topic Re: How to check if next claim get paid or rejected in SAS Programming

How to check if next claim get paid or rejected

sasuser77 — Thu, 09 Jun 2016 02:38:45 GMT

Hi,

I have to identify if the next claim is paid or rejected look at historical data of that member. I have dataset as shown below.

The rule is the next claim gets paid if the sum of any active claims MED in history + new claim MED doesn't exceeds 200.

The claim will be active for starting its fill_date to the 75% of its total days supply( rounded below).

ID	Days_Supply	Fill_dt	MED	CLM_START_DTE	CLM_END_DTE
1	30	1/21/2015	180.00	1/21/2015	2/19/2015
1	30	1/21/2015	30.00	1/21/2015	2/19/2015
1	20	1/21/2015	4.50	1/21/2015	2/9/2015
1	30	2/28/2015	30.00	2/28/2015	3/28/2015
1	20	2/28/2015	4.50	2/28/2015	3/19/2015
1	30	3/29/2015	30.00	3/29/2015	4/25/2015
1	20	4/13/2015	100.00	4/13/2015	5/2/2015
1	30	4/15/2015	80.00	4/26/2015	5/4/2015
2	25	2/16/2015	30	2/16/2015	3/12/2015
2	25	4/15/2015	30	4/15/2015	5/9/2015
2	10	7/1/2015	56	7/1/2015	7/10/2015
2	4	7/5/2015	180	7/8/2015	8/8/2015

and wanted to see data as below. New column with claim status whether it gets Paid or Rejected.

ID	Days_Supply	Fill_dt	MED	CLM_START_DTE	CLM_END_DTE	Clm_Deactive_Date	Claim_Stts
1	30	1/21/2015	180.00	1/21/2015	2/19/2015	2/12/2015	Pays
1	30	1/21/2015	30.00	1/21/2015	2/19/2015	2/12/2015	Rejects as there is a active claim in history and Med ecceeds 200(180+30)
1	20	1/21/2015	4.50	1/21/2015	2/9/2015	2/5/2015	Pays 180+4.5 < 200
1	30	2/28/2015	30.00	2/28/2015	3/28/2015	3/22/2015	Pays ( No active claim in history and 30 < 200)
1	20	2/28/2015	4.50	2/28/2015	3/19/2015	3/15/2015	Pays (30+4.5 < 200)
1	30	3/29/2015	30.00	3/29/2015	4/25/2015	4/20/2015	Pays (No active claim in history 30 < 200)
1	20	4/13/2015	100.00	4/13/2015	5/2/2015	4/28/2015	Pays (100+30 < 200)
1	30	4/15/2015	80.00	4/26/2015	5/4/2015	5/7/2015	Rejects (Med ecceeds 200(30+100+80) two claims active in history
2	25	2/16/2015	30	2/16/2015	3/12/2015	3/6/2015	Pays
2	25	4/15/2015	30	4/15/2015	5/9/2015	5/3/2015	Pays
2	10	7/1/2015	56	7/1/2015	7/10/2015	7/8/2015	Pays
2	4	7/5/2015	180	7/8/2015	8/8/2015	7/8/2015	Rejects (56+180 exceeds 200)

Thanks in advance for help!

Re: How to check if next claim get paid or rejected

PGStats — Thu, 09 Jun 2016 03:16:23 GMT

How do you know in which order to process claims that have the same fill_dt?

Re: How to check if next claim get paid or rejected

Reeza — Thu, 09 Jun 2016 03:49:19 GMT

How do you know if a claim is 'active'?

Re: How to check if next claim get paid or rejected

Ksharp — Thu, 09 Jun 2016 12:19:28 GMT

How do we know whether there is a active claim in history or not ?

Re: How to check if next claim get paid or rejected

sasuser77 — Fri, 10 Jun 2016 16:22:49 GMT

Could you assume that my data is already in the order of its processing.

Re: How to check if next claim get paid or rejected

sasuser77 — Fri, 10 Jun 2016 16:30:45 GMT

A claim is active from its fill_dt to the 75% of Days_supply rounded to lowest interger value.

for below example

ID	Days_Supply	Fill_dt	MED	CLM_START_DTE	CLM_END_DTE
1	30	1/21/2015	180.00	1/21/2015	2/19/2015

claim is active for floor(30*.75) = 22 days from fill_Dt

1/21/2015 + 22 days i.e(2/11/2015) this claim will be active.

ID	Days_Supply	Fill_dt	MED	CLM_START_DTE	CLM_END_DTE	Clm_Deactive_Date	Claim_Stts
1	30	1/21/2015	180.00	1/21/2015	2/19/2015	2/12/2015	Pays

Re: How to check if next claim get paid or rejected

Ksharp — Sat, 11 Jun 2016 02:15:53 GMT

No. I mean.


1
30
3/29/2015
30.00
3/29/2015
4/25/2015
4/20/2015
Pays (No active claim in history 30 < 200)
---- Why would there be No active claim in history?


1
20
4/13/2015
100.00
4/13/2015
5/2/2015
4/28/2015
Pays (100+30 < 200)
----Why 30 should be active claim in history ?



1
30
4/15/2015
80.00
4/26/2015
5/4/2015
5/7/2015
Rejects (Med ecceeds 200(30+100+80) two claims active in history
-----Why 30,100 should be active claim in history ?



2
25
2/16/2015
30
2/16/2015
3/12/2015
3/6/2015
Pays
----Why is there no active claim in history ?

Re: How to check if next claim get paid or rejected

sasuser77 — Sat, 11 Jun 2016 11:29:24 GMT

Sorry, I could'nt get your question.

