Combination Adjustment Rules Not Applying Correctly When the Primary Procedure is Denied (Doc ID 2234602.1)

Last updated on FEBRUARY 22, 2017

Applies to:

Oracle Health Insurance Claims Adjudication - Version 2.14.2 and later
Information in this document applies to any platform.

Symptoms

On :  2.14.2 version, Processing

Combination Adjustment rules are not applying correctly when the primary procedure is denied.

There seems to be a defect within OHI for pricing Combination Adjustments when the primary procedure is denied. Here are the two examples. (Same member, provider and DOS)

In other words,

Claim 1 – is marked as primary, but is denied post pricing, and finalized with status "Denied".
Claim 2- is processed after finalization of claim 1 – it is marked as secondary and therefore paid at the reduced rate (50%).


The expected behavior is that claims process as described in OHI Implementation Guide for Claims Flow
According to the OHI guide for Combination adjustment rule.

Claims flow page 151:
"Combination adjustment rules are evaluated across claims, not just within a single claim, also
taking into account approved claim lines from other finalized claims that have the same member,
provider and price input date to which the same combination adjustment rule was previously
applied. This has as a consequence that the sequence in which claims are (re)processed can
lead to different outcomes."

In other words,

Claim 1 – is marked as primary, but is denied post pricing, and finalized with status Denied
Claim 2- is processed after finalization of claim 1 – but because line 1 does not have status Approved, it is marked as primary and is therefore paid at the full rate.


Changes

 

Cause

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