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OHI Claims is Applying Two Provider Limits when the Claim Line Has Procedure 1 and 2 Indicated (Doc ID 2358961.1)

Last updated on FEBRUARY 12, 2018

Applies to:

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


OHI Claims Adjudication is applying two provider limits when the claim line has procedure 1 and 2 indicated.

When there is a claim line with procedure1 and procedure2 indicated, the system is applying the provider limit twice. One for the procedure1, which actually has the provider limit configured, and another for the procedure2 which does not have any limit configured.

The limit should only be counted for the procedure which actually has the rule linked to it. There is no known work around.

The issue can be reproduced at will with the following steps:
1) Create a provider limit without the amount for the period.
2) Use a period of 1 day for the sake of simplicity.
3) Create a ppc using this provider limit, and indicate the amount of 2, and link it to a procedure group.
4) Add a procedure into this procedure group.
5) Create a claim, where the claim line has the this procedure in the field procedure1 and use a different procedure in the field procedure2.
6) Process the claim, and check the limits being used.




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