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Screen Catalog — pricing and moon libraries

Pricing library​

w_pricing_plan_maintenance — "Pricing Plan Maintenance"​

Purpose: maintain pricing plans, their dated methods, and each method's ordered rules with match criteria (pricing/w_pricing_plan_maintenance, PBExportComments "This window maintains a list of pricing plans").

Layout / field groups:

  • Plan name search box (typing a new name + New creates a plan via all_purpose_seq.nextval; name must be ≥2 characters).
  • Methods grid (d_pricing_plan_methods over pricing_methods joined to valid_methods): sequence, method, pricing type (WHOLE/DETAIL, display-only from valid_methods), from/thru dates, detail indicator Y/N, rollover indicator Y/N, EOB description (allowed_reason → reason codes), savings type (dddw_pricing_plan_savings_types), default DRG multiplier, default DRG cap rate.
  • Rules grid (d_pricing_plan_rules, filtered to selected method) and rule editor strip (d_pricing_plan_rule_edit): description, Rule Type (Base/Inlier/Outlier), Inpatient/Outpatient (In/Out/Both), anesthesia-lines indicator (Yes/No/Both), per-diem amount + Per Diem Type (Day/Case), day from/thru, case rate amount, allow %, apply-allow-% code (dddw_pricing_apply_pct), allow additional amount, "Force Repriced Amt" (replace-with-claimed) Y/N, benefit def, Pricing Schedule button.
  • Criteria tab strip: Syntax (read-only rendering of the composed criterion, "All lines" when empty), Procedure codes (per code type or Group), Diagnosis codes (per type/Group), DRG codes, Revenue codes, LOS, Specialties, POS codes — each with IN / BETWEEN / EQUAL TO operators and a NOT checkbox (wf_encode / wf_decode).

Behaviors / validations: method dates and required EOB/savings-type checks; PER DIEM whole rules require per-diem amount > 0; changing a method's type deletes its rules after confirmation; schedule button allowed only for FEE/DRG/TIERED PD/UNIT methods and opens w_pricing_schedule_select; methods and rules reorder by drag; save runs plan insert/update plus manual cascade deletes of pricing_rule_procs/pricing_rule_diags/pricing_rules (wf_check_row, dw_rule_edit buttonclicked, pfc_update, pfc_preupdate). Menu m_pricing_plan_maintenance.

Windows opened: w_pricing_schedule_select, w_pricing_plan_maintenance_select (plan pick list).

w_pricing_plan_maintenance_single — single-plan selector/editor​

Purpose: response variant that maintains/selects a single pricing plan; opened from HCN/panel/contract pricing tabs with the current plan key and returns the selected plan key (pricing/w_pricing_plan_maintenance_single; caller e.g. provider/w_provider_hcn_maintenance dw_pricing buttonclicked).

w_pricing_fee_schedule (+ w_pricing_fee_schedule_select) — "Fee Schedule Maintenance"​

Purpose: maintain named fee schedules (fee_schedules / fee_schedule_details) (pricing/w_pricing_fee_schedule).

Fields: schedule name search/create; detail rows: procedure code + type, modifier, specialty, state, zip, effective/expiration dates, fee amount; filter controls for code/date range.

Validations: effective date and fee amount required; expiration after effective; procedure code must exist in procedure_codes for the type.

w_pricing_conversion_schedule (+ w_pricing_conversion_schedule_select) — "Conversion Factor Schedule Maintenance"​

Purpose: maintain conversion factor schedules (conversion_factors / conversion_factor_details): per procedure-code range and optional zip, dated multipliers Base / Time / Work / Practice / Malpractice (pricing/w_pricing_conversion_schedule, d_pricing_conversion_schedule). Start/end procedure codes validated against procedure_codes.

w_pricing_unit_schedule (+ w_pricing_unit_schedule_select) — unit schedule maintenance​

Purpose: maintain unit schedules (unit_schedules / unit_schedule_details): per procedure code (+ type, modifier, zip, dates) units Base / Time / Work / Practice / Malpractice; schedule carries a unit type (dddw_pricing_unit_schedule_type, e.g. RBRVS) (pricing/w_pricing_unit_schedule, d_pricing_unit_schedule).

w_pricing_drg_schedule (+ w_pricing_drg_schedule_select) — "DRG Weight Maintenance"​

Purpose: maintain DRG weight schedules (drg_weights / drg_weight_details): DRG code (validated against drg_codes), weight, from/thru dates (pricing/w_pricing_drg_schedule).

w_pricing_per_diem_schedule (+ w_pricing_per_diem_schedule_select) — "Tiered Per Diem Schedule Maintenance"​

Purpose: maintain tiered per-diem schedules (tiered_per_diem_schedules / tiered_per_diem_details): day bands (days from/thru) with per-diem amount and type, dated (pricing/w_pricing_per_diem_schedule).

w_pricing_schedule_select — schedule pick list​

Purpose: given a method (FEE/DRG/TIERED PD/UNIT) select the matching schedule; returns the schedule sys key stored in pricing_rules.schedule_sys_key (pricing/w_pricing_schedule_select; name resolution pricing/f_pricing_schedule_name).