Think off in this way. At any point of time a member can't exceed the dosage of 200. Exception is if his re-fill is after 75% exhaust of his dosage(ex: if member had fill for 10 days and he next filled on 8th day from his fill date we are ignoring) other wise we are summing up his previous dosages that are active and current dosage and see if it exceeds 200. One more thing if a member no past claim and his present fill dosage > 200 that is still rejected.

Re: How to check if next claim get paid or rejected

Ksharp — Sun, 12 Jun 2016 03:24:17 GMT

OK. Assuming I understand what you are talking about .

History Claim is when Fill_dt < Clm_Deactive_Date .

data have;
input 
ID
Days_Supply
Fill_dt : mmddyy10.
MED
CLM_START_DTE  : mmddyy10.
CLM_END_DTE  : mmddyy10.
Clm_Deactive_Date  : mmddyy10.;
format Fill_dt CLM_START_DTE  CLM_END_DTE  Clm_Deactive_Date  mmddyy10.;
cards;
1
30
1/21/2015
180.00
1/21/2015
2/19/2015
2/12/2015
1
30
1/21/2015
30.00
1/21/2015
2/19/2015
2/12/2015
1
20
1/21/2015
4.50
1/21/2015
2/9/2015
2/5/2015
1
30
2/28/2015
30.00
2/28/2015
3/28/2015
3/22/2015
1
20
2/28/2015
4.50
2/28/2015
3/19/2015
3/15/2015
1
30
3/29/2015
30.00
3/29/2015
4/25/2015
4/20/2015
1
20
4/13/2015
100.00
4/13/2015
5/2/2015
4/28/2015
1
30
4/15/2015
80.00
4/26/2015
5/4/2015
5/7/2015
2
25
2/16/2015
30
2/16/2015
3/12/2015
3/6/2015
2
25
4/15/2015
30
4/15/2015
5/9/2015
5/3/2015
2
10
7/1/2015
56
7/1/2015
7/10/2015
7/8/2015
2
4
7/5/2015
180
7/8/2015
8/8/2015
7/8/2015
;
run;
data want;
array x{99999} _temporary_;
array y{99999} _temporary_;
call missing(of x{*} y{*});
length Claim_Stts $ 8;

 do i=1 by 1 until(last.id);
  set have;
  by id;
  x{i}=Clm_Deactive_Date;
  y{i}=MED;
 end;
 
 do j=1 by 1 until(last.id);
  set have;
  by id;
  pays=0;
  do k=1 to j;
   if Fill_dt lt x{k} then pays+y{k};
  end;
  if pays lt 200 then Claim_Stts='Pays';
   else Claim_Stts='Rejects  ';
  output;
 end;
drop i j k pays;
run;

Re: How to check if next claim get paid or rejected

sasuser77 — Sun, 12 Jun 2016 12:33:08 GMT

Thank you Xia, it seems working as expected. except third observation shouldn't have been Rejected.

Claim_Stts	ID	Days_Supply	Fill_dt	MED	CLM_START_DTE	CLM_END_DTE	Clm_Deactive_Date
Pays	1	30	1/21/2015	180	1/21/2015	2/19/2015	2/12/2015
Rejects	1	30	1/21/2015	30	1/21/2015	2/19/2015	2/12/2015
Rejects	1	20	1/21/2015	4.5	1/21/2015	2/9/2015	2/5/2015

since you already rejected 2nd observation. Total MED for 3rd observation would be 180+4.5 < 200 and should be paid.

Re: How to check if next claim get paid or rejected

Ksharp — Mon, 13 Jun 2016 01:23:11 GMT

data have;
input 
ID
Days_Supply
Fill_dt : mmddyy10.
MED
CLM_START_DTE  : mmddyy10.
CLM_END_DTE  : mmddyy10.
Clm_Deactive_Date  : mmddyy10.;
format Fill_dt CLM_START_DTE  CLM_END_DTE  Clm_Deactive_Date  mmddyy10.;
cards;
1
30
1/21/2015
180.00
1/21/2015
2/19/2015
2/12/2015
1
30
1/21/2015
30.00
1/21/2015
2/19/2015
2/12/2015
1
20
1/21/2015
4.50
1/21/2015
2/9/2015
2/5/2015
1
30
2/28/2015
30.00
2/28/2015
3/28/2015
3/22/2015
1
20
2/28/2015
4.50
2/28/2015
3/19/2015
3/15/2015
1
30
3/29/2015
30.00
3/29/2015
4/25/2015
4/20/2015
1
20
4/13/2015
100.00
4/13/2015
5/2/2015
4/28/2015
1
30
4/15/2015
80.00
4/26/2015
5/4/2015
5/7/2015
2
25
2/16/2015
30
2/16/2015
3/12/2015
3/6/2015
2
25
4/15/2015
30
4/15/2015
5/9/2015
5/3/2015
2
10
7/1/2015
56
7/1/2015
7/10/2015
7/8/2015
2
4
7/5/2015
180
7/8/2015
8/8/2015
7/8/2015
;
run;
data want;
array x{99999} _temporary_;
array y{99999} _temporary_;
array z{99999} $ 8 _temporary_;
call missing(of x{*} y{*} z{*});
length Claim_Stts $ 8;

 do i=1 by 1 until(last.id);
  set have;
  by id;
  x{i}=Clm_Deactive_Date;
  y{i}=MED;
 end;
 
 do j=1 by 1 until(last.id);
  set have;
  by id;
  pays=0;
  do k=1 to j;
   if Fill_dt lt x{k} and z{k} ne 'Rejects' then pays+y{k};
  end;
  if pays lt 200 then Claim_Stts='Pays';
   else Claim_Stts='Rejects';
  z{j}=Claim_Stts;
  output;
 end;
drop i j k pays;
run;

Re: How to check if next claim get paid or rejected

sasuser77 — Mon, 13 Jun 2016 11:35:57 GMT

Perfect, Thank you! This is exactly what I was looking for.