Procella HelpdeskGeneral Information
As part of the benefit design setup, the adjudication rules control how claims are processed, paid or denied. This manual will provide general information on Criteria and Edits. Criteria and edits are the key components that make up an Adjudication Rule.
Benefit Plan Hierarchy
There are 3 primary levels of the benefit plan hierarchy: Complex, Exception, and Default. Adjudication rules are evaluated in this order, Complex, Exception, and then Default.
Complex Level
There is no functional difference between Complex and Exception levels. They are designed to assist in prioritizing the adjudication rules. The most specific rules are established at the Complex level. As a rule of thumb, criteria that include multiple domains are typically established at the Complex level.
Exception Level
The Exception level captures adjudication rules that are applied after the Complex level rules are applied. The Exception Level is generally for less specific adjudication rules. We consider the Exception level adjudication rules to be exceptions to the Default level rules.
Default Level
The Default level is the catch-all level. When a claim processes and does not use any adjudication rules in the Complex or Exception levels, the Default Level rules will be applied.
The Default Level is the most important level of the Benefit Plan Hierarchy. The adjudication rules established at the Default level will apply to all claims that are not previously addressed.
NOTE: It is not required to have adjudication rules at each and every level. The only level that is required to have adjudication rule setup is the Default level.
Claims will run through the adjudication rules in order of priority in the Complex level before moving on to the Exception level, and finally the Default level.
When a match is evaluated, the claim moves on to the next process. This means, for example, if the Copay is identified and applied, the process will not look for another Copay rule.
Sub Hierarchy Levels
Within each primary Plan Hierarchy, there are sub-hierarchy levels. Today, there are 2 sub-hierarchy levels, Provider and Plan. (Future enhancement will include Prescriber.)
Plan Sub Hierarchy
The Plan sub-hierarchy is established the same for Complex or Exception. The Plan Complex or Plan Exception sub-hierarchies are set up the same, associating a criteria with edits. The difference is the Plan Complex rules are evaluated before the Plan Exception rules.
Provider Sub Hierarchy
The Provider Sub Hierarchy is evaluated before the Plan sub-hierarchy. The Provider level has the same structure for adjudication rules, with one additional enhancement. In a Provider sub-hierarchy, provider(s) or provider group(s) are associated with the adjudication rule.
A common example where a provider sub-hierarchy adjudication rule is beneficial is enabling one set of providers to have a different copay than other parts of the benefit design.
Within each of these levels, there are 3 sub-hierarchies: Prescriber (not active today), Provider, and Plan.
As an example, the first hierarchy level evaluated is the Complex Level.
Within the complex level, there are 2 active sub-hierarchy options, Provider and Plan. Any adjudication rules in Provider Complex are evaluated before the Plan Complex adjudication rules.
Adjudication Rule Application
The Procella Platform evaluates adjudication rules differently than many systems. To understand the process, we need to understand what an adjudication rule is.
An adjudication rule is the combination of a criteria and one or more edits.
Edits
Edits are predefined controls that are used to ensure claims meet appropriate standards or have financial calculations.
Edits control financials (ingredient rates, dispensing fees, accumulations, etc), claim limits (Claim Min/Max, Quantity Limits, Age Limits, Days Supply limits, etc), benefit maximums (units, quantities, fills, etc), and clinical rules (Step Therapy, DUR, etc)
A simple edit is a Claim Min/Max edit. In the example below, the edit will reject a claim if the total cost of the claim is below $25.00 or above $500.00.
Criteria
A Criteria is a set of fields and values used to create an equation. This outcome of the equation will indicate if an edit or process will occur. What does this really mean?
A Criteria, at its core, is a Condition made up of a simple expression. An expression includes an Attribute, an Operator, and a Value. In the example below, the attribute is the Multi-Source Code from the drug data. The Operator is an EQUAL sign [ = ]. The Value is Y.
Order of Adjudication
When the claim is processed, the system evaluates the claim by ordering all the edits. When a claim is processed, the system gathers all the edits by edit type in the order of priority established in the plan. A snapshot of the order of adjudication can be found in Appendix A (below).
What this means is all edit type of Claim Min/Max are ordered based on the adjudication rule priority as established in the plan. In the example below, the adjudication rule of Criteria 7/CL MAX 1500 is checked to see if claim should use this edit. If the CL MAX 1500 edit was not applied, the Criteria 15/CL MAX$800 edit would be evaluated.