w_pricing_lookup_ucr — "Lookup UCR" unit-price calculator​

Purpose: interactive UCR price check: pick a conversion schedule, enter procedure code + type, modifiers, zip, service dates, units and anesthesia minutes; computes price = units × Σ(multiplier × unit) with anesthesia units 1 + ⌊min/15⌋ and an RBRVS master-multiplier gate; "Could not determine price" when any component is missing (pricing/w_pricing_lookup_ucr ue_retrieve). Menu m_pricing_lookup_ucr.

w_pricing_rbrvs — "RBRVS multiplier maintenance"​

Purpose: maintain dated master multipliers per unit type (master_multipliers: unit type, multiplier, from/thru) consumed by RBRVS unit pricing (pricing/w_pricing_rbrvs, d_pricing_rbrvs; consumer pricing/w_pricing_lookup_ucr reads rbrvs_master_multipliers — see Open questions on the table-name pair). Menu m_pricing_rbrvs.

MOON library​

w_moon_claims — "MOON Claims"​

Purpose: the negotiation work queue over moon_negotiations (moon/w_moon_claims).

Field groups (d_moon_negs grid): Claim Id, Group Id, Provider, Specialty, Provider Phone, Orig Claim Amt, Date to MOON (bill_dt), Bill Status (MOONSTATUS codes, filter list d_moon_keys), Negotiator, Negotiated Amt, Discount Amt, Percentage (computed display), Information, PPO's (ppo_field), MOON Claim (bill_claim_id), Examiner, Date to Examiner, Submitter.

Validations / behaviors: claim must exist and not already be in negotiations; auto-fill of examiner/amount/group/provider/specialty/phone on claim-id entry; submitter stamped by department (BACKGROUND/EXAMINER/NURSE); status defaults PENDING with today's bill date; outcome columns editable only by UM/MIS; examiner assignment stamps sent-to-examiner date; queue filter by claim id or selected bill statuses (saved per user in the ini "MOON PREFS"); print via d_moon_negs_rpt; double-click locks and opens the claim editor (w_claim_editor) through the claim-control service. Can also be opened programmatically with a claim id to silently enqueue a claim (moon/w_moon_claims open event). Menu m_moon_claims.

w_moon_oon_product_maintenance (+ w_moon_oon_product_select) — "OON Products"​

Purpose: maintain out-of-network negotiation products (moon/w_moon_oon_product_maintenance, PBExportComments "Main window for Moon product maintenance").

Field groups: product header (d_moon_oon_products: Product, Description, Comments); purchasing groups (d_moon_oon_product_groups: group + name, from/thru dates — captioned "The following groups have purchased the above product for the types of claims listed below."); HCN exclusions (d_moon_oon_product_hcn_exclusions: HCN, from/thru dates); claim types (d_moon_product_claim_types: Claim Type, from/thru, Minimum Claimed $, Threshold Claimed $, Allowance Days, Pay By Days, Retention Days, Override All CM, Override CM Neg. Rates, Override Manual Price).

Validations: product id + description required; group and HCN rows require assignment + valid dates with no overlapping ranges per group/HCN; claim-type rows require claim type, valid minimum and threshold amounts, and override CM / override rates values; hard delete with confirmation. Menu m_moon_oon_product_maintenance.

w_moon_in_repricing — inbound EDI repricing review​

Purpose: "Review responses to outbound EDI requests for repricing" (moon/w_moon_in_repricing PBExportComments) over edi_in_repricing.

Fields (d_moon_in_repricing): Claim Id, Claim Line, Procedure Code, From Date, Claimed Amount, Line Pricing Amount, Whole Claim Pricing Amt, Reject Code, Trading Partner, Processed Indicator, Processed Date.

Behaviors: filter by claim id, trading partner (d_edi_trading_partner_search / dropdown, "All" wildcard), Active (processed_ind='N') vs Complete radio, and processed date (added for the automation process); warns when one claim has lines in both Active and Complete statuses; rows editable and saved back (library CRUD on edi_in_repricing). Menu m_moon_in_reprice_menu.

w_moon_provider_list — "MOON Provider List"​

Purpose: read-only distinct list of providers/phones that have appeared in negotiations (moon/w_moon_provider_list, d_moon_neg_providers: distinct provider_name, phone_no, created date from moon_negotiations).

Claim-side companion screens (other libraries, for reference)​

  • claims/w_claim_line_pricing_rules — "Enter Pricing Information": popup from the claim editor to record a line's savings type, savings amount and reason into claim_line_pricing_rules (PBExportComments "Pop up Window used in the Claims editor to record manually entered pricing data").
  • claims/w_convert_to_reprice_form — "Convert To Reprice Form": converts a non-repricing claim form to a repricing form.
  • clmentry/u_claims_tab_ub92_reprice_in / ..._out / generic / HCFA variants — claim-entry tabs for repricing sheets; reprice info page (dw over claims_reprice_info) requires repriced amount + discount pct unless out-of-network / member-not-on-file (see PRV-38).
  • clmutils/w_edi_outbound_edi_processor — "Outbound edi main window": builds and cuts outbound repricing EDI files from the outbound_edi_* staging tables.