Claim Days for the New Plan Year are Not Being Applied

(Doc ID 2363833.1)

Last updated on FEBRUARY 21, 2018

Applies to:

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


There is a high dollar claim for a period of 105 days – dates from 6/14/2017 thru 9/27/2017.  The benefit has a limit of 100 days.  The member’s product is a plan year product with an anniversary date of 7/01/2017.  Currently the claim is only paying the days up through 6/30/2017 and not seeing that there are more days beginning on 7/1/2017. 

The expected behavior is that starting on the anniversary date the claim processing would allow for the new year's dates to be used.

This high dollar claim can't be paid which is a problem for the provider.




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