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External Intervention Rules Not Triggered When There Is Concurrent Use Of Benefits (Doc ID 2426060.1)

Last updated on JULY 25, 2018

Applies to:

Oracle Health Insurance Claims Adjudication - Version 2.17.2.0.0 and later
Information in this document applies to any platform.

Symptoms

There is an external intervention rule based on message generated by benefits calculation.  When there are two or more claims "consuming" the same benefit rule, for some reason the external intervention rules is not being triggered. And the claim is not being pended. A  benefit limit is configured with a message to be attached when the limit is reached.  There is an a external intervention rule created based in a message group. The limit message is part of this group.  When the claim gets this message, the external intervention rule should be triggered, and make the claim pended.

The problem appears when there are two claims consuming the same limit at same time.  When this happens, OHI reevaluates benefits for the 2nd claim to make sure that the limit is being consumed correctly.  But the external intervention rule is not being triggered even when the claim has the message attached.

The workaround is to avoid to receiving claims at same time (seconds).  But this is too complicated to implement.

Use Case:
Dialysis patients are allowed 3 sessions per week. If there is a fourth session the Dialisis center has to provide evidence that a doctor requested this fourth session (this happens for instance during pregnancy). So when the fourth sessions comes in the claim is pended and starts a workflow to request more information to the Dialisis center once that is provided the claim should be reprocessed and paid. In the situation where two claims come in at the same time the pend is not coming which means the flow is not working and we are going to pay the claim.
A possible workaround is to deny the fourth claim and pend the denied claim and then at least the claim will not get paid. But the workflow will not be started because there is no pend.

The expected behavior is the external intervention rule should be triggered and the claim with the limit message should be pended because of the rule.

The issue can be reproduced at will with the following steps:
1) Create an adjudication limit with a exceeded message, and configure the benefits in a way that this limit is being used.
2) Create a message group, and attach the message into it.
3) Create an external intervention rule, based on this message group.
4) Send two claims at same time, using the procedure configured.

Since the claims is not being pend, we would have two claims being paid where only one should.

Changes

 

Cause

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