Encounter Rule is Not Getting Applied on Claim Lines Even Though Risk Indicator is Y (Doc ID 2259335.1)

Last updated on APRIL 26, 2017

Applies to:

Oracle Health Insurance Claims Adjudication - Version 2.16.1.0.0 and later
Information in this document applies to any platform.

Symptoms

Claims are not processing correctly.  The Encounter rule is not getting applied on claim lines even though the risk indicator is Y
Expect that the Encounter rule would be applied to claim lines.

The issue can be reproduced at will with the following steps:
1. Extract the production ClaimsIn IP claim payload where the risk indicator is set to Y and load it to OHI through ClaimsIn IP

2. Claim will get processed further based on fields populated on claim and price and then adjudicated.

Changes

 

Cause

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