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Use caseUC0063

Catch a provider contract loaded at the wrong rate

A payer's contract states each term's rate, but the system it's loaded into can carry something else, and terms rarely get re-checked after an amendment. This app reads the contract and the loaded record together and flags every term where they no longer agree.

For the contract configuration teamCross-domain · Healthcare

Why it matters

Today's manual process, and the same job with the app

A contracting and configuration review team at a health plan, checking agreements after they go live.

✕Today's manual process

1Read every term in the contract and note the rate, the dates and the carve-outs stated for each one.
2Check the loaded configuration against notes taken from the contract, term by term.
3Watch for amendments that changed a rate or date after the contract took effect.
4One term missed means claims keep paying at a rate the parties already replaced.
Every term checked against the contract manually

✓With the app

1The contract is read and every term's rate, dates and carve-outs are pulled out automatically.
2The loaded configuration is checked against the same term, and any difference is called out.
3Amendments are caught so a rate or date the parties already changed doesn't slip through.
4Mismatches are flagged for review before a claim ever pays at the wrong rate.
Only the mismatches need a person's review

See it work

One real case, read by the app, step by step

In agreement PC-2022-737, an amendment moved the skilled nursing rate to a percent of the schedule, but the loaded configuration still carries the old per diem basis.

Catch a provider contract loaded at the wrong rateReference appBuilt to be shaped to your process
  1. 1One agreement, ready to compare five terms loaded from the contract and the configuration record.
  2. 2What the Agreement doesn't settle left open, not guessed, when the contract never states a rate.
  3. 3Where they part an amendment changed the rate; the configuration never caught up.
  4. 4The outcome flagged for contracting review, with the reason stated in plain words.

For engineers

How it is built, and how we measured it

All fourteen steps of the build are written up, from the business case to running it in your own environment.

Kit overview →
150 of 150calls correctly left openmeasured in 01 Business case →
275 of 275terms identified correctlymeasured in 01 Business case →
2,800 of 2,800worksheet cells filled in rightmeasured in 01 Business case →
2.1¢to check one contract's termsmeasured in 07 Unit cost →

The build, step by step

14 steps

Make it yours

What you see is a reference app. We shape it to how you work.

Every part of it is built to change, and none of it means starting over.

Your rulesYour payer's rate and effective-date policies, escalators, carve-outs and what counts as an amendment.
Your recordsYour own executed agreements, amendments and the configuration extracts your system already keeps.
Your systemsReads from your contract management and configuration systems, wherever your team already keeps them.
Your screensThe term codes, categories and column layout your contracting and configuration teams already use.

Want this for your team?

Talk to us

We can run this on your own contracts and configuration records, inside your environment.

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