Procella Helpdesk

EDIT - Plan Amount Stop Loss

The Plan Stop Loss (PSP) is the accumulator to capture the totals that the plan paid.  Many of the options will be consistent with other accumulation edits such as deductible and MOOP.  There are some additional options, though, that enable certain data to be included or excluded from the PSP accumulations.

Edit Name is the unique name for the edit.

Claim Type

  • All, POS, DMR

Message Group is the assigned Message group to be captured each time the edit is used.

Override Global Settings

Below are the standard financials that the Plan Pay Amount may include.  Some of the amounts, though, may not be considered part of the Plan Stop Loss accumulations for specific business reasons.  For instance, if the member selected a Brand when a Generic was available, there may be an amount attributable to the DAW (Product Selection/Brand Drug) that should not be considered towards the PSL.  Here is where excluding the Program Admin Fee from the PSL setting is established. 

With the switch on for Program Admin Fee, those amounts will be excluded from accumulating in the Plan Stop Loss amount.

Maximum Accumulation

Accumulation Method

  • Individual:  The Plan Stop Loss Maximum is accumulated and applied to each individual member.
  • Family:  The Plan Stop Loss Maximum is accumulated and applied to each Family unit.
  • Individual & Family:  There is a Plan Stop Loss Maximum for each member and for the entire Family unit.  Once the Family Plan Stop Loss Maximum is met by any combination of Family members, no other members are required to pay a Plan Stop Loss Maximum amount.  Individual members may hit their Individual Plan Stop Loss Maximum before the Aggregate (Family) Plan Stop Loss Maximum is met.
  • Family # to Meet:  The number of Family members required to reach their Plan Stop Loss Maximum before Plan Stop Loss is considered satisfied for all Family members.
    • # to Meet:  The minimum number of family members who need to meet their Plan Stop Loss Maximum before the Family Plan Stop Loss can be considered satisfied.  This field is only active when the Accumulation Method is # to Meet

Maximum, Member:  The Plan Stop Loss Maximum for the Individual 

Maximum, Family:  The Plan Stop Loss Maximum for the Family.

Members to Meet:  The number of individuals within the Family that must meet their Plan Stop Loss before the Family Maximum can be considered met.

Maximum Period

Period Type:

  • Term:  The Term period has a defined start date and then a defined number of months.
  • Rolling:  This type of period accumulates for a fixed period (months) and then restarts for another fixed period of the same length.  The maximum accumulation period begins on the Date of Service of the first claim for the member that meets the criteria for the EDIT.

Proration:  Check Box.  This indicates that the Proration rules in the Group/Plan setup should be used.

The other Proration settings are set at the Group/Plan level.  The Group/Plan settings will identify if the Proration is setup for the Plan or the Member and if it is Plan, the Start Date.  For Member, the start date will be the Subscriber’s coverage effective date.

Start Date:  The date a maximum accumulator starts.  Only for Term.

Duration, Length:  The length associated with the Period Type for the maximum accumulation.  This field reflects the number of months.  Only available for Term and Rolling.

Rollover Option: (only available for Period Type of TERM and Accumulation Method is Individual or Aggregate) Max, No Max.

  • Rollover Percent: (only if Rollover Option is Max or No Max) This reflects the percentage of the Periodic maximum (does not apply to Lifetime) that is eligible for Rollover. 
  • Rollover $ Max: (only for Rollover Option is Max) This reflects the maximum amount that is available for Rollover. When there is a value in both the Percent and $ Max, the $ maximum is compared to the Rollover Percent of the benefit Maximum.  If the Percent calculation is less than the maximum, the percent amount is rolled over.  If the Percent calculation is greater than the $ maximum, the $ maximum amount is rolled over.

Exceed Maximum

Exceed Maximum:  Deny the claim or have member pay 100% of claim cost.

Reject Message:  If DENY is the exceed maximum selection, the Reject Message of 76-Plan Limitations Exceeded will be used.

Processing

  • Default (check boxes)
    • Include in Plan Accumulation
    • Use Plan Accumulation
  • Advanced
    • Include in Plan Accumulation (check box)
    • Use Plan Accumulation (check box)
    • Use Accumulation (check box)
    • Network Classification: All, In Network, Out of Network
    • Network Type: All, Retail, Retail 90, Mail, Specialty (multi select)

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