjustments that are specified in the sections below are in the context of this default time period.
Default Time Periods
| Display Name | Start Date | End Date |
|---|---|---|
Calendar Year 2018 |
01-01-2018 |
12-31-2018 |
Rates
The base rate amount that is paid per member is based on whether or not the member has hit his/her out of pocket max or deductible (time valid dynamic field on the member), so a schedule definition with hit deductible and hit out of pocket max dimensions is configured.
Schedule Definition
| Code | Description | Type |
|---|---|---|
DEDUCTIBLE OOPM BASED |
Hit deductible and out of pocket max based rates |
Rate |
Schedule Dimensions
| Display Name | Field Name | Type | Usage |
|---|---|---|---|
Hit Deductible |
hitDeductible |
Dynamic Field (person.hitDeductible) |
Value |
Hit OOPM |
hitOopm |
Dynamic Field (person.hitOopm) |
Value |
A rate schedule is configured with rate schedule lines for the default time period "Calendar Year 2018", based on the above specified schedule definition.
Rate Schedule
| Code | Schedule Definition | Amount Interpretation | Currency |
|---|---|---|---|
DED OOPM RATES |
DEDUCTIBLE OOPM BASED |
Contract Calculation Period |
$ |
Rate Schedule Lines
| Hit Deductible | Hit OOPM | Rate |
|---|---|---|
N |
N |
5.00 $ |
Y |
N |
4.00 $ |
Y |
Y |
3.00 $ |
Capitation Contract
A capitation contract is configured that uses the DED OOPM RATES rate schedule. Payment is made to the providers, so the attribution type of the contract is set to Member and Provider.
Capitation Contracts
| Code | Description | Attribution Type | Rate Schedule | Reference Date Function |
|---|---|---|---|---|
PRIMARY CAP |
Primary Cap Payment Contract |
Member and Provider |
DED OOPM RATES |
RD CP 15TH |
In the sections below the contract calculation periods, contract provider filter rules, contract rate splits and dynamic logic that are part of this contract are described.
Contract Calculation Periods
Payments are made monthly so for each month in 2018 a contract calculation period is configured.
Contract Calculation Periods
| Start Date | End Date |
|---|---|
01-01-2018 |
01-31-2018 |
02-01-2018 |
02-28-2018 |
03-01-2018 |
03-31-2018 |
04-01-2018 |
04-30-2018 |
05-01-2018 |
05-31-2018 |
06-01-2018 |
06-30-2018 |
07-01-2018 |
07-31-2018 |
08-01-2018 |
08-31-2018 |
09-01-2018 |
09-30-2018 |
10-01-2018 |
10-31-2018 |
11-01-2018 |
11-30-2018 |
12-01-2018 |
12-31-2018 |
Contract Provider Filter Rules
The contract only applies to primary care providers that are in the PCP PROVIDERS network, so a contract provider filter rule is configured with a PCP provider assignment type and a PCP PROVIDERS provider group. Only the provider who was the member’s PCP on the 15th day of the month (reference date) is paid, so an attribution filter condition is configured that checks this.
Contract Provider Filter Rules
| Sequence | Provider Assignment Type | Provider Group | Attribution Filter Condition |
|---|---|---|---|
1 |
PCP |
PCP PROVIDERS |
AF RD |
Contract Rate Splits
The entire result amount is paid to the provider, so no rate spits are needed. Setting the provider as the counterparty on the financial transaction details is done in the financial transaction dynamic logic.
Dynamic Logic
The dynamic logic conditions and functions that are used within the contract are configured as specified below.
Dynamic Logic
| Code | Signature | Logic |
|---|---|---|
RD CP 15TH |
Calculation Period Reference Date |
java.sql.Date dat = contractCalculationPeriod.startDate dat[DATE] = 15 return dat |
AF RD |
Attribution Filter |
return attribution.startDate ⇐ referenceDate && attribution.endDate >= referenceDate |
FT |
Financial Transaction |
for financialTransactionDetail in financialTransaction.financialTransactionDetailList( financialTransactionDetail.financialTransactionDetailProcessData.counterpartyCode = calculationResult.provider.code ) financialTransaction.financialTransactionProcessData.finTransactionSetGrouping = calculationResult.contractCalculationPeriod.capitationContract.code return financialTransaction |
Contract Alignments
A subset of the contract alignments, members and providers that are in the context of this contract are specified in the sections below.
