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Claims Stuck on NPE Because Product Change During Claim-Span Not Taking Copays Correctly (Doc ID 2926570.1)

Last updated on FEBRUARY 17, 2023

Applies to:

Oracle Health Insurance Claims Adjudication - Version 3.21.2.0.0 and later
Information in this document applies to any platform.

Symptoms

OHI Product: Oracle Health Insurance Claims Adjudication
OHI Version: 3.21.2.0.8

If the claim dates of service span dates with a change in the member’s product, duplicate cost-share is getting applied.
There are three claims which a Classification of OUTPT_SURGERY_SDC and all three claims have the Surgical Day Center Copay expected to max out at $250.
The copay shouldn’t be applied twice. For all three examples two copays where applied for a total of $500 on each claim.

Example: Claim had dates of service before and after 7/1, the member’s anniversary and windchill date change.
The service/operation room procedure took place on 6/30 and SDC Copay of $250 was applied, additional ancillary services were billed with a date of service 7/1.
The Product changed on 7/1 and the SDC was again applied for those services such as Lab Chemistry, Lab Hematology, etc..

This could happen with other service with the same type of counters/case logic such as emergency room care.

Note: This was getting detected on claims that were previously stuck on Null Pointer Exception for members changing products during duration of claim which was fixed in 3.21.2.0.8.

EXPECTED:
There should not be two SDC Copays applied even when the windchill is getting changed.


 

Changes

 

Cause

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In this Document
Symptoms
Changes
Cause
Solution


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