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Splitting claims based on provider information

Suggest edit Updated on August 31, 2021

The provider eligibility module is also used to split claims based on specific provider related scenarios. These are in the instances where the provider or their contract is terminated, and the claim or line needs to be split to support adjudication against the covered period. The SCE can split the claims or lines based on the appropriate effective and ineffective dates.

The provider split models use the standard split claims criteria and bypass models to include or exclude the claims for split. Information on the split rules applied and the criteria and bypass rules can be found in the Split Claims section.

Split claims based on business entity termination dates

To enable the splitting of claims based on the business entity termination dates, the criterion “Provider termination” needs to be set to True on the SplitClaimsCriteria table.

The split claims logic based on the provider termination dates uses the dates of service on the claim and line and the effective and end dates of the billing provider (business entity) on the provider record. In the instance the dates of service on the claim overlap the effective period for the provider, the claim will be split into multiple claims, where one claim contains the active period and the other, the inactive period.

The effective and end dates for the provider is found in the Billing Provider record on the clipboard and is part of the provider data structure.

The table below, provides an example when the provider effective period does not cover the complete claim.

ProviderEffective DateEnd Date
Provider 11/1/201810/30/2018
ClaimDOSExpected Results
Line 110/20/2018-10/22/2018
Line 210/25/2018-10/27/2018
Line 311/1/2018-11/2/2018
Line 410/28/2018-10/29/2018

The table below shows another scenario where some of the lines have dates of service spanning the provider effective period. In this situation, the lines are also split.

ProviderEffective DateEnd Date
Provider 11/1/201810/30/2018
ClaimDOSExpected Results
Line 110/20/2018-10/22/2018
Line 210/25/2018-11/5/20/18
Line 311/1/2018-11/2/2018
Line 410/28/2018-10/29/2018

When a claim is split based on Provider termination dates then the new split claim which is comprised of the lines where the provider is not active will set event code SPE-0090 (Billing provider not active). The new split claim with the active Provider dates will set event code SGB-0035 (Provider termination split) assigned for review if required.

Action code ASOC (automatic split original claim) will be assigned to the original claim, and the new claims will have action code SPC-4 (Provider termination) assigned.

The description of the process involved with splitting the claims can be found in the Splitting the claims section of the user guide.

In the instance there is an uneven split of amounts, units, COB amounts, or COB units, then the respective event codes will be raised. The system will also show the relevant audit messages for the uneven split amounts and units.

Split claims based on provider contract termination

The split claims logic based on the provider contract termination dates uses the dates of service on the claim and line and the effective and end dates of the contracts on the associated provider record. In the instance the dates of service on the claim overlap the effective period for the contract, the claim will be split into multiple claims, where one claim contains the active period and the other, an inactive contract period or another active contract period. This split logic will ensure that the claims and lines can be processed successfully against the appropriate provider contracts.

The effective periods for the provider contracts are seen in the contracts section of the business entity record. The claims for any non-covered contracts will be adjudicated based on the plans non-covered contract rules.

Note: provider contract validation and line split are also performed as part of the ratesheet selection module, where the appropriate contracts and ratesheets are aligned to the claim lines.

The tables below show some examples for the contract split:

Example 1: - Contract terminated

ProviderContract Effective DateContract End Date
Provider 11/1/20189/30/2018
ClaimDOSExpected Results
Line 19/25/2018-9/28/2018
Line 29/28/2018-9/30/2018
Line 39/28/2018-10/2/2018
Line 410/1/2018-10/2/2018

Example 2: - Multiple effective contracts

Provider
Provider 1
ClaimDOSExpected Results
Line 19/25/2018-9/28/2018
Line 29/28/2018-9/30/2018
Line 39/28/2018-10/2/2018
Line 410/1/2018-10/2/2018

When a claim is split based on provider contract dates then the new split claim which is comprised of the lines where the contract is not active will set event code SGB-0039 (No active provider contract). Any new split claims with the active contract dates will set event code SGB-0036 (Provider contract termination split) assigned for review if required. If multiple overlapping active contracts are found, then SGB-0040 (multiple provider contracts) is assigned, as a manual split will be required.

Action code ASOC (automatic split original claim) will be assigned to the original claim, and the new claims will have action code SPC-3 (Provider contract split) assigned.

The description of the process involved with splitting the claims can be found in the Splitting the claims section of the user guide.

In the instance there is an uneven split of amounts, units, COB amounts, or COB units, then the respective event codes will be raised. The system will also show the relevant audit messages for the uneven split amounts and units.

Split claim lines based on provider contract termination

The SCE will also split claim lines based on the provider contract termination dates. In this situation, where the claim line has a date of service spanning the provider contract, the SCE will cancel the original line and create two new split lines based on the contract effective and end dates.

In this situation, the system splits the claim lines into 1.1S, 1.2S as per the effective and end dates. On the split claim line where the dates of services are outside the effective and end dates of the provider contract, the system raises the event code SPE-0090 - Billing provider not active.

All the original claim lines which have been split are assigned a cancelled status and visible in the UX just below the active claim lines. The new split claim lines are assigned action code SP-102 – Claim line has been split.

Along with the action codes while splitting the claim lines, the system will also show relevant audit messages on split lines stating the line is a split line, the original line ID and the reason for splitting the claim line.

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