You use TPL Matrix in the Adjudication function of Claims to maintain cost avoidance and pay-and-chase criteria that ND MMIS uses to determine what exception code to post to claims in which another payer has at least some liability, including Medicare cross-over claims. In addition, the configuration of the TPL Matrix and its associated maps also allows for the use of bypass criteria such as Absent Parent, Good Cause, and Domestic Violence.
On the TPL Matrix page, you establish the line of business, coverage type, and claim dates as the high-level claim selection criteria and associate that to a map definition containing the specific criteria to be matched against the claim. If a match is found, you also assign the exception code to post to the claim that determines its final disposition:
This process allows for a unique exception code to post per TPL Matrix configuration row.
For the same line of business, coverage code and map ID, there should not be more than one TPL Matrix row with the same or overlapping beginning and ending dates.
Maps are sets of logical conditions used to determine if a particular action is to be done or not. You use the Map Definition page in the Rules Management function to establish rules to select the particular items in a coverage area that should be the responsibility of another third-party policy associated with the claim. Examples of specific criteria are system lists containing certain procedures, diagnosis, specialties, provider types, place of service, category of service, and claim type. How these various maps are processed is determined by the rank you assign to the TPL Matrix row associated with it.
Rank is simply the order in which rows in a table are evaluated by the system. You assign ranks to the various TPL matrix rows. Rank is used for processing efficiency, determining which set of TPL Matrix criteria should be executed first. Usually the bypass criteria are executed first so that if the claim matches the bypass criteria, it does not need to go any further in the TPL Matrix process.
The lower the rank number assigned to something, the earlier in the sequence it is evaluated. When assigning the sequence order, we recommend that you skip numbers to make it easier to add rows and assign new rankings. For example, assign rankings of 100, 200, and 300 instead of 1, 2, and 3.
There is effective dating at each level in the process: TPL Matrix, map definition, system list.
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Version as of 5/16/14.
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