Billing

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Billing Workflows Process Guide: Add new line Workflow

1. Overview: Adding Billable Items to a Claim

This guide focuses on the Add new line workflow, which is an essential step in the broader Billing Workflows Process. Think of it as the mechanism for ensuring all services and items provided during a patient's visit are accurately recorded and billed. This workflow's main work is to incorporate new, valid billable items into an existing patient claim.

1.1. What This Workflow Does

The Add new line workflow's main function is to append a new invoice line item, representing a billable service or product, to a patient's current claim. It receives specific details about the item, its cost, quantity, and the intended billing scheme, then applies a series of validations to append it.

1.2. Why This Workflow Is Critical (The "Why It Matters")

Getting billable items added right from the beginning is important for accurate financial management and claim processing. The workflow is therefore essential in the following ways:

• Accurate billing and revenue collection: It ensures that services or items are properly added with the right information, making sure that the facility will be properly reimbursed for care provided to a patient.
• Claim Acceptance: Correct and compliant line items (e.g., not exceeding tariffs, valid scheme codes) lead to the claim being accepted by the payer.
• Financial Accuracy: Accurate billing leads to matches between services rendered and payments received, leading to easy reconciliation and correct financial records.
• Audit compliance: Having the proper documentation for each billable item makes claims easily audited and provides transparency and visibility.

In short, this workflow is the foundation for accurate claim amounts. It ensures that every subsequent step of the Billing Workflows Process is built on the right financial information.

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2. Workflow Details: Add new line

2.1. Workflow Description: Step-by-Step System Behavior

When a request to add a new bill item to a claim comes into our system, here's the internal process that unfolds:

1. Input Reception: The system first receives the consent_token for the active patient visit, along with details of the new line item: intervention_code, charge_date, invoice_number, unit_price, quantity, scheme_name, scheme_code, and an optional line_number.

2. Visit and Consent Validation: The system immediately validates the provided consent_token to confirm that the patient's visit is still active/open and that the consent is valid.

3. Financial and Scheme Validation:

   • The system calculates the total bill amount for the new line item (and the cumulative claim).
   • It checks if the bill amount is less than the keph level tariff or the overall tariff.
   • If the scheme_code is 'PMF', it verifies that the bill amount is less than the PMF balance + ex gratia.
   • It ensures that the scheme_code and scheme_name provided for the invoice line are valid and recognised by the system.
   • If the intervention_code is a ‘per diem’ intervention, the system checks that the bill from and bill to dates are present for the invoice line.
   • It also handles cases where an intervention falls under both UHC and PMF, splitting the bill to exhaust UHC first if the amount exceeds the tariff.

4. Item Addition: If all validations pass, the system proceeds to add the new line item to the patient's claim, associating it with the specified intervention_code and invoice_number.

2.2. Key Validations: Our System's Essential Checks

There are some essential checks our system performs behind the scenes to ensure a successful and accurate "Add new line" operation. Understanding these helps you provide the correct information from your end, preventing errors.

• Active Visit/Consent Validation:
  The consent_token provided must correspond to a patient visit that is currently open and active.

• Bill Amount vs. Tariff/Balance Validation:
  The financial amount must adhere to the maximum allowed tariffs or available PMF balance + ex gratia.

• Valid Scheme Code/Name:
  Every invoice line must be associated with a valid scheme_code (e.g., UHC, PMF) and scheme_name.

• Per Diem Intervention Date Validation:
  If the intervention_code indicates a 'per diem' service, the line must include valid bill from and bill to dates.

• UHC/PMF Bill Splitting Logic:
  If an intervention falls under both UHC and PMF and exceeds the KEPH level tariff, the bill will be split to prioritise UHC.

2.3. Workflow Data Dictionary: What Information We Work With

Field Name	Description	Data Type	Required	Purpose
consent_token	The consent token for the patient visit.	string	Yes	Authorises the billing action for the correct patient and active visit.
intervention_code	The code for the intervention you are trying to add.	string	Yes	Specifies the particular service or item being billed.
charge_date	The charge date for the item. Defaults to today.	ISO 8601 datetime	No	Records when the item was provided/charged.
invoice_number	Unique reference to the invoice from the provider.	string	Yes	Links to internal billing records, essential for tracking/auditing.
unit_price	The unit price charged for this item.	float (2dp)	Yes	Defines cost per unit of service/item.
quantity	Quantity of the item. Defaults to 1.	float (2dp)	No	Number of units provided.
scheme_name	Name of the scheme you intend to bill to.	string	No	Human-readable name for payer.
scheme_code	Code you intend to bill against.	string	Yes	Standard code that directs billing to the correct payer.
line_number	Unique identifier for the invoice line/item.	string	No	Internal line reference for easier cross-referencing.

2.4. Expected Outcomes from this Workflow

When you query this workflow, here's what you can expect in return:

• Success: Line Item Added to Claim – the system adds the item and passes all validations.
• Failure: Invalid Visit/Consent – the consent_token is invalid, expired, or visit is closed.
• Failure: Financial Limit Exceeded – the unit_price or total bill exceeds allowed tariffs or balances.
• Failure: Invalid Scheme Information – unrecognised scheme_code or scheme_name.
• Failure: Missing Per Diem Dates – for per diem services, bill from / bill to dates are required.
• Failure: Missing Required Data – any required field (e.g., consent_token, intervention_code, invoice_number, unit_price, scheme_code) is missing or malformed.