Capitation Contracts
A capitation contract is a payment arrangement between the payer and providers or provider networks paying them a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. Refer to the scenarios described in the Capitation Calculation guide for examples of capitation contracts. A capitation contract has the following fields:
| Field | Description |
|---|---|
Code |
The functional identifier of the contract |
Description |
The description of the contract |
Attribution Type |
The type of the attributions of the contract (Member and Provider or Member) |
Rate Schedule |
The rate schedule that applies to the contract |
Organization |
The contracting organization |
Reference Date Function |
The dynamic logic function that determines the reference date of a contract calculation period. If left unspecified, the start date of each contract calculation period will act as reference date during capitation calculation. |
Contract Alignment Filter Condition |
The dynamic logic condition that holds restrictions on the contract alignment |
Data Access Group |
The data access group that is used to differentiate between user access rights |
Contract alignments specify which members are possibly relevant to which capitation contracts. For example: member John Smith is possibly relevant to capitation contract CONTR123 from 2017/01/01 to 2017/12/31. A contract alignment has the following fields:
| Field | Description |
|---|---|
Capitation Contract |
The contract to which the contract alignment belongs |
Person |
The person that is aligned to the contract |
Start Date |
The start date of the contract alignment |
End Date |
The end date of the contract alignment |
To be able to perform capitation calculation for a contract, contract calculation periods need to be configured. These periods specify the time lines for calculating a contract. A contract calculation period has the following fields:
| Field | Description |
|---|---|
Capitation Contract |
The contract to which the calculation period belongs |
Start Date |
The start date of the calculation period |
End Date |
The end date of the calculation period |
Attribution Threshold |
The minimum number of attributions (for distinct members) required before payment is made |
To be able to evaluate if the member that is linked to the contract (through a contract alignment) has a provider that meets certain conditions (for example the member needs to have a provider that is assigned to the member as a PCP and that is in provider group PCP_PROVIDERS), contract provider filter rules need to be configured. A contract provider filter rule has the following fields:
| Field | Description |
|---|---|
Capitation Contract |
The contract to which the provider filter rule belongs |
Sequence |
The sequence of a provider filter rule within a contract |
Provider Assignment Type |
The provider assignment type that the assigned provider of the member needs to be of (must be specified if the attribution type of the contract is Member and Provider) |
Provider Group |
The provider group that the assigned provider of the member needs to be affiliated with |
Attribution Filter Condition |
The dynamic logic condition that holds restrictions on the provider of the attribution that cannot be evaluated through the static dimensions for provider assignment type and provider group or it holds restrictions on the time validity of the attribution |
Note that at least one of provider assignment type, provider group and condition must be specified if the attribution type of the contract is Member.
Contract Rate Splits
If the rates for a contract need to be split between different payment receivers, contract rate splits need to be configured. A contract rate split has the following fields:
| Field | Description |
|---|---|
Capitation Contract |
The contract to which the rate split belongs |
Split Level |
The level that the rate split applies to (Rate, Adjustment or All) |
Adjustment Schedule |
The specific adjustment schedule to which the rate split applies (may only be specified if the rate split is of level Adjustment; if specified the rate split only applies to the specific adjustment schedule else it applies to all adjustments) |
A contract rate split has one or more contract payment receivers, specifying what percentage of the rate is payed to which payment receiver. A contract payment receiver has the following fields:
| Field | Description |
|---|---|
Contract Rate Split |
The contract rate split to which the payment receiver belongs |
Percentage |
The percentage of the rate that is payed to the payment receiver |
Payment Receiver Function |
The dynamic logic function that determines the payment receiver |
Contract Adjustments
Contract adjustments are added to contracts in the context of contract time periods. A contract time period has the following fields:
| Field | Description |
|---|---|
Capitation Contract |
The capitation contract to which the time period belongs |
Display Name |
The display name of the time period (must be unique within a contract) |
Start Date |
The start date of the time period |
End Date |
The end date of the time period |
Contract adjustments specify which adjustment schedules apply to a contract and the order in which they are executed within a contract. A contract adjustment has the following fields:
| Field | Description |
|---|---|
Contract Time Period |
The contract time period to which the contract adjustment applies |
Adjustment Schedule |
The adjustment schedule that applies (only adjustment schedules of adjustment type Contract may be added to a contract) |
Sequence |
The sequence of the adjustment schedule within a contract time period |
A contract adjustment override stores an overriding value for an adjustment schedule line that is used in the context of a contract. A contract adjustment override has the following fields:
| Field | Description |
|---|---|
Contract Adjustment |
The contract adjustment to which the override applies |
Adjustment Schedule Line |
The adjustment schedule line for which the override applies |
Amount |
The amount by which the rate is adjusted |
Currency |
The currency of the adjustment amount (this field is read-only; it is automatically set to the adjustment currency specified on the adjustment schedule when the amount is specified) |
Percentage |
The percentage by which the rate is adjusted |
Amount Function |
The dynamic logic function that calculates the adjustment amount |
Note that exactly one of amount, percentage and function must be specified. Also note that the adjustment schedule line and the contract adjustment of the contract adjustment override must refer to the same adjustment schedule.