Filters, OON Allowed Amounts, & Testing Best Practice Reminder

Summary

Summary

  • Filters - 400 Limit
    • FAQ for 400 filter logic
    • Change location to the location of the provider
    • If NPI only, then increases data size and can hit limit sooner
    • New call out: Setting up providers to avoid appearance of duplication:
      • Options:
        • Instead unique Provider Key in the provider data then multiple Location Key » This is set up as recommended
        • NPI and TINS need to match across rather than by only NPI
  • Filters - POS (see top of page 28 - Cost Implementation Guide)
    • Three types of Place of Service need to match - negotiated rate data, service code, provider specialty POS. Options to address:
      • Override the Service POS to include
        • This may also require the data for the rate or the specialty POS to be updated
      • Override the Specialty
        • This may also require the data for the rate or the specialty POS to be updated
      • Remove the HealthSparq POS filtering
        • Additional testing needed to ensure mapping is better without the filtering
      • Request for a change in the Cost Data Domain
        • This may also require the data for the rate or the specialty POS to be updated

OON Allowed Amounts:

  • The OON Allowed amount will come from data
  • If there are multiple rates, the lowest rate will be shown in the application
  • OON is the amount insurance will pay for the service vs INN is the amount the member will pay

Testing best practice reminder:

  • Use documented test cases vs comparing production to UAT