If the CL MAX$800 edit was applied, no further Claim Min/Max edits will be evaluated. The process would move on to the next edit category setup. In this example, the next edit category evaluated is Dispense as Written/DAW edits.
| PRIORITY | STRATEGY/CRITERIA | EDIT CATEGORY | EDIT NAME | ACTION |
| 1 | CRITERIA 7 | Claim MIN/MAX | CL Max 1500.00 | Rule not applied |
| 2 | CRITERIA 15 | Claim MIN/MAX | CL MAX $800.00 | RULE APPLIED |
| 3 | CRITERIA ALPHA | Claim MIN/MAX | CL Max 4K | Bypassed |
| 4 | CRITERIA LEMON | Claim MIN/MAX | CL Max 10K | Bypassed |
| 5 | CRITERIA BROWNIES | Claim MIN/MAX | CL MAX $25 | Bypassed |
| 1 | CRITERIA BROWNIES | DAW | Platinum DAW | Rule not applied |
| 2 | CRITERIA CIRCUS | DAW | CORE DAW | Rule not applied |
| 3 | CRITERIA ALPHA | DAW | Special DAW | RULA APPLIED |
| 4 | CRITERIA 7 | DAW | Delta DAW | Bypassed |
Adjudication rule processing evaluates claims through a defined order of adjudication. Ultimately, the claim is evaluated against adjudication rules by edit category and then its rule priority. If the claim satisfies the criteria in the adjudication rule, the process applies the edit and then moves on to the next edit category.
Adjudication Rule
An adjudication rule is a combination of a criteria and one or more edits. Adjudication Rules can be set up at all levels of the Benefit Plan Hierarchy, Default, Exception, and Complex.
In the Plan/Manage Rules screen, the Benefit Hierarchies are listed on the left side of the screen. These are laid out on the screen in order of most specific to the broadest (Plan Default).
When opening the Benefit Hierarchy, the Adjudication Rules option is found within each level. This is important as adjudication rules are created within the hierarchy.
When selected, the Benefit Assignment Group is shown. The standard Active/Draft status and date requirements continue with these functions.
The Benefit Hierarchy level for Adjudication Rules will have important information. In the upper left corner, the Benefit Hierarchy level is listed are the number of Active rules contained in the benefit assignment group. The effective start and end date of the benefit assignment group are provided as well.
On the right side of the screen, the effective date is populated with the current date. This date can be changed to see the rules established at any given date.
NOTE: When a Benefit Assignment Group has not been created, the number of rules will be ZERO and there will be no adjudication rules listed.
Creating a Benefit Assignment Group (BAG)
A Benefit Assignment Group is effectively a container, or “BAG”, of adjudication rules. Unless there exists a need, it is only important to have one BAG per benefit hierarchy.
To create a Benefit Assignment Group (BAG), click on the adjudication rules screen. Click on the New Assignment Group CREATE button.
A new window will open. The only information necessary is the Effective Start Date. This is the earliest date that any claim will be allowed. Enter the Start date. If the effective end date is needed, enter that date as well. Once the dates are set (typically only the Start date), click on the SAVE button.
At this point, the BAG is created and is in DRAFT status. It is now ready to add Adjudication Rules.
Creating an Adjudication Rule
To create an adjudication rule, open the benefit hierarchy level and select the adjudication rule option. If a BAG has been created, there will be information in the upper left of the BAG window showing the number of rules and the effective start and end date of the BAG.
To create a new Adjudication Rule, click on the plus icon at the bottom right of the screen. The following window will open.
Click on the New Rule CREATE button. This will open the Adjudication Rule window.
The Adjudication rule screen requires all fields to be complete.
- Rule Name: The Rule Name is your description of the rule. It is a required field and it is required to be unique (within a plan).
- Effective Start Date: This is the date of service the rule will first be eligible for use in claim processing.
- Effective End Date: This is the last date of service the rule will be eligible for use in claim processing. This is a THRU date, meaning the claim is good on the effective end date until midnight of that day. The default effective end date is 12/31/9999.
- Criteria: The Criteria section identifies which claims are to be validated against the associated Edits. To populate the Criteria, there are 2 options, defined criteria or an ad-hoc identifier.
- Defined Criteria: A defined criteria is a criteria built in the Criteria Manager. On the right side of the create/edit adjudication rule screen, the available CRITERIA are listed/searchable.
criteria are listed in the results, click on the 6-dot icon to the left of the appropriate criteria and drag the criteria to the criteria section of the adjudication rule.
- Adhoc Identifier: The ad hoc identifier enables the use of one drug attribute. The supported attributes include NDC11, NDC9, GPI-14 through GPI-02.
To use the ad-hoc option, in the criteria box, click on the Select an Attribute drop-down. Select the attribute needed. A value box will appear. Type in the Attribute value to associate with the edits.
NOTE: Only 1 attribute can be used in the Adhoc identifier approach.
- Edits: The Edits section will “capture” the drag and dropped edits selected for this rule. On the right side of the adjudication rule screen, the available edits are listed. First, select the edit category required for the rule and then select the edit to apply. If multiple edits are required, simply change the edit category, search, and select the next edit.
