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Cost Share is Appearing on Later Claim Line Even After the Deductible Amount Has Been Consumed (Doc ID 2940639.1)

Last updated on APRIL 13, 2023

Applies to:

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


Cost share is getting applied on claim line even after the deductible amount has been consumed in earlier lines.

Product# MD00000xxx
Claim# 220114M66xxxwith member xx227746302
Line 1: 151.65
Line 2: 151.65
Line 3: 151.65
Line 4: 125.48
Line 5: 117.61
Line 6: 51.96
DED_MEM_IN_PCY_3MC of $750 has been met at line 6. $0.29, $0.4 & $0.34 is getting applied on claim line 8, 9 and 10.

Expected Results:
Cost share should not be applied if the deductible has been consumed.


1. Process a claim with multiple lines, with some lines with date of service as 12/31/2021(date of service should be in the 4th quarter of 2021 and product should be 3 month carryover.)
2. Rest of the lines should be with date of service in 1/1/2022.
3. Process the claim.
4. In limit consumption screen, limit is exceeding for the member in 2022.  But what was observed is that the carryover deductible of 2021 is getting to added to 2022 counter period in adjudication limit counter screen. Also, 2022 deductible is getting added to the counter period and limit is met.  Once limit is met thecost share should not be added towards deductible.


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