Modeling clauses and terms

Clauses and terms are provision building blocks; they are the vehicle that defines contract terms, rates, and limits. A clause and term are interchangeable in how they calculate; however, a term always resides beneath a clause. The clause is considered the parent of the term. A clause can have no terms or it can have multiple terms. A term always has the one clause under which it resides. The order and the selections made on a clause/term determine how the claims filter through the calculation criteria.

Clause and term order significance

Axiom Contract Management calculates claims in a top-down manner for both clauses and terms. This means that a claim initially tries to match to the first clause listed in the provision. If there is no match, it continues on to the next clause, regardless of whether or not a term exists on clause 1. If, on clause 2, the claim matches the defined criteria, it stops and makes the calculation. Then it continues on to the first term of the clause (if it exists), and then the second term (again, if it exists) before moving on to clause 3, and so on. The only way to stop a claim from moving to the next clause (or term) is to set it as terminal. For information on changing the order of a clause or term, see Edit or delete a clause or term.

Clause or term Calc Basis

The following example shows some of the possible selections for the clause/term calculation basis. You cannot edit these. The calculation basis is used in conjunction with the calculation type and measure to determine a specific reimbursement method.

The Calc Basis The calculation basis is one of the elements that defines how a claim pays on a clause or term. The calc basis is used in conjunction with the calculation type and measure to determine a specific reimbursement method. In normal contract building rules, the Calc Basis is used to determine if a claim qualifies for the clause or term. paired with the rates loaded for the clause or term determine whether a claim will qualify. For example, if you select Admit Diagnosis Code, Axiom Contract Management only finds claims for which the defined clause/term codes match the admitting diagnosis code on a claim.

The CMS-based options include specially built calculation rules that are used with the defined factors for the provision.

Certain calc basis options are considered claim level and some are considered line item level. Selecting one or the other determines the options available for Calc Type and Calc Measure. For example, DRG is considered claim level, whereas RevCode is considered a line item level calculation basis.

Example of Calc Basis column in list of clauses

Calc Type

There are three possible selections for the Calc Type field. Either the clause/term will be paid at a Dollar Rate, a % of Charge, or a % of Cost, with the first two selections being the most commonly used. The calc types available for selection are determined by the Calc Basis selected.

Calc Measure

The five possible selections for the Calc Measure field are: Per Claim, Per Diem, Per Date, Per Line Item, and Per Line Item Qty. These options are limited based on the calc basis selected for the clause/term. For example, if DRG is selected as the calc basis, the option for Per Date, Per Line Item, and Per Line Item Qty are not applicable because those are used with line item level parameters only.

Terminal vs. Non-terminal

Setting a clause or term as terminal or non-terminal (the default) determines if a claim will continue calculating on the clause or term below it.

Setting a clause to Terminal (i.e., Yes) stops the claim from progressing to the next clause; it does not stop it from moving through all of the terms (if any) below that clause.

Setting a term to Terminal stops it from progressing to the next term under the same clause; it does not stop it from moving through any clauses (if any) below it. For the terminal logic to apply to a claim, it must qualify on the defined calculation criterion for the clause or term.

For example, if a claim has an implant revenue code, a certain dollar amount will apply to that rev code line item for all claims, and even if a claim qualifies for this payment, it will continue down to the next clause. If the claim qualifies for Orthopedics, it stops there, and Orthopedics will be the only other possible payment method on the claim, as that is a terminal clause. If it is not an Orthopedic claim (based on the defined DRG), it will continue on. If a claim qualifies on Clause 8 Med/Surg, it could also qualify and reimburse on Clause 9 ICU, as that is a non-terminal clause.

Example Clauses/Terms page with Terminal column outlined in red