What Is a Plan Hierarchy?

The LOB/Benefits Plan Hierarchy is a list of MMIS benefit plans and lines of business (LOBs) along with the sequence number (rank) in which each should be assigned to a claim line when more than one benefit plan can cover the same service for a member.

In other words, if

• The member is eligible for more than one benefit plan,
• And the service on the claim line is found to be covered by more than one of those benefit plans,
• And the provider on the claim is an eligible provider in the networks tied to these plans,

Then the plan hierarchy is used to determine which MMIS benefit plan is assigned. For example, a member may be assigned to benefit plan A and benefit plan B, based on that member's information and the benefit plan eligibility criteria defined in the Member Control Table (MCT) map definitions. When a claim line is processed for the member, it includes service X which is covered by both benefit plan A and benefit plan B. At this point, ND MMIS must determine which benefit plan should be assigned to the claim line by using the plan hierarchy to identify the plan that has the highest ranking (the lowest number in the sequence).

The hierarchy (sequence) is ranked in ascending order starting with highest ranked plan that should be assigned first - which would have the lowest numerical rank. The rankings are across all lines of business and all benefit plans.

The process of updating the hierarchy is a critical component that impacts the claims processing assignment of benefit plans to claim lines, and, as such, is very controlled.

You must include an MMIS benefit plan in a hierarchy before it can be used to process claims. You set up and edit this sequence of benefit plans on the LOB/Benefits Plan Hierarchy page.

This ranking list can change over time, and therefore each hierarchy is assigned a beginning and ending date. However, the range of dates of different hierarchies cannot overlap. Only one hierarchy can be effective at a time.

The ranking list can also be voided in the event that it is set incorrectly for a time period. This means that ND MMIS will not use that benefit plan hierarchy ranking list at all during claims processing for that date span. This serves the purpose of keeping a visible historical record of the hierarchy for research purposes, in the event that any claims processed against the voided hierarchy while it was effective but incorrect.

Once a hierarchy becomes effective, it cannot be changed except to void it or to close it by editing the ending date.

Instructions

How to Add or Edit an LOB/Benefit Plan Hierarchy

How to Replicate a Plan Hierarchy

How to Void or Close a Benefit Plan Hierarchy

Field Descriptions

LOB/Benefit Plan Hierarchy Page

See Also

About Benefit Plans

Version as of 5/16/14.