Contract Management - Technical Specification

Provider contract and rate management system

Purpose

The Contract Management module manages agreements between the platform and healthcare vendors/providers, defining payment rates, terms, and conditions. It handles complex rate structures including percentage-based and fixed-amount rates, specialty-specific pricing, visit-type rates, and TPA requirements. The module is essential for claim adjudication, determining allowed amounts, and managing contractual relationships with providers.

Key Concepts

Term	Definition
Contract	Agreement between platform and vendor for services
Contracted Rate	Negotiated payment rate for services
Rate Type	Method of calculation (percentage or fixed amount)
Rate Kind	Level of rate application (CPT, specialty, visit type)
TPA Flag	Third Party Administrator requirements
Medical Necessity	TPA review requirement flag
Prior Auth Allowable	Services requiring prior authorization
Contract Term	Duration of the agreement
Rate Schedule	List of all rates in a contract
Fee Schedule	Standard rates before contract adjustments

User Roles

Role	Description	Permissions
Contract Manager	Manages all contracts	Full CRUD
Financial Analyst	Reviews rates and terms	Read, Calculate
Provider Relations	Negotiates contracts	Create, Read, Update
Claims Processor	Uses rates for claims	Read only
CFO/Director	Approves contracts	Read, Approve
System Administrator	System configuration	All permissions

Field Documentation - Contract Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique contract identifier	Auto-generated CUID	Primary Key
Contract Number	String	Yes	Human-readable number	Format: CON-YYYY-XXXXX, unique	-
Contract Name	String	Yes	Descriptive name	Max 200 chars	-
Vendor	Vendor	Yes	Contracted vendor	Must be active vendor	Vendor
Contract Type	ContractKind	Yes	Type of agreement	Valid contract kind	ContractKind
Contract Status	String	Yes	Current status	Enum: Draft, Pending, Active, Expired, Terminated	-
Status Reason	String	No	Reason for status	Required if Terminated	-
Effective Date	DateTime	Yes	Contract start date	Required for Active status	-
Expiration Date	DateTime	Yes	Contract end date	Must be after effective date	-
Auto Renewal	Boolean	Yes	Auto-renews on expiry	Default false	-
Renewal Term	Integer	No	Renewal period in months	Required if auto-renewal	-
Renewal Notice Days	Integer	No	Days notice for non-renewal	Default 30	-
TPA Agreement	Boolean	Yes	Is TPA contract	Default false	-
TPA Name	String	No	TPA organization name	Required if TPA	-
TPA Medical Necessity	Boolean	Yes	TPA reviews medical necessity	Default false	-
TPA Prior Auth Required	Boolean	Yes	TPA requires prior auth	Default false	-
Payment Terms	String	Yes	Payment schedule	Enum: Net30, Net45, Net60	-
Billing Frequency	String	Yes	How often to bill	Enum: Weekly, Biweekly, Monthly	-
Contract Value	Decimal	No	Estimated annual value	Positive decimal	-
Minimum Volume	Integer	No	Minimum monthly claims	Positive integer	-
Maximum Volume	Integer	No	Maximum monthly claims	Greater than minimum	-
Default Rate Type	String	Yes	Default calculation method	Enum: Percentage, Amount	-
Default Rate Value	Decimal	No	Default rate if no specific	Positive decimal	-
Stop Loss Amount	Decimal	No	Maximum per case	Positive decimal	-
Administrative Fee	Decimal	No	Admin fee percentage	Between 0-100	-
Network Participation	String	No	Network affiliation	Free text	-
Credentialing Required	Boolean	Yes	Requires credentialing	Default true	-
Direct Bill	Boolean	Yes	Bill directly vs patient	Default true	-
Requires Referral	Boolean	Yes	Referral required	Default false	-
Geographic Coverage	String	No	Service area	State codes or regions	-
Excluded Services	Text	No	Services not covered	Comma-separated CPT codes	-
Special Terms	Text	No	Additional terms	Max 5000 chars	-
Contract Document	Document	No	Signed contract PDF	PDF format	Document
Amendment Documents	Document[]	No	Contract amendments	PDF format	Document (1:Many)
Approved By	User	No	Who approved contract	Valid user ID	User
Approval Date	DateTime	No	When approved	Required if Active	-
Created At	DateTime	Yes	Creation timestamp	Auto-generated	-
Updated At	DateTime	Yes	Update timestamp	Auto-updated	-
Created By	User	Yes	Creating user	Valid user ID	User
Updated By	User	Yes	Updating user	Valid user ID	User
Contracted Rates	ContractedRate[]	No	Rate schedules	-	ContractedRate (1:Many)

Field Documentation - Contracted Rate Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique rate identifier	Auto-generated	Primary Key
Contract	Contract	Yes	Parent contract	Must be active	Contract
Rate Kind	ContractedRateKind	Yes	Type of rate	Valid rate kind	ContractedRateKind
Rate Type	String	Yes	Calculation method	Enum: Percentage, Amount	-
Rate Value	Decimal	Yes	Rate value	Positive decimal	-
Specialty	Specialty	No	Specific specialty	Required for specialty rates	Specialty
Visit Kind	String	No	Visit type	Required for visit rates	-
CPT Code	String	No	Specific CPT	Required for CPT rates	-
CPT Range Start	String	No	CPT range beginning	Valid CPT code	-
CPT Range End	String	No	CPT range ending	Valid CPT, >= start	-
Modifier	String	No	CPT modifier	Valid modifier	-
Place of Service	String	No	Service location type	Valid POS code	-
Effective Date	DateTime	Yes	Rate start date	Within contract dates	-
End Date	DateTime	No	Rate end date	Before contract end	-
Minimum Units	Integer	No	Minimum billable units	Positive integer	-
Maximum Units	Integer	No	Maximum billable units	>= minimum	-
Requires Auth	Boolean	Yes	Prior auth required	Default false	-
Requires Review	Boolean	Yes	Medical review required	Default false	-
Active	Boolean	Yes	Rate is active	Default true	-

