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OHI Creates Limits for Procedures that Do Not Have a Limit When Using Proc1, Proc2 in Claim Line (Doc ID 2403180.1)

Last updated on MARCH 26, 2019

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 Procedure1 and Procedure2 indicated. It applies 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.

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

The issue has the following business impact:
The limits can be counted in the wrong way which may lead to incorrect denial of coverage to member and payment to provider.


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