Use determination risk coverage datastructure for on-demand and increased efficiency coverage detection and rebalancing apparatuses, processes and systems
The Use Determination Risk Coverage Datastructure for On-Demand and Increased Efficiency Coverage Detection and Rebalancing Apparatuses, Processes and Systems (“UDRCD”) transforms coverage enrollment request, event signal, ACGG request, search request, props ratios calculation request, encounters build request, episodes build request, price calculation request, price range generation request, price range lookup request inputs via UDRCD components into coverage enrollment response, add-in recommendation, ACGG response, search response, props ratios calculation response, encounters build response, episodes build response, price calculation response, price range generation resp., price range lookup resp. outputs. An episodes build request datastructure identifying an encounter type is obtained. An anchor encounter datastructure is selected. A set of other encounter datastructures for the anchor encounter datastructure is determined. A props ratio relevance function associated with the encounter type is determined, and used to determine a set of accessory encounter datastructures for the anchor encounter datastructure. An episode datastructure is generated.
1. A system comprising:
one or more processors and at least one memory storing processor-executable instructions, that, when executed by any one of the one or more processors, cause the one or more processors to perform operations comprising:
obtaining an episodes build request datastructure, the episodes build request datastructure structured including a data field for identifying an encounter type;
comparing the encounter type with a value specified in a corresponding data field of a set of available encounter datastructures;
selecting an anchor encounter datastructure, in which the value specified in the corresponding data field of the anchor encounter datastructure matches the encounter type;
determining analysis window rules associated with the encounter type, the analysis window rules specifying at least one of: a pre- window time period, a post-window time period, a time period length;
determining an analysis window for the anchor encounter datastructure using the analysis window rules and a service date value specified in a corresponding data field of the anchor encounter datastructure;
determining an enrollee identifier value specified in a corresponding data field of the anchor encounter datastructure;
determining a set of other encounter datastructures for the anchor encounter datastructure, in which a service date value specified in a corresponding data field of each other encounter datastructure is in the analysis window for the anchor encounter datastructure, and in which the determined enrollee identifier value matches an enrollee identifier value specified in a corresponding data field of each other encounter datastructure;
determining a props ratio relevance function associated with the encounter type, the props ratio relevance function structured classifying claim codes as either relevant or irrelevant to the encounter type;
determining an encounter relevance classification for each other encounter datastructure in the set of other encounter datastructures using the props ratio relevance function;
determining a set of accessory encounter datastructures for the anchor encounter datastructure, the set of accessory encounter datastructures corresponding to other encounter datastructures for the anchor encounter datastructure classified as relevant based on the encounter relevance classification; and
generating an episode datastructure structured including a set of data fields for identifying: the anchor encounter datastructure, the set of accessory encounter datastructures, and the encounter type.
2. The system of claim 1 , in which the data field for identifying the encounter type is structured identifying a coverage family.
3. The system of claim 1 , in which the data field for identifying the encounter type is structured identifying an encounter type.
4. The system of claim 1 , in which the instructions for determining the analysis window rules cause the one or more processors to perform operations comprising:
determining an episode archetype datastructure associated with the encounter type, wherein the episode archetype datastructure is associated with a plurality of encounter types; and
retrieving the analysis window rules from a corresponding data field of the episode archetype datastructure.
5. The system of claim 1 , in which the instructions for determining the analysis window for the anchor encounter datastructure cause the one or more processors to perform operations comprising:
adding the pre-window time period associated with the encounter type to the service date value associated with the anchor encounter datastructure.
6. The system of claim 1 , in which the instructions for determining the analysis window for the anchor encounter datastructure cause the one or more processors to perform operations comprising:
adding the post-window time period associated with the encounter type to the service date value associated with the anchor encounter datastructure.
7. The system of claim 1 , in which the instructions for determining the analysis window for the anchor encounter datastructure cause the one or more processors to perform operations comprising:
determining a first analysis window based on an event corresponding to the service date value associated with the anchor encounter datastructure;
determining a second analysis window based on a repeat event corresponding to a later service date value associated with the anchor encounter datastructure; and
combining the first analysis window and the second analysis window into the analysis window for the anchor encounter datastructure, in which the first analysis window and the second analysis window are overlapping analysis windows.