Alignments
In the table below a number of contract alignments that apply to the contract are specified.
Contract Alignments
| Member | Start Date | End Date |
|---|---|---|
John Smith |
01-01-2018 |
12-31-2018 |
Alice Jones |
01-01-2018 |
12-31-2018 |
Members
The members that are aligned to the contract have specific characteristics which are important in the context of this contract.
Members
| Name | Code | Hit Deductible (2018) | Hit OOPM (2018) | Assigned Providers |
|---|---|---|---|---|
John Smith |
M631893 |
N |
N |
Rodrigo Martinez (PCP from 01-01-2015) |
Alice Jones |
M259012 |
Y |
Y |
Rodrigo Martinez (PCP from 01-01-2000 to 01-15-2018) Michael Lawrence (PCP from 01-16-2018) |
Providers
The providers that are assigned to the above specified members have specific characteristics which are important in the context of this contract.
Providers
| Name | Code | Provider Group |
|---|---|---|
Rodrigo Martinez |
P10654 |
PCP PROVIDERS (from 01-01-2015) |
Michael Lawrence |
P33421 |
PCP PROVIDERS (from 01-01-2013) |
Calculation
When multiple Capitation Calculation activities are run for the contract with calculation input dates in January 2018, February 2018 and March 2018, a number of attributions, calculation results and financial results are created based on the contract alignments and the configuration of the contract.
Attributions
A number of attribution are created in the context of the contract alignments that are specified above.
Attributions
| Member | Calc. Period | Provider | Start Date | End Date |
|---|---|---|---|---|
John Smith |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
01-31-2018 |
Alice Jones |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
01-15-2018 |
John Smith |
February 2018 |
Rodrigo Martinez |
02-01-2018 |
02-28-2018 |
Alice Jones |
February 2018 |
Michael Lawrence |
02-01-2018 |
02-28-2018 |
John Smith |
March 2018 |
Rodrigo Martinez |
03-01-2018 |
03-31-2018 |
Alice Jones |
March 2018 |
Michael Lawrence |
03-01-2018 |
03-31-2018 |
Calculation Results
For every attribution a calculation result with calculation result lines is created, based on the configured rate schedule.
Calculation Results
| Member | Calc. Period | Provider | Attr. Start Date | Rate | Adj. | Result | Vers. | Rev. |
|---|---|---|---|---|---|---|---|---|
John Smith |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
N |
Alice Jones |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
1.45 $ |
0.00 $ |
1.45 $ |
1 |
N |
John Smith |
February 2018 |
Rodrigo Martinez |
02-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
N |
Alice Jones |
February 2018 |
Michael Lawrence |
02-01-2018 |
3.00 $ |
0.00 $ |
3.00 $ |
1 |
N |
John Smith |
March 2018 |
Rodrigo Martinez |
03-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
N |
Alice Jones |
March 2018 |
Michael Lawrence |
03-01-2018 |
3.00 $ |
0.00 $ |
3.00 $ |
1 |
N |
The calculation result lines are created per rate/adjustment component.
Calculation Result Lines
| Calculation Result | Seq. | Schedule | Am. Inter. | Retr. Value | Input Am. | Result |
|---|---|---|---|---|---|---|
John Smith - January 2018 (01-01-2018) - Rodrigo Martinez - V1 |
1 |
DED OOPM RATES |
CCP |
5.00 $ |
5.00 $ |
|
Alice Jones - January 2018 (01-01-2018) - Rodrigo Martinez - V1 |
1 |
DED OOPM RATES |
CCP |
3.00 $ |
1.45 $ |
|
John Smith - February 2018 (02-01-2018) - Rodrigo Martinez - V1 |
1 |
DED OOPM RATES |
CCP |
5.00 $ |
5.00 $ |
|
Alice Jones - February 2018 (02-01-2018) - Michael Lawrence - V1 |
1 |
DED OOPM RATES |
CCP |
3.00 $ |
3.00 $ |
|
John Smith - March 2018 (03-01-2018) - Rodrigo Martinez - V1 |
1 |
DED OOPM RATES |
CCP |
5.00 $ |
5.00 $ |
|
Alice Jones - March 2018 (03-01-2018) - Michael Lawrence - V1 |
1 |
DED OOPM RATES |
CCP |
3.00 $ |
3.00 $ |
Financial Results
For every calculation result a base financial object is created.
