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Processing financial accumulators from Smart Claims Engine

Suggest edit Updated on April 26, 2021

Within the main CE_CoverageAccumulators collection, there are different steps included.

  1. SetActionCodeForPenaltyCalc
  2. CalculateShares
  3. CE_DetermineBenefitLifeTimeMax
  4. CE_DetermineCOBSavings
SetActionCodeForPenaltyCalc
This first collection within the coverage accumulators module will help in setting the action codes for each of the penalty calculation methods available. In total there are 24 action codes which are configured for different penalty calculation criteria.
Within this collection, the FindActionCodeForPenalty DT will be triggered to find the respective action codes.
Calculate shares
Calculate Shares is the main collection, which calculates the copay, coinsurance, and deductible based on the OOP Max amount.
The Calculate Shares collection screen displays the general description of the steps.
Within this collection there are 4 steps as mentioned below.
  • The application removes the pages existing on the clipboard (AMR_SingleAccum, AMR_FamilyAccum, AMR_OOPMaxSingleAccum, and AMR_OOPFamilyAccum).
  • The CheckForReadmission DT step would be to check whether the claim is a re-admission claim or not and if it it a readmission claim then the co-pay will be waived for that claim.
  • In this step, the CalculateCopayDeductibleConinsuranceES collection runs on all the claim lines calculating the cost shares based on the CalculatedAllowedAmount of the claim line.
  • The application copies the calculated accumulators to the work object and TempFinancialAccumsToCommit for updating the module.
CheckForReadmittance
This DT will check whether the claim is a readmission claim or not and if it is a readmission claim then the copay will be waived in this claim.
CalculateCopayDeductibleCoinsuranceES
This section describes steps in detail for the entire cost shares calculation.
  1. CalculatePenaltyAmount: Step 1 calculates the Penalty Amount if applicable.
  2. Step 2 checks if the Claim Line has matched to a benefit.
  3. CheckForCalculationMethod: Step 3 checks the deductible calculation methods on the Benefit.

    Based on the Options available in PCS or in the Flattened Structure, the application is able to adjudicate Claims using the following Deductible Calculation Methods:

    1. Number of Members (who have to meet the Individual Deductible) - Deductible Structures.
    2. Policy Method (all Family Members contribute until the Max Deductible Amount is met).
    3. Embedded Deductible Method [Existing].

    The data transform CheckForCalculationMethod is used to identify if the deductible calculation method was configured in the benefit. If any of the above mentioned calculation methods are not present in the benefit, the system considers it an invalid deductible configuration and raises an event 8060 at line level. For number of members, the max deductible for a Claim Calculated should be Number of Members * Individual deductible. If this is not true, the system raises an event 8062 (Incorrect configuration).

  4. CalculateCostShares: Step 4 calls the CalculateCostShares data transform rule will perform the actual cost share calculations like copay, coinsurance and deductible as per the order of cost shares configured in the PCS instance.

    Within the CalculateCostShares DT, there will be many steps involved like

    GetValuesForCalculationMethod: This DT will fetch the benefit name, network ID as well as benefit group and units of service paid count etc. information.

    Determine the order of cost shares: DetermineOrderOfCostShares DT will check for the order of cost shares as configured within the PCS instance and will calculate cost shares as per the order.

    CalculateApprovedAmountForCostShareNA: This particular DT will update the approved amounts if cost share is not applicable and manually entered.

    1. Count towards calculation: The CountTowardsCalculation DT will check which cost shares will be contributed to which accumulators. Enhancing the SCE adjudication to accommodate the incorporation of "Count towards flag/Contributes To".

      In PCS we have an option to select the count towards flag for each of the cost shares to determine whether the respective cost share will contribute to.

      1. Network and Benefit level Individual deductible
      2. Network and Benefit level Individual out of pocket
      3. Network level Family deductible
      4. Network level Family out of pocket

      Based on this indicator only the cost share will be contributed to respective accumulators towards which the count towards flag for that cost share is enabled/checked.

      Only the accumulators for which the “contributes To” flag is enabled will be updated on adjudication of a claim and rest all accumulators for which the contributes to flag is disabled or not checked will not be consumed or updated.

    2. Process manual cost shares: ProcessManualCostShares DT will set the manually entered cost shares information if the accumulators are not exhausted.

    If the accumulators are exhausted and if there are manually entered cost shares then SCE will raise an event.

    Calculate copay for claim line: Copay will be calculated for each of the claim line from CalculateCopayForClaimLine DT.

    CalculateCoinsForClaimLine: This DT will calculate coinsurance for each claim line.

    CalculateDeductForClaimLine: This DT will calculate deductible for each claim line.

  5. CalculateAnnualAndLifetimeMax: The fifth step will be to calculate the annual and Llife time max from the CalculateAnnualAndLifetimeMax DT.

    If the approved amount is greter than 0 then the approved amount will be contributed towards the annual and life time max based on the contributes to flag.

  6. CrossNetworkAccumulation: The sixth step will be the cross network accumulation. In CrossNetworkAccumulation DT, SCE will check whether the accumulators should be accumulated across the networks as configured within the PCS instance.

    In PCS instance, within network level cost share configuration page, there will be an option for the user to choose whether any particular network level accumulators should accumulate to other networks as well which can be configured in the below screen.

    If the check boxes found above are checked then the current network accumulators will also contribute to the other accumulators whichever are checked in for respective networks.

CopyAccumsToFinancialTransactions
The last step within the CalculateShares collection would be CopyAccumsToFinancialTransactions DT where the accumulator details will be copied to the work object.
CE_DetermineBenefitLifeTimeMax:
Once the calculate Shares collection is completed then CE_DetermineBenefitLifeTimeMax DT will trigger to calculate the benefit life time max. This DT will calculate the benefit life time maximums for only Dental claims.
CE_DetermineCOBSavings
If the claim identifier is CH or 31 then this collection will be triggered to check if the plan is eligible for COB savings and will apply COB savings to out of pocket expenses for that particular claim as applicable.

As part of this collection, the first check will be to retrieve COB savings accumulator by triggering CE_RetrieveCOBSavingsAccumulator DT.

If there is no COB savings accumulator found then the claim will exit from that collection.

If there are more than 1 accumulators found for COB savings then an event code SCA-0010- Multiple active financial accumulators found, will be raised.

CE_CheckForCOBSavingsEligibility
This collection will check whether that particular member is eligible for COB savings or not.

In this collection, CE_CheckForCOBSavingsEligibility DT will be triggered to find out whether the member is eligible for COB savings.

Within PCS, while configuring a plan, under the plan cost shares section, there is a collapsible column by name Co-ordination of benefits within which user can configure whether the members enrolled under the plan are eligible for COB savings account or not.

If the user checks any of the cost shares shown above then those cost shares will be contributed towards the COB savings accumulator. If the cost shares are not checked in then they will not contribute to COB savings account.

There are 2 payment calculation methods to calculate COB savings:

  • Lesser of COB calculation
  • Remaining Patient liability

Regarding the COB calculation methods you can refer to COB Recutions module for more insight.

The COB savings calculated will be added and shown within the additional patient liability section.

Event Codes in Coverage Accumulators module: As part of the coverage accumulators module, we are raising 13 event codes.

The validations will be like invalid calculation methods, invalid cost share amounts, invalid cost share configurations, exhausted accumulators, Invalid penalty configurations as well as multiple header level penalties etc.

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