8. The system of claim 1 , in which the props ratio relevance function associated with the encounter type is structured as a best fit cut line, in which claim codes above the best fit cut line are classified as relevant and claim codes below the best fit cut line are classified as irrelevant.
9. The system of claim 1 , in which the instructions for determining an encounter relevance classification for each other encounter datastructures cause the one or more processors to perform operations comprising:
determining a claim code associated with a selected other encounter datastructure;
determining a props ratio associated with the determined claim code;
determining a claim code relevance classification for the claim code by evaluating the determined props ratio using the props ratio relevance function, in which the determined claim code is classified as either relevant or irrelevant to the encounter type; and
setting the encounter relevance classification for the selected other encounter datastructure to the claim code relevance classification for the determined claim code.
10. The system of claim 1 , in which the instructions for determining an encounter relevance classification for each other encounter datastructure cause the one or more processors to perform operations comprising :
determining claim codes associated with a selected other encounter datastructure;
determining a props ratio associated with each of the determined claim codes;
classifying each of the determined claim codes as either relevant or irrelevant to the encounter type by evaluating the determined props ratio for a respective determined claim code using the props ratio relevance function; and
determining the encounter relevance classification for the selected other encounter datastructure based on a proportion of the determined claim codes classified as relevant.
11. The system of claim 1 , in which the instructions for determining an encounter relevance classification for each other encounter datastructure cause the one or more processors to perform operations comprising:
determining claim codes associated with a selected other encounter datastructure;
determining a props ratio associated with each of the determined claim codes;
determining an average of the determined props ratios; and
determining the encounter relevance classification for the selected other encounter datastructure by evaluating the determined average of the determined props ratios using the props ratio relevance function.
12. The system of claim 1 , the operations further comprising:
determining the value of an encounter attribute of the anchor encounter datastructure, in which the encounter attribute is one of: a provider location, a practitioner, or a place of service; and
setting the value of a corresponding episode attribute of the episode datastructure to the determined value of the encounter attribute.
13. The system of claim 1 , the operations further comprising:
calculating an episode cost associated with the episode datastructure; and
setting the value of a corresponding data field of the episode datastructure to the calculated episode cost.
14. The system of claim 13 , in which the instructions for calculating the episode cost cause the one or more processors to perform operations comprising:
determining an encounter cost specified in a corresponding data field of the anchor encounter datastructure;
determining an encounter cost specified in a corresponding data field of each accessory encounter datastructure in the set of accessory encounter datastructures; and
calculating the episode cost as a sum of the determined encounter costs.
15. The system of claim 13 , in which the instructions for calculating the episode cost cause the one or more processors to perform operations comprising:
determining an episode archetype datastructure associated with the encounter type, in which the episode archetype datastructure is associated with a plurality of encounter types;
retrieving episode cost calculation rules from a corresponding data field of the episode archetype datastructure; and
calculating the episode cost in accordance with the retrieved episode cost calculation rules.
16. One or more non-transitory computer-readable storage media storing processor- executable instructions that, when executed by one or more processors, cause the one or more processors to perform operations comprising:
obtaining an episodes build request datastructure the episodes build request datastructure structured including a data field for identifying an encounter type;
comparing the encounter type with a value specified in a corresponding data field of a set of available encounter datastructures;
selecting an anchor encounter datastructure, in which the value specified in the corresponding data field of the anchor encounter datastructure matches the encounter type;
determining analysis window rules associated with the encounter type, the analysis window rules specifying at least one of: a pre- window time period, a post-window time period, or a time period length;
determining an analysis window for the anchor encounter datastructure using the analysis window rules and a service date value specified in a corresponding data field of the anchor encounter datastructure;
determining an enrollee identifier value specified in a corresponding data field of the anchor encounter datastructure;
determining a set of other encounter datastructures for the anchor encounter datastructure, in which a service date value specified in a corresponding data field of each other encounter datastructure is in the analysis window for the anchor encounter datastructure, and in which the determined enrollee identifier value matches an enrollee identifier value specified in a corresponding data field of each other encounter datastructure;
determining a props ratio relevance function associated with the encounter type, the props ratio relevance function structured classifying claim codes as either relevant or irrelevant to the encounter type;
determining an encounter relevance classification for each other encounter datastructure in the set of other encounter datastructures using the props ratio relevance function;
determining a set of accessory encounter datastructures for the anchor encounter datastructure, the set of accessory encounter datastructures corresponding to other encounter datastructures for the anchor encounter datastructure classified as relevant based on the encounter relevance classification; and
generating an episode datastructure structured including a set of data fields for identifying: the anchor encounter datastructure, the set of accessory encounter datastructures, and the encounter type.
