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ISH_SG_CONTRACT_CAT - XV2 (Payment Distribution): Maintain Contract Schemes

ISH_SG_CONTRACT_CAT - XV2 (Payment Distribution): Maintain Contract Schemes

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Contract schemes let you qualify the insurance information pertaining to an insurance relationship for a case. You can specify different contract schemes for each institution. Contract schemes are independent of insurance providers and insurance provider types.

The information contained in the contract schemes is stored on two levels:

  • The header data contains general information that is relevant for the contract scheme as a whole.
  • The item data contains information at service or service group level.

The following fields are available to you here:

  • Validity Period
    The validity period (Valid From and Valid To fields) determines the validity of the contract scheme. You can only assign a contract scheme to an insurance relationship if the insurance relationship and the contract scheme have a common validity period.
  • Currency
    In this field, you stipulate the currency for all amounts in the contract scheme. If you do not make an explicit specification, the system fills the field with the local currency of the institution.
  • Max. Days/Year
    Here you stipulate for how many days in the year the contract scheme is to be valid for an inpatient case. The system uses this specification as the maximum value for this contract scheme in the payment distribution function. The specifications relate to a calendar year.
If the system is to take into account days already covered from a previous case of the patient, enter the number of days in the Previous Days field when maintaining the insurance relationship.
This field is taken into account for inpatient cases only.
Example:
You enter the value 8 in the Max. Days/Year field of the contract scheme.
The system takes into account no more than the first 8 days of the hospitalization for this contract scheme.
Service charges incurred after this time must be borne by other insurance providers.

If you also specify the value 5 in the Previous Days field , the system only takes into account the first 3 days for this contract scheme.

  • Compensation Service and Service catalog
In the country version Switzerland , you can specify a compensation service in these fields.
With compensation, the insurance provider covers the amounts specified in the contract scheme irrespective of the prices of the services that are actually performed.
If the total amount of the relevant services is less than the amount the insurance provider has agreed to cover, the compensation service specified here is valuated with this difference. The compensation service is then assigned to be covered by this insurance provider. The compensation service is generated in relation to the billing agreement. This means that a corresponding billing agreement must exist for each insurance provider for which compensation is allowed.
Example:
The contract scheme specifies that the insurance provider covers CHF 30.- for all laboratory services. The compensation service COMPENSATION is defined in the system.

Laboratory services for a value of CHF 20.- are now performed for a case (with corresponding insurance provider and contract scheme). This means that the COMPENSATION service is valuated with the price CHF 10.- and is assigned along with the laboratory services for coverage by the insurance provider.

  • Case Type
    In this field, you can specify for which type of case your contract scheme is to be valid.
  • Interim Billing
    Select Interim Bill. if interim billing is allowed with the contract scheme. This field is only evaluated for outpatient cases.
  • Ext. FM and Destination
Here you can specify a function module and an RFC destination.
When payment distribution is performed, the system evaluates the function module specified in the Ext. FM field and not the header and item structure.
In this function module you can tailor payment distribution to meet your specific requirements.
The interface of this function module is predefined. For more information, refer to the documentation on contract schemes for external processing.
  • Percent, Max./Case and Max.Day/Visit
Using these fields, you can limit the maximum amount covered by an insurance relationship.
The fields Percent and Max./Case relate to the complete case. If you make an entry in both fields, the lower of the two amounts is relevant for payment distribution.
With regard to the Max.Day/Visit field, you can also specify whether the valuation is to be made per day/visit or for the whole case.
If you select Overall Valuat., the system multiplies the amount in the Max.Day/Visit field by the number of days the patient spends in your healthcare facility or by the number of visits to produce the maximum amount for the case.
If you select the Valuation per Day field, the system re-evaluates the maximum amount for each single day/visit.
Example:
A patient spends 3 days in your healthcare facility. The following costs are incurred during this period:
Day 1: 100.-
Day 2: 200.-
Day 3: 50.-
The particular contract scheme assigned limits the insurance coverage to 100.- per day.
If you selected Overall Valuat., the insurance covers 300.- for the complete stay (100.- for each of the three days). However, if you selected Valuation per Day, the insurance covers only 250.- in total. The costs incurred per day are compared with the Max./Case.
Day Costs Costs Covered by Insurance
1 100.- 100.-
2 200.- 100.-
3 50.- 50.-

  • Restrictions for Contract Schemes
The enhancement NPDIST00 lets you specify a requirement governing the use of the contract scheme in a function exit. The system evaluates this requirement when carrying out payment distribution. If the requirement is met, the contract scheme is evaluated. In the contrary case, the processing of the current insurance relationship is terminated. No payments are assigned to the insurance relationship.
Please read the documentation on the enhancement NPDIST00 and on the function exit EXIT_SAPLNPD1_001.
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The items contain restrictions at service level. Here you can make specifications relative to the coverage of single services or groups of services:

  • Rank
You have to specify a rank for each item. This rank determines the processing sequence for payment distribution.
  • Movement Type
Enter a movement type for which the item is to be valid.
  • If the contract scheme is evaluated for an inpatient case, the system only evaluates the item if the admission type of the case is identical to the movement type specified in this field.

  • If the contract scheme is evaluated for an outpatient case, only those services that are assigned to a visit of a type identical to the movement type specified in this field are taken into account for the item. However, if you have set the system parameter Outp. Billing: Billing with Visit Type of 1st Visit (AMB_BESF), the system always uses the visit type of the first outpatient visit for all of the services of an outpatient case.

  • Percent, Max./Case and Max.Day/Visit
Just as in the header data, here you can make specifications relative to the maximum coverage. However, in the item data these values refer to specific services only (see below).
  • To-Day
This field is available in the country version Switzerland only.
In this field, enter the date to which the item is to be valid. The item must refer to exactly one extended service here. An entry is not possible for service groups or immediate services.
By defining several items with the same service but with a different entry in the To-day field, you can create a daily scale for the coverage of this concrete service.
The day specifications always relate to the days in which the corresponding service was performed.
Example:
  • Item 1, To-day: 5, Service: XYZ, Max/Case: 30.-

  • Item 2, To-day: 8, Service: XYZ, Max/Case: 20.-

  • Item 3, To-day 12, Service: XYZ, Max/Case: 10.-

From the 1st to the 5th day on which the service XYZ was performed, the insurance provider covers the amount 30.- for this service. From the 6th to 8th day, the amount 20.- is covered and for the days 9 to 12 the amount 10.-.
The following services are then entered for the case:
XYZ, 01/01/98 - 01/06/98 (quantity 6)
XYZ, 01/08/98 - 01/14/98 (quantity 7)
In the period from 01/06 to 01/05, 30.- is covered (item 1). For 01/06 and the period from 01/08 to 01/09, 20.- is covered (item 2). For the period 01/10 to 01/13, 10.- is covered (item 3).
  • Med. Indication
In the country version Switzerland this field lets you stipulate that the system is to check whether services flagged as mandatory services only in cases of medical indication in the master data have been performed for a medical indication. This information can be specified in service entry.
The following logic is used to determine if the billable service is a mandatory service only for a medical indication:
UVG Requirement If the main insurance when the service is performed is an accident insurance, invalidity insurance or military insurance (UVG) (the internal type of the insurance provider type of the main insurance is checked here), the field Pflleicd UVG is in the service master data is evaluated. If this field contains the value 03, the service is a mandatory service only for a medical indication.
KVG Requirement
If the main insurance when the service is performed is not an accident insurance, invalidity insurance or military insurance, the field Pflleicd KVG is evaluated. If this field contains the value 03, the service is a mandatory service only for a medical indication.
Example:
You have set up an item of the contract scheme so that 100% of the costs of service group XYZ are covered if these services were performed for a medical indication. Three services from this service group are entered in the case to be billed. Service S1 does not have an entry in the fields Pflleicd UVG and Pfleicd KVG, service S2 and service S3 are mandatory services only for a medical indication as stipulated by UVG.
The main insurance relationship for the case is an accident insurance. UVG is therefore applicable.
Service S2 was performed for a medical indication and service S3 was performed not for a medical indication.
When the contract scheme is processed, no further checks are performed for service S1, since there are no restrictions relative to UVG defined in the master data of this service. For services S2 and S3, the system must check whether these services were performed in relation to a medical indication. Since service S3 was not performed for a medical indication, it is not covered by the accident insurance whereas service S2 is covered.

  • Charge Factor Value
In the country version Switzerland, in this field you can specify a maximum charge factor value that is to be covered per charge factor.
Example:
You configured an item such that a maximum charge factor value of 2.- is to be covered for the service XYZ. The service XYZ is valuated with a charge factor of 3 during pricing. The resulting coverage for this service is 6.- (charge factor of 3 times 2.- maximum).

  • Svce Catalog
In this field, you enter the service catalog to which the services defined under Field Name and Field Value are assigned.
  • Field Name
In this field, you define the criterion (for example, charge type) for the formation of the service group to which the item refers. You can list the available selection criteria in the input help (F4).
You can use the Business Add-In (BAdI) ISH_CONTRACT_SCEME to add customer-specific selection criteria.
  • Field Value
In this field, you specify the actual value the criterion must contain. The item then refers to all services that have this value.
The value help (F4) is adjusted according to the entry in the Field Name field.
Specify services in the billing catalog.
When breaking down service groups during payment distribution, the system uses the admission date of the current case as the key date. This means only service assignments that are valid on admission apply.

  • Include and Exclude
By means of these radio buttons, you can include or exclude the service or service group entered above in or from the items covered by the insurance.

Example
You have specified the following in the item:
  • Maximum per case 100.-

  • Service group: laboratory services

  • If you select Include, the insurance will cover a total of 100.- for all laboratory services.

  • If you select Exclude, the insurance will cover a total of 100.- for all services excluding laboratory services.

  • Service Filter for Contract Scheme Items
If you have individual requirements for the selection of relevant services, you can define these in your own function exit.
Please read the documentation on the enhancement NPDIST00 and on the function exit EXIT_SAPLNPD1_001.
  • Requirements for Contract Scheme Items
The enhancement NPDIST00 enables you to specify a requirement governing the use of the item in a function exit. The system evaluates this requirement when carrying out payment distribution. If the requirement is met, the item is evaluated. In the contrary case, the item is skipped and the next item is processed.
Please read the documentation on the enhancement NPDIST00 and on the function exit EXIT_SAPLNPD1_002.
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  1. Create the required contract schemes.
  2. For Singapore: Create a contract scheme for each of the insurance relationships Medisave and MediShield. Function modules are provided for these insurance relationships. You can enter the respective insurance relationship in the Ext. FM field. In this case, the Destination field is not filled. The function module for Medisave is ISH_MEDISAVE and that for MediShield is ISH_MEDISHIELD.
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  • You can store default values for contract schemes by insurance provider in the system. For more information about this topic, refer to the section Maintain Default Values of the IS-H Implementation Guide.
  • When assigning contract schemes to insurance relationships you can overwrite individual values of the contract scheme for a specific case. This is expedient if, for example, particular conditions apply to the contract with the insurance provider for a given case. For more information, read the documentation Individual Contract Schemes.





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