Edit Category & Search
On the right side of the adjudication rule screen, the Edit Category is selected/clicked on. In the Choose Edits area, the available edits will be listed. Searching for an edit is also an option.
Drag and Drop to Edit section
Once the edit desired is listed in the results section, click to the left of the edit name, a 6-dot icon will appear, hold, drag the edit, and drop in the edit section of the adjudication rule.
Repeat to add all the appropriate edits. Once the adjudication rule is designed, the record can be canceled, saved as a Draft, or Activated.
Completed Adjudication Rule
Once completed, the adjudication rule will resemble the example below. This example only has one associated edit, but multiple edits can be applied to an adjudication rule.
Remove an Edit from Rule
To remove an edit from an adjudication rule, click on the 9-dot icon in the adjudication rule, edit section. This will display the edits associated with the rule, including the edit name. In the upper right corner of each edit, a circular icon is displayed. Click on the icon and then click on Apply. The edit will be removed from the rule.
Activate the Benefit Assignment Group
When all adjudication rules have been added, the rules will be listed in the benefit assignment group.
The benefit assignment group will need to be changed from DRAFT status to ACTIVE for the adjudication rules to be active in production. Note: Benefit Assignment Group is a container for rules, the BAG has to be active for the active rules to be applied when processing a claim. If the BAG is in draft, the active rules inside the BAG will not be applied when processing a claim
Click on the triple ellipse icon to the right of the status.
Click on Edit Assignment Group. Click on the Status drop-down and select Activate.
The system will prompt for confirmation of the save. Click on SAVE to complete the saving of the benefit assignment group record with its adjudication rules.
The system will direct back to the now active benefit assignment group record with the associated adjudication rules.
The example below shows the active benefit assignment group record with the single adjudication rule created.
Adding an Additional Adjudication Rule
With the Adjudication Rule open to the Benefit Assignment Group, click on the
To add a new rule. The rule setup is the same as others.
Once the new adjudication rule is added, go to the Benefit Assignment Group and search for ASSIGNMENT GROUP STATUS of Draft. The newly added rule will be added as the next priority.
NOTE: When new rules are added, they are always added to a DRAFT benefit assignment group. This enables you to work on the adjudication rules before making them ACTIVE for use.
When the additional rules have been added/activated as appropriate, save the Assignment Group. If the Assignment Group is ready to activate, change the Assignment Group record from DRAFT to ACTIVE and then save.
Setting Rule Priorities
While the Benefit Assignment group is in DRAFT status, click on the Assignment Group ellipse. Select the Edit Assignment Group.
In the Edit Assignment Group screen, there are 2 ways to change the priority of the rules.
Drag and Drop
Click and hold to the left of the priority number of the adjudication rule, on the 6-dot icon, and drag to the priority level desired. Rules can be dragged up or down.
Priority Menu
Click on the ellipse of the adjudication rule, located between the STATUS and the down caret. The MOVE TO option will be presented. The move to option is looking for the priority number for the selected adjudication rule to move to. If the current adjudication rule is PRIORITY 2 and it should be Priority 1, simply click on the ellipse for Adjudication Rule 2, in the Move To option, type 1, and then click on Apply.
The selected rule will be placed at Priority 1 and the other adjudication rules will be updated with the new priority.
Provider Exception & Complex level Rules
The system allows for the establishment of adjudication rules with select Providers. All steps for creating an adjudication rule are the same as previously noted. An additional option is the ability to specify individual providers or provider groups.
The example below has different copay and days supply limits for the Criteria COMPOUNDS but only applies to the Provider Group of ACCESSHEALTH PLUS and the Provider ASHLEY CLINIC PHARMACY.
Provider and Provider groups are selected from the right side of the screen where Criteria and Edits are located.
As with the other screens, click on the ellipse to remove the providers.
Default Levels
The Default levels of the Benefit Hierarchy Level are slightly different than the Exception and Complex levels. The default level is where adjudication rules are applied when they have not been satisfied with adjudication rules at the Exception or Complex levels.
Plan Default
The Plan default level is the catch-all level. When a claim is not subject to any adjudication rules in prior levels, the edits established at the Plan Default will be applied.
Below is a sample of a Plan Default Adjudication rule. Note there are 5 edits established for any claim that passes through the prior adjudication rules.
The question arises, though, where are the Criteria. Simply, the criteria are inferred as everything not otherwise applied.
Provider Default
The Provider Default section is slightly different than the Plan Default.
In this adjudication rule section, the edits selected are associated with the Provider Type as defined in the Provider Network Panel. The options here include Retail, Retail90, Mail, Specialty, and Other. As with Plan Default, the Provider Default has no specific criteria but is everything not otherwise applied.