17. A system comprising:
means to store processor-executable instructions; and
means to process processor-executable instructions, wherein the processor-executable instructions are configured to cause the means to process the processor-executable instructions to perform operations comprising:
obtaining an episodes build request datastructure, the episodes build request datastructure structured including a data field for identifying an encounter type;
comparing the encounter type with a value specified in a corresponding data field of a set of available encounter datastructures;
selecting an anchor encounter datastructure, in which the value specified in the corresponding data field of the anchor encounter datastructure matches the encounter type;
determining analysis window rules associated with the encounter type, the analysis window rules specifying at least one of: a pre- window time period, a post-window time period, or a time period length;
determining an analysis window for the anchor encounter datastructure using the analysis window rules and a service date value specified in a corresponding data field of the anchor encounter datastructure;
determining an enrollee identifier value specified in a corresponding data field of the anchor encounter datastructure;
determining a set of other encounter datastructures for the anchor encounter datastructure, in which a service date value specified in a corresponding data field of each other encounter datastructure is in the analysis window for the anchor encounter datastructure, and in which the determined enrollee identifier value matches an enrollee identifier value specified in a corresponding data field of each other encounter datastructure;
determining a props ratio relevance function associated with the encounter type, the props ratio relevance function structured classifying claim codes as either relevant or irrelevant to the encounter type;
determining an encounter relevance classification for each other encounter datastructure in the set of other encounter datastructures using the props ratio relevance function;
determining a set of accessory encounter datastructures for the anchor encounter datastructure, the set of accessory encounter datastructures corresponding to other encounter datastructures for the anchor encounter datastructure classified as relevant based on the encounter relevance classification; and
generating an episode datastructure structured including a set of data fields for identifying: the anchor encounter datastructure, the set of accessory encounter datastructures, and the encounter type.
18. A processor-executed method comprising:
obtaining, by one or more processors, an episodes build request datastructure, the episodes build request datastructure structured including a data field for identifying an encounter type;
compare, via the any of at least one processer, comparing, by the one or more processors, the encounter type with a value specified in a corresponding data field of a set of available encounter datastructures;
selecting, by the one or more processors, an anchor encounter datastructure, in which the value specified in the corresponding data field of the anchor encounter datastructure matches the encounter type;
determining, by the one or more processors, analysis window rules associated with the encounter type, the analysis window rules specifying at least one of: a pre-window time period, a post-window time period, a time period length;
determining, by the one or more processors, an analysis window for the anchor encounter datastructure using the analysis window rules and a service date value specified in a corresponding data field of the anchor encounter datastructure;
determining, by the one or more processors, an enrollee identifier value specified in a corresponding data field of the anchor encounter datastructure;
determining, by the one or more processors, a set of other encounter datastructures for the anchor encounter datastructure, in which a service date value specified in a corresponding data field of each other encounter datastructure is in the analysis window for the anchor encounter datastructure, and in which the determined enrollee identifier value matches an enrollee identifier value specified in a corresponding data field of each other encounter datastructure;
determining, by the one or more processors, a props ratio relevance function associated with the encounter type, the props ratio relevance function structured classifying claim codes as either relevant or irrelevant to the encounter type;
determining, by the one or more processors, an encounter relevance classification for each other encounter datastructure in the set of other encounter datastructures using the props ratio relevance function;
determining, by the one or more processors, a set of accessory encounter datastructures for the anchor encounter datastructure, the set of accessory encounter datastructures corresponding to other encounter datastructures for the anchor encounter datastructure classified as relevant based on the encounter relevance classification; and
generating, by the one or more processors, an episode datastructure structured including a set of data fields for identifying: the anchor encounter datastructure, the set of accessory encounter datastructures, and the encounter type.