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Catastrophe action code

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Updated on August 31, 2021

The catastrophe action code (A-418) enables the SCE to identify claims that have been made in areas affected by a natural catastrophe.

The configuration for this utilizes a series of extensible decision tables which perform the following actions. If all the criteria on the supporting tables are matched, the A-418 catastrophe action code is assigned. The primary use case for this configuration is to turn off specific event codes or change any limitations in liability calculations. For example: bypassing authorization requirements, timely filing limits and out of network provider restrictions. This action code is provided as part of the claim business edits module.

Catastrophe Geographic Configuration

The decision table AM_Catastrophe_StateCityZip is used to configure the service dates and the Patient’s State, City or Zip/Postal Code for the catastrophe. The return from this table identifies the name of the catastrophe. All the configured fields on the decision table need to be true to return the catastrophe.

Catastrophe Effective Configuration

The decision table AM_Catastrophe_Dates is used to check the effective dates for the catastrophe. This is different from the service dates as this controls the system processing dates for the claims that meet the catastrophe configuration. This will enable a client to support late billing and any other delays associated with claim submissions. This table also provides the name and description for the catastrophe to support logging and auditing. The other fields for diagnosis, provider and member provide a higher level of configuration in the catastrophe control, limiting the reporting to specific diagnoses, billing providers or members.

The existence of a True value in the Check Diagnosis, Check Billing Provider or Check Member columns will enable the SCE to check the associated decision table against the claim data. The decision tables controlling these configurations are:

AM_Catastrophe_DiagnosisCode – Validates the primary diagnosis on the claim for the catastrophe to see if the catastrophe is limited to this diagnosis code.

AM_Catastrophe_Provider – Validates the billing provider’s Tax ID on the claim for the catastrophe to see if the catastrophe is limited to this provider.

AM_Catastrophe_Member - Validates the patient contract ID or ID on the claim for the catastrophe to see if the catastrophe is limited to this member.

The tables controlling the catastrophe configuration can be easily updated or extended to support the processing requirements.

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