How to route claim to specific Group using BIN/PCN

Network Pricing is defined in the Provider Network module. Provider Networks are grouped into Panels which are added to Group/Plan Association. When a claim starts processing

• First, the adjudication group is identified. (Refer to this document for more details on the group identification process)
• In the Group Plan Association, we have a list of networks. The Service Provider ID in the claim is matched with an appropriate network and the pricing is applied accordingly.
• Adjudicating against the correct group and network is important to apply correct pricing.

Business Requirement

1. A Client had multiple network panels, with the same stores in it. Each network has slightly different pricing strategies. There were various programs each with their own BIN and/or BIN/PCN combination.
2. The client wants the group ID to be the same on all the programs.
3. The client wants to enforce the routing of claims using BIN/PCN number

In the Procella platform, PBM users must create different groups for different programs to handle the different pricing. With different groups in the system, it is required to submit the group ID appropriately to apply the correct pricing. However, the client has the business requirement to have same group ID for all programs. 

Solution

• As a BIN and/or BIN/PCN combination is unique to the program, those data's are going to be used to determine the group identification. If the group is identified correctly, then the right pricing will be applied. The system is enhanced to hold a 'BIN/PCN -> Group Routing' data to drive the claim to correct pricing.

Check If the "BIN/PCN -> Group routing" data is available,

           If available, it will be used to determine the group based on BIN/PCN, if we are unable to determine the group,

          Then it will move the usual logic to identify the group (Refer here for more details on how the group is identified)

    

How to Setup the BIN/PCN to Group Routing

• In the PBM configuration screen, you will have BIN/PCN Routing toggle.

• When you enable the toggle, you can add multiple BIN/PCN combinations to specific groups.

• Once saved and activated, this data will be used to identify the group with BIN and/or BIN/PCN combination. If the group is not identified, then the system will iterate through further steps to identify the group. The logic is explained in the below diagram.
• Note: User can enter * in the PCN field to denote any PCN

BIN/PCN -> Group Routing explained with Examples

Example 1

BIN	PCN	Group	Comments
456111	111	GroupA	Claims will be routed to GroupA only when BIN/PCN is 456111/111
456111	121	GroupB	Claims will be routed to GroupB only when BIN/PCN is 456111/121
456111		GroupC	Claims will be routed to GroupC when BIN is 456111 and PCN is blank
456111	*	GroupD	Claims will be routed to GroupD when BIN is 456111 and PCN is any value other than 111 and 121

The system uses 'BIN/PCN -> Group routing' data to match in the following order 

• First, Both BIN and PCN data are matched with BIN and PCN in the claim. If there is no exact match, then
• Then BIN and <wildcard> are matched if a PCN is submitted in the claim. For eg., If BIN/PCN is 456111/999, then the claim will be routed to GroupD
• Then BIN and <blank> PCN. For eg., BIN/PCN 456111/<blank> will be routed to GroupC)

Note: The system identifies the group in the above order irrespective of the entry order in the PBM configuration. It is not necessary to leave 10 spaces to denote blank PCN.

Example 2

Example 2 is same as Example 1 but without a wildcard option (Wildcard here ANY PCN value)

BIN	PCN	Group	Comments
456111	111	GroupE	Claims will be routed to GroupE only when BIN/PCN is 456111/111
456111	121	GroupF	Claims will be routed to GroupF only when BIN/PCN is 456111/121
456111		GroupG	Claims will be routed to GroupG when BIN is 456111 and PCN is blank

With the above configuration.

• If BIN/PCN is 456111/<blank> then the claim will be routed to GroupG
• If BIN/PCN is 456111/999 then NO group from this configuration will be used. The system will try to match the submitted group with the existing group in the system and move further in the existing group identification logic

Example 3

Multiple combinations of BIN/PCN to single group can also be configured in PBM configuration.

BIN	PCN	Group	Comments
456111	111	GroupE	Claims will be routed to GroupE only when BIN/PCN is 456111/111
456111	121	GroupE	Claims will be routed to GroupF only when BIN/PCN is 456111/121
456111		GroupE	Claims will be routed to GroupG when BIN is 456111 and PCN is blank

Note:

• Either the adjudicated group ID or Submitted group ID can be sent in the claim response. This option can be configured in group configuration. If the Return Response Group is 'Adjudicated Group ID' then adjudication group will be sent in the claim response. If the Return Response Group is 'External Group ID' then the submitted group ID will be sent in the claim response

• Procella platform allow multiple PBMs in a single instance. Routing the claim to specific PBM based on BIN/PCN is handled at the instance level. This configuration is available in Super Admin menu. This menu can be accessed only by Super Admin.  Once the claim reaches a PBM, the BIN/PCN routing at the PBM configuration is used to route the claim to specific group.