Before you Begin

In this business scenario, we create a group customer in the Prototype company. For this group customer, a client is made a member of a child-class based on the membership rules. Then, the client is enrolled in a policy, and the bill amount, is reconciled.

Note:

This use case may differ from your actual requirements. This is written to help understand the steps to implement a group customer in OIPA. To follow steps in this use case, it is recommended that the default Prototype company is available in your environment.

Scenario

In this business scenario, we are using the Prototype company and we are using the Prototype company default configuration.

Prerequisites

Prototype company default configuration in your environment.

Step 1: Create a Group Customer

To create a Group Customer, follow these steps:

1. From the Central Add drop-down, select Customer, and click the Create icon. The Customer screen appears with Customer detail fields and History tab.
2. On the Customer tab, from the Type drop-down, select Group Customer.
3. Enter the applicable customer information in the appropriate fields. If required information is left blank, then an error message will appear. In this use case:
   • Enrollment Relationship: Employment
   • Enrollment Class: Eligibility
   • Hierarchy Relationship: Employment
4. Click Save.

   

   Group Customer

Step 2: Add an Agreement to the Group Customer

In this use case we are adding a Contract agreement to the above group customer.

To add a contract agreement, follow these steps:

1. On the Group Customer screen, in the Left Navigation list, click Agreements. The Agreements tab appears.
2. Hover over the Contract node, the + New icon appears.
3. Click the + New icon, the Details tab appears.
4. Enter the fields and update the Status to Active. In this use case:
   • Type: Master Agreement – Insured
   • Agreement Name: Master Agreement – Insured
5. Click Save.

   

   Agreement

Step 3: Add a Product

Before adding a plan, you must add a product to the group customer.

To add a product, follow these steps:

1. On the Agreement screen, expand Contract, click the required agreement, and then click the Products tab.
2. Click the Add Product button. The (Agreement Name) page appears.
3. From the Company drop-down, select the required company. In this use case, we select Prototype Group Child Company.

   

   Select the Product

4. Select the required product and click OK. The Details page appears. (In this use case, we select Group Prototype Product.)
5. On the Details page, enter the Effective Date and update Status to Active.

   

   Product

6. Click Save. The product is added under the Products tab in a tabular format.

Step 4: Add a Plan

Once, you have added a product, you can add a plan and plan segments.

To add a plan, follow these steps:

1. On the Agreement screen, expand Contract, click the required agreement, and then click the Plans tab.
2. In the Add option, select newplan from the drop-down list, and then click the Create icon. The (Agreement Name)- New Plan window appears.
3. Enter the applicable information for the new plan. In this use case:
   • Company: Prototype Group Child Company
   • Product Name: Group Prototype Product
   • Status: Approved
   • Effective Date: 6/21/2020
   • Currency: US Dollar
   • Expiration Date: blank
   • Allocation Method: Default
   • PIT Valuation: Yes
   • Mixed Valuation: No
   • Market Maker: USA

   

   Plan

4. Click Add Plan Segment. The Add Plan Segment page appears.
5. Enter the segment information. In this use case, Segment Name is BaseCoverageBasic and Plan Segment Type is Type1.

   

   Plan Segment

6. Click Save. The (Agreement Name)-New Plan window appears.
7. Click Save. The Details page appears.
8. Update the Status to Active and click Save. A new plan is added and displayed in the tabular view under the Plans tab.

Step 5: Activate the Plan

To activate the plan, follow these steps:

1. On the Group Customer screen, in the Left Navigation list, click Plans. The Plans screen appears.
2. Use > to expand the required plan.
3. Under the Action column, click the Submit icon.
4. Under the Action column, click the Process icon. The plan Record Status is updated to Active.

   

   Active Plan

Step 6: Add a Class Group

The class group represents the entire tree node structure for a collection or arrangement of classes in the Class Group screen. The Group client must arrange classes into a class group. The arrangement may be constructed for any number of reasons, based on the client's business needs, including billing, reporting, and eligibility.

To add a Class Group, follow these steps:

1. On the Agreement screen, expand Contract, click the required agreement, and then click the Class Groups tab.
2. In the Add option, select New from the drop-down list, and then click the Create icon, the Add Class Group page appears.
3. Enter the applicable class group Information on the Details tab. In this use case:
   • Type: Eligibility
   • Status: Approved
   • Effective Date: 6/15/2020
   • Expiration Date: blank
   
   Class Group
4. Click Add Class tab to add a class within the newly created class group.
5. Select the Class Type to match the class group type and enter the applicable class information in the fields provided according to the class type. In this use case, Class Type is Eligibility.
6. Click Save. The Add Class Group window appears.
7. Update the Status to Active and then, click Save. The class group is added under the Class Groups tab in a tabular format.

Step 7: Add Child Classes

Group policy members are added to a child class depending on the membership rules.

To add child classes, follow these steps:

1. On the Left Entity Navigation list, click Class Groups. The Class Groups screen appears.
2. On the Class Groups screen, expand a (Class Group Name).
3. Click the (hyperlink). The Class Group window appears.
4. Click the Classes tab. It displays the classes that are added to a class group in a tree-like structure. In each structure, there is one root node (which has no parent node) and one default orphan class node.
5. Hover over a class. The New icon appears.

   

   New Icon

6. Click the New icon. The Definition page appears.

   

   Child Class

7. Select the Class Type to match the class group type and enter the applicable class information in the fields provided according to the class type.
8. Click OK to add the class.

Step 8: Create Class Rule Variables

You can use Class Rule Variables as membership rules for a class.

To add a class rule variable, follow these steps:

1. On the Classes tab, select the required class.
2. Click the Class Rule Variables tab.
3. Click the Add Variable button. A row is added with fields. Enter the fields with appropriate data. In this use case:
   • Type: Expression
   • Data Type: Boolean
   • Text: 1==1

   

   Class Rule Variables

4. Click Save. The class rule variable is added for the class.

   Note:

   Ensure that you add class rule variables for both parent and child classes.

Step 9: Use Class Rule Variables as Membership Rules

You need to assign class rule variables as membership rules to parent and child classes.

To assign membership rules, follow these steps:

1. On the Classes tab, select the required class.
2. Click the Membership Rules tab.
3. Move the required Class Rule Variables from the Variables box to the Conditions box.
4. Click Save.

   

   Membership Rule

Step 10: