Pricing Contract to Plan Prep
Background
Each Health Plan has Pricing Contracts that dictate negotiated allowed amounts and In Network Providers for that Employer Group/Plan combination. Pricing Contracts include: Machine Readable files (CMS compliant Negotiated Rate Files), Fee Schedules, and Reference Based Pricing (RBP) Agreements. RBP's can display Providers as either In Network or Out of Network.
During initial setup and each time a new Employer Group or Plan are added, at least one, and sometimes several or many, pricing contracts must be mapped to the Employer Group/Plan combination. TALON can't accomplish that mapping task without the assistance of a Client Team Member familiar with the Plans.
Once mapped, the precedence for picking up pricing and In/Out of Network Provider status can be determined by the Client. The default precedence is Fee Schedules, then MRF's, then RBP's (which can be displayed as in or out of network).
TALON CSM Role
- Optimal Method: If the Claims Adjudication Platform has Pricing Contracts mapped to Employer Group/Plan combinations, we will seek to inherit these mappings as part of the overall integration.
- First Alt Method: The Client establishes a Narrow Network in their Claims adjudication system with a Name that represents a Pricing Contract. The Narrow Network can have no NPI's associated with it. Narrow Networks representing Fee Schedules should include precedence. They then map that Narrow Network to the Plans that use that associated Pricing Contract in the adjudication system. TALON then does a one time pairing of the Named Narrow Network to the Pricing Contract itself.
- Second Alt Method (requires the most human intervention): TALON will provide a Book of Business spreadsheet for the Client to fill out.
Book of Business Columns
- Employer Group Name
- Employer Group ID
- Plan Name
- Plan ID
- Number of Lives
- Primary Carrier
- Primary Network
- Secondary Network
- Tertiary Network
- RBP
- Fee Schedules/Special Pricing Arrangements
Client Role
Work with the TALON CSM and Engineering Team to achieve the best available method and highest achievable level of automation.
Process
Confirmation Steps
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Step 1: Discovery of existing mapping within the Claims Adjudication Platform.
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If it exists, document it and maintain it. This will become part of the data feeds.
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If it doesn't exist, can it be created? Can legacy Network associations to Plans be leveraged?
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Step 2: If the CAP can't be used, begin the process to create and update a Book of Business.