Field Documentation - Contract Kind Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique kind identifier	Auto-generated	Primary Key
Kind Name	String	Yes	Type name	Max 100 chars	-
Description	String	No	Kind description	Max 500 chars	-
Is TPA	Boolean	Yes	TPA contract type	Default false	-
Requires Rates	Boolean	Yes	Must have rate schedule	Default true	-
Template Document	Document	No	Contract template	DOCX/PDF format	Document

Field Documentation - Contracted Rate Kind Entity

Field Name	Type	Required	Description	Validation Rules	Related Entity
ID	String	Yes	Unique kind identifier	Auto-generated	Primary Key
Kind Name	String	Yes	Rate kind name	Max 100 chars	-
Priority	Integer	Yes	Application priority	1 (highest) - 99	-
Description	String	No	Kind description	Max 500 chars	-

Workflows

Contract Creation Workflow

1. Initial Setup

   • Select vendor
   • Choose contract type
   • Set contract terms
   • Define effective dates

2. Rate Configuration

   • Set default rates
   • Add specialty rates
   • Configure CPT-specific rates
   • Define visit type rates

3. TPA Configuration

   • Set TPA flags
   • Define medical necessity rules
   • Configure prior auth requirements
   • Set review thresholds

4. Terms Definition

   • Payment terms
   • Volume commitments
   • Geographic coverage
   • Excluded services

5. Review and Approval

   • Legal review
   • Financial analysis
   • Management approval
   • Activation

Rate Calculation Workflow

1. Rate Lookup Priority

   1. CPT + Modifier + Specialty
   2. CPT + Specialty
   3. CPT Code alone
   4. Specialty + Visit Kind
   5. Specialty alone
   6. Visit Kind alone
   7. Contract default rate
   8. System default rate

2. Rate Application

   • If Rate Type = "Percentage":
     • Allowed = Billed × (Rate Value / 100)
   • If Rate Type = "Amount":
     • Allowed = Rate Value × Units

3. Rate Validation

   • Check effective dates
   • Verify within limits
   • Apply stop loss if configured
   • Calculate administrative fee

Contract Renewal Workflow

1. Renewal Notification

   • Check renewal notice period
   • Send notifications
   • Create renewal task
   • Set review deadline

2. Renewal Negotiation

   • Review utilization
   • Analyze profitability
   • Negotiate new rates
   • Update terms

3. Renewal Processing

   • Create new contract version
   • Copy or modify rates
   • Set new effective dates
   • Approval process

Rate Amendment Workflow

1. Amendment Request

   • Document change reason
   • Specify affected rates
   • Set amendment date
   • Create amendment document

2. Rate Modification

   • Add new rate records
   • End-date old rates
   • Maintain rate history
   • Update effective dates

3. Communication

   • Notify affected parties
   • Update claims system
   • Train staff on changes
   • Monitor implementation

Business Rules

Contract Rules

• Vendor must be active for new contracts
• Cannot have overlapping active contracts for same vendor
• Effective date cannot be retroactive beyond 30 days
• Contract must have at least one rate or default rate
• TPA contracts require TPA name and terms

Rate Priority Rules

• More specific rates override general rates
• CPT-specific rates highest priority
• Specialty rates override visit kind rates
• Active rates only used for calculation
• Most recent rate used if multiple match

Rate Validation Rules

• Percentage rates: 0-200% valid range
• Amount rates: Must be positive
• Rates cannot exceed stop loss amount
• Effective date within contract period
• Cannot delete rates with claim history

TPA Rules

• TPA contracts require review flags
• Medical necessity triggers TPA review
• Prior auth required based on CPT
• TPA decision overrides internal
• TPA response time limits enforced

Integrations

System	Integration Type	Purpose
Vendor Management	Direct Database	Vendor validation
Claims Processing	Direct Database	Rate calculation
Authorization System	Direct Database	Prior auth rules
Financial System	Direct Database	Payment processing
Business Central	API Sync	Contract sync
Document Management	File System	Contract documents
Reporting System	Database Views	Contract analytics

Common Issues

Issue	Description	Resolution
No Rate Found	Claim has no matching rate	Use default rate
Expired Contract	Contract expired during service	Honor rates, renew contract
Rate Conflict	Multiple rates match	Use priority rules
TPA Timeout	TPA system not responding	Manual override process
Wrong Rate Applied	Incorrect rate calculation	Adjustment process

Screenshots Needed

• Contract Creation Wizard
• Rate Configuration Grid
• Rate Priority Diagram
• Contract Search Interface
• Contract Detail View
• Rate Calculator Tool
• Amendment Management
• Renewal Dashboard
• TPA Configuration
• Contract Analytics

Performance Considerations

• Rate lookup must be sub-second
• Support 10,000+ rate records per contract
• Rate calculation caching strategy
• Bulk rate updates optimization
• Contract search indexing

Security Considerations

• Contract approval audit trail
• Rate change history tracking
• Financial data encryption
• Role-based contract access
• Document access control

Notes

• Rate changes not retroactive unless specified
• Contract templates reduce setup time
• Rate import/export functionality planned
• API for rate queries in development