What Is a Map Definition?

At their most basic level, maps are the system components that are used to define tables of conditions that, when met, return a "true" or a "false" condition. These conditions match one component with its appropriate resolution; for example, a member with the correct benefit plan or a claim with the correct payment amount based on a benefit plan.

Maps are used in many areas of ND MMIS. Maps are sets of logical conditions used to determine benefits and assign benefit plans to members. Maps are also used to define the coverage criteria used by the Third Party Liability (TPL) Cost Avoidance Matrix.

A map definition is one logical condition assigned to a map and its associated data element criteria. Each effective-dated section in the map definition table is an OR condition for this map. Each data element in that section is an AND criteria that must be met for a match to be found for the OR condition. If this condition is found to be true (is matched) then process as directed OR if false, test the next condition until one is found to be true.

A map must contain at least one map definition with at least one data element to be tested, but it can contain more.

Example: Map to Assign a Benefit Plan to a Member 

For example, you could set up a map with three OR conditions, as follows, that would result in assigning a member to benefit plan BP001.

Note: In the table, Excl is an abbreviation for Exclude. In addition, all the rows have been given the same effective date, though this is not shown here.

Excl	Data Element 1 (Program Code)	Excl	Data Element 2 (Special Eligibility Code)	Excl	Data Element 3 (Age)	BP
	Program Code List 101		Special Eligibility Code List 201		Range 0 to 21	BP001
	Program Code List 102	X	Special Eligibility Code List 202		Range 65 to 999	BP001
	Program Code List 103		blank		blank	BP001

In the above map,

• IF the member's program code is in List 101 AND his or her special eligibility code is in List 201 AND the member's age is between 0 and 21

OR

• IF the member's program code is in List 102 AND his or her special eligibility code is NOT in List 202 AND the member's age is between 65 and 999

OR

• IF the member's program code is in List 103

THEN

• Assign benefit plan BP001 to the member.

Adding Maps

Normally, you add map definitions using the Map Definition function of Rules Management when you add a new benefit plan, create the TPL Matrix, identify certain claims for special processing, etc.. When you add a map definition, you must identify the line of business this map belongs to or that it can be used by all lines of business (system-wide) and what type of map this will be.

Map Types

Map types are determined by what information is being retrieved to create the various conditions; in other words, the database table and the map's data criteria elements pulled from that table. Pre-defined map types can include:

• BPT - Benefit Plan Table. Defines services in a plan, services that require authorization, and services that have plan limits). Map IDs are associated with various components of the benefit plan on the Plan Navigator page in the Benefits area.
• CHT - Managed Care Cohort Table. Defines member groups subject to certain capitation or case management fees to be paid to a managed care organization or case manager, usually on a per member, per month basis). The map ID is associated with the benefit plan on the main page of the Plan Navigator in the Benefits area.
• FFP - Fiscal Pend Processing. Defines to-be-paid claims that should be held and not paid during a particular payment cycle. The map ID is associated with a fiscal pend request on the Fiscal Pend Administration page of the Claims Adjudication function.
• FUN - Fund Code Processing. Defines the criteria for assigning fund codes to claims. The map ID is associated with the fund code on the Fund Code Administration page of the Claims Adjudication function.
• MCT - Member Control Table. Defines eligibility parameters used to assign a member to a plan when he or she is being added to ND MMIS. For example, if it is known that all members with a particular special eligibility code should be assigned a particular benefit plan, this information is defined in the MCT map. Other examples of the membereligibility parameters used in the MCT map include program code (sometimes called aid category), age, gender, etc.
• PMC - Pharmacy Member Control. Defines eligibility parameters used to assign a member to a pharmacy benefit plan when he or she is being added to ND MMIS. Typical parameters used in the PCM map include special eligibility codes, program codes, age, and gender.
• MRV - Member Review Spans. Defines lock-in and lock-out criteria, and processing instructions for claims that match the map criteria. The map ID is associated with the review span on the Review Span Maintenance page of the Member Maintenance function.
• PRV - Provider On Review. Defines the claims that need to have particular exception codes applied when a provider's claims need to be reviewed carefully The map ID is associated with a provider and other criteria on the Incentive/Sanction/Review page of the Provider Maintenance function.
• TPL - Third Party Liability Matrix. Defines the criteria for posting certain exception codes that identify claims for third party liability processing. The map ID is associated with other criteria on the TPL Matrix page in the Claims Adjudication function to determine if a claim for which a member has other insurance should be paid or denied.

Editing Maps

Occasionally you may need to change some of the information associated with a map definition. You do this by adding an ending date to the appropriate map definition condition to close it and creating a new effective-dated condition with the updated information in it. However, if the map references a system list or a range that is changed, you do not necessarily need to change your map definition condition. If the system list is still a valid data element for the map definition, no changes to the map need to be made. Instead, the system list is given a new effective date.

You can also void an effective-dated map definition condition if it was entered incorrectly and should not be considered when processing claims.

Instructions

How to Search for a Map Definition

How to Add or Edit a Map Definition

How to Replicate a Map Definition

How to Void or Close a Map Definition

Field Descriptions

Map Definition Search Page

Map Definition Page

See Also

About TPL Matrix

What Is Systems List?

About Fund Code

About Fiscal Pend

About Review Spans

Provider Inquiry/Maintenance - Incentive/Sanction/Review Page

About Benefit Plans

About Rules Management

Version as of 5/16/14.