Key Takeaways

Well done! There was a lot of important information in this course, so lets review some key takeaways:

Agenda:

  • Historical claims consists of the encounters list table and the treatment table 
  • The negotiated rates consists of supported service, service to specialty mapping, and specialty to place for service code mapping
  • It is important to understand this because data drives the Kyruus Connect for Payers user experience and cost is very important to patients. In order to give accurate cost estimates, you need to understand why and how the historical claims based and the negotiated rates-based cost estimates are dependent on the cost domain data 

Historical Claims: 

  • “Encounters” is a cost estimate for service check-in to check-out
  • Billing codes and default place of service are defined
  • Encounter data consists of: 
    • Encounter key, encounter name (searchable), submission format (type of provider associated with any given encounter), default EQ/service type, default place of service value, gender column, CPT code, encounter to service overlap (if there is a full match of service code displayed in Kyruus Connect for Payers)

Negotiated Rates:

  • Negotiated rates identifies the billing service code value and type for each support service code and defined the default service/EQ type for billing service code
  • Defines the default places of service code for the billing service code: code, code type, key, name, description, EQ type, place of service, CMS mandated service
  • Service to specialty mapping table: specific to CMS defined 500 shoppable services and identifies the specialties mapped to a given billing service code values as those most likely to perform the service 

Comparing Historical Claims and Negotiated Rates Domain Data:

  • Domain data comparison: 
    • Historical: 
      • Anchors on encounter key and treatment/treatment sub-category
      • May consist of a single billing service code(s)
      • Represents check-in to check-out cost methodology
      • Assigned to a single default facility or professional provider type, a single default EQ/service type, and a single default place of service value
      • Negotiated:
        • Anchors on the billing service code value and type
        • Consists of single billing service code
        • Multiple billing service code searches may be needed to see a full cost of care
        • Facility or professional rate type is assigned in the negotiated rates file
        • Assigned to a single default EQ/service type and a default place of service value or set of values