Notice:
Insurance Rules are mostly applicable to the USA claim process (although Canadian customers can use them)
Since most Canadian Claim rules are managed automatically by the Claim payor when using the specified Claim Connector. The need to use the Insurance rules is typically not applicable in a Canadian setting.
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The Insurance Manager Policy section permits users to define the business rules ( eligibility and Billing) for each policy entered under a given Insurance company.
Filopto uses the concept of Business Rules to determine how a claim is to be created. Business Rules is a form of artificial intelligence which applies, or not, the processing rules defined by the users. A rule can be informational in nature or can calculate a value (price, write off, transfers, balance due) for a given item or service.
Filopto supports multiple types of rules. In the Insurance Manager, two types of rules are defined; Eligibility Rules and Billing Rules. An unlimited number of rules can be created for a given policy. A rule tester is included with Filopto for users to test how their various rules will be applied by Filopto.
Rule Tester:
It is important to verify the validity of the rules created. By running the Rule Tester for the various services or inventory items you sell, the rule tester will provide a list of each rule applied or if a conflict exist between rules created, the rules which are conflicting with each other. If a conflict exists in the rules, Filopto will report in the tester that the selected rule is in conflict. It is extremely important that you test the rules you create for accuracy. If you instruct Filopto via a rule to do the wrong action, it will execute this incorrect rule and cause your claim to be inaccurate.
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Each policy can (normally will) have more than one rule to describe the terms of the insurance policy. Business rules are applied based on their criteria and on the items or services that they apply to. For example, if you have a rule which only applies in a certain circumstance, it will only be triggered when that circumstance exists. This is why it is important to test your rules to insure that they run at the appropriate time or circumstance.
Eligibility Rules
Eligibility Rules are informational rules designed to prompt a user to review or ask a question. The Eligibility rules cannot be enforced by Filopto since many of the criteria on which they are based, are outside the scope of the knowledge Filopto contains. For example, if a patient has already seen another provider in another practice, this information is not recorded in Filopto and hence outside of its knowledge scope. Not having this information could cause a rule not to be properly applied.
The eligibility rules can help reduce oversights or errors by advising a user of a particular requirement that the insurance policy may require. By reducing the knowledge required by the user to remember, Filopto can insure that all processes required by the insurance company is properly completed; reducing errors and speeding up the processing of a claim.
Billing Rules
Billing rules are rules which specify direct action to be taken by Filopto in calculating and preparing a claim. Extremely flexible, the billing rules are created by the user, by completing in English, the sentences describing the action to be done in a particular situation. Filopto then interprets these rules at claim preparation time to determine the price or fee for a given item or service. These rules can also automate the process of transferring amounts to patients or writing off fees that will not be paid.
How are the Rules Applied
Filopto rules engine applies the rules based on their specific application criteria. The rule must have an active status and be valid for the date of the invoice in question. If the rule has expired or has a non-active status, it will be ignored. It will only apply one rule for every type of rule available.
Rules are applied in the following order:
1) Specific items
2) Group of Items
3) Flat Fee for complete Invoice
IF FILOPTO FINDS A RULE THAT APPLIES IT WILL STOP PROCESSING AT THAT POINT. FOR EXAMPLE IF A RULE IN ITEM 1 IS FOUND FILOPTO WILL STOP PROCESSING AND WILL NOT DO STEP 2 AND 3.
Important:
If you have two rules that can affect the same item, the Filopto engine will always use the rule specific to the item. and ignore the other rules. For example if you create a rule for the inventory category Frame and you create a second rule for the specific frame # XXX, when the rule engine is active it will automatically go an choose the rule for the specific item in this case Frame #XXX and will ignore the rule for the general class called Frames.
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For example it will only apply one rule for what the policy pays and what the patients pays. You can have as many rules as you want, but for one item or service, only one rule for every type of rule will be applied. The rule tester will identify any known conflicts which may result in applying the rules you created.
Basically, the rules engine first looks for specific rules applying to the selected item or service. If it finds one, it will apply this specific rule and stop processing for that rule type. If it does not find a specific rule for the specific item or service, it will look for rules that apply for the type of items or services selected. If it finds a rule applying to the type, it will apply that rule and stop processing for that rule type.
For example, if a specific rule states that the Insurance policy pays $X for a specific item, it will be used, and any other rule will be ignored. If a rules states that for a given type of item, for example; Frames, a price table rule is to be used, then, if no specific rule for the specific frame can be found, the price table rule will be applied.
If more than one rule exists for a given item, the rule tester will show the rules in conflict. You will need to address the rules in conflict so to have only one rule apply for your test case to function. Once you are confident that your test case properly reflects the various billing scenarios you will encounter, you can start using the billing rule to auto-create that type of claims. Do not use a defective rule since it will generate erroneous claims.
Rule Conflicts:
When rules conflict with one another the Rule Tester will display in it's report information that can be used to correct the error. In the example below the rule tester identifies that rule 79 and rule 67 are in conflict. If the conflict is not resolved the Filopto engine will not be able to determine which rule to apply and will arbitrarily apply one of the rules in conflict which may result in an incorrect claims being sent to the insurance company.
There are more than one rule for Policy Pays. This will cause a conflict and an uncertainty of which one of the rules found that will end up being applied to the item. List of conflicting rules: - 79, Exam - 67, Exam Balance Amount: $ 80.00 No Applicable Rules. |