Base Financial Objects
| Member Code | Contract Code | Calc. Period Start Date | Attr. Start Date | Provider Code |
|---|---|---|---|---|
M631893 |
PRIMARY CAP |
01-01-2018 |
01-01-2018 |
P10654 |
M259012 |
PRIMARY CAP |
01-01-2018 |
01-01-2018 |
P10654 |
M631893 |
PRIMARY CAP |
02-01-2018 |
02-01-2018 |
P10654 |
M259012 |
PRIMARY CAP |
02-01-2018 |
02-01-2018 |
P33421 |
M631893 |
PRIMARY CAP |
03-01-2018 |
03-01-2018 |
P10654 |
M259012 |
PRIMARY CAP |
03-01-2018 |
03-01-2018 |
P33421 |
For every base financial object a financial transaction is created.
Financial Transactions
| Base Financial Object | Total Am. | Rev. | Vers. |
|---|---|---|---|
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
5.00 $ |
N |
1 |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
1.45 $ |
N |
1 |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) |
5.00 $ |
N |
1 |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) |
3.00 $ |
N |
1 |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) |
5.00 $ |
N |
1 |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) |
3.00 $ |
N |
1 |
The financial transaction details are created per rate/adjustment component.
Financial Transaction Details
| Financial Transaction | Seq. | Component Code | Counterparty Code[1] | Amount |
|---|---|---|---|---|
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
5.00 $ |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
1.45 $ |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
5.00 $ |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P33421 |
3.00 $ |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
5.00 $ |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P33421 |
3.00 $ |
*⇒ The counterparty code is stored on the related financial transaction detail process data records
Recalculation
Let’s consider that rates in the rate schedule are retroactively (effective from 01-01-2018) changed (10.00 $ normal rate, 8.00 $ hit deductible rate and 6.00 $ hit OOPM rate). This change is monitored by a configured change event rule of type Recalculation, which results in the creation of a contract mutation. When the Capitation Calculation activity is run for the contract with a calculation input date in April 2018 (and a look back date of 24 months before the input date) new results are of course created for April 2018, but because a contract mutation exists, the existing results for January, February and March are reversed and new results are created for those months.
The existing calculation results are reversed and new calculation results are created.
Calculation Results
| Member | Calc. Period | Provider | Attr. Start Date | Rate | Adj. | Result | Vers. | Rev. |
|---|---|---|---|---|---|---|---|---|
John Smith |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
Y |
John Smith |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
2 |
N |
Alice Jones |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
1.45 $ |
0.00 $ |
1.45 $ |
1 |
Y |
Alice Jones |
January 2018 |
Rodrigo Martinez |
01-01-2018 |
2.90 $ |
0.00 $ |
2.90 $ |
2 |
N |
John Smith |
February 2018 |
Rodrigo Martinez |
02-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
Y |
John Smith |
February 2018 |
Rodrigo Martinez |
02-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
2 |
N |
Alice Jones |
February 2018 |
Michael Lawrence |
02-01-2018 |
3.00 $ |
0.00 $ |
3.00 $ |
1 |
Y |
Alice Jones |
February 2018 |
Michael Lawrence |
02-01-2018 |
6.00 $ |
0.00 $ |
6.00 $ |
2 |
N |
John Smith |
March 2018 |
Rodrigo Martinez |
03-01-2018 |
5.00 $ |
0.00 $ |
5.00 $ |
1 |
Y |
John Smith |
March 2018 |
Rodrigo Martinez |
03-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
2 |
N |
Alice Jones |
March 2018 |
Michael Lawrence |
03-01-2018 |
3.00 $ |
0.00 $ |
3.00 $ |
1 |
Y |
Alice Jones |
March 2018 |
Michael Lawrence |
03-01-2018 |
6.00 $ |
0.00 $ |
6.00 $ |
2 |
N |
John Smith |
April 2018 |
Rodrigo Martinez |
04-01-2018 |
10.00 $ |
0.00 $ |
10.00 $ |
1 |
N |
Alice Jones |
April 2018 |
Michael Lawrence |
04-01-2018 |
6.00 $ |
0.00 $ |
6.00 $ |
1 |
N |
New calculation result lines are created for the new calculation results.
Calculation Result Lines
| Calculation Result | Seq. | Schedule | Am. Inter. | Retr. Value | Input Am. | Result |
|---|---|---|---|---|---|---|
John Smith - January 2018 (01-01-2018) - Rodrigo Martinez - V2 |
1 |
DED OOPM RATES |
CCP |
10.00 $ |
10.00 $ |
|
Alice Jones - January 2018 (01-01-2018) - Rodrigo Martinez - V2 |
1 |
DED OOPM RATES |
CCP |
6.00 $ |
2.90 $ |
|
John Smith - February 2018 (02-01-2018) - Rodrigo Martinez - V2 |
1 |
DED OOPM RATES |
CCP |
10.00 $ |
10.00 $ |
|
Alice Jones - February 2018 (02-01-2018) - Michael Lawrence - V2 |
1 |
DED OOPM RATES |
CCP |
6.00 $ |
6.00 $ |
|
John Smith - March 2018 (03-01-2018) - Rodrigo Martinez - V2 |
1 |
DED OOPM RATES |
CCP |
10.00 $ |
10.00 $ |
|
Alice Jones - March 2018 (03-01-2018) - Michael Lawrence - V2 |
1 |
DED OOPM RATES |
CCP |
6.00 $ |
6.00 $ |
|
John Smith - April 2018 (04-01-2018) - Rodrigo Martinez - V1 |
1 |
DED OOPM RATES |
CCP |
10.00 $ |
10.00 $ |
|
Alice Jones - April 2018 (04-01-2018) - Michael Lawrence - V1 |
1 |
DED OOPM RATES |
CCP |
6.00 $ |
6.00 $ |
Reversal financial transactions for the reversed calculation results and new financial transactions for the new calculation results are created.
Financial Transactions
| Base Financial Object | Total Am. | Rev. | Vers. |
|---|---|---|---|
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
-5.00 $ |
Y |
1 |
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
10.00 $ |
N |
2 |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
-1.45 $ |
Y |
1 |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) |
2.90 $ |
N |
2 |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) |
-5.00 $ |
Y |
1 |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) |
10.00 $ |
N |
2 |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) |
-3.00 $ |
Y |
1 |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) |
6.00 $ |
N |
2 |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) |
-5.00 $ |
Y |
1 |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) |
10.00 $ |
N |
2 |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) |
-3.00 $ |
Y |
1 |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) |
6.00 $ |
N |
2 |
M631893 - PRIMARY CAP - P10654 - April 2018 (04-01-2018) |
10.00 $ |
N |
1 |
M259012 - PRIMARY CAP - P33421 - April 2018 (04-01-2018) |
6.00 $ |
N |
1 |
New and reversal financial transaction details are created for the above specified financial transactions.
Financial Transaction Details
| Financial Transaction | Seq. | Component Code | Counterparty Code[1] | Amount |
|---|---|---|---|---|
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P10654 |
-5.00 $ |
M631893 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
10.00 $ |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P10654 |
-1.45 $ |
M259012 - PRIMARY CAP - P10654 - January 2018 (01-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
2.90 $ |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P10654 |
-5.00 $ |
M631893 - PRIMARY CAP - P10654 - February 2018 (02-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
10.00 $ |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P33421 |
-3.00 $ |
M259012 - PRIMARY CAP - P33421 - February 2018 (02-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P33421 |
6.00 $ |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P10654 |
-5.00 $ |
M631893 - PRIMARY CAP - P10654 - March 2018 (03-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
10.00 $ |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) - V1 - Reversed Y |
1 |
DED OOPM RATES |
P33421 |
-3.00 $ |
M259012 - PRIMARY CAP - P33421 - March 2018 (03-01-2018) - V2 - Reversed N |
1 |
DED OOPM RATES |
P33421 |
6.00 $ |
M631893 - PRIMARY CAP - P10654 - April 2018 (04-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P10654 |
10.00 $ |
M259012 - PRIMARY CAP - P33421 - April 2018 (04-01-2018) - V1 - Reversed N |
1 |
DED OOPM RATES |
P33421 |
6.00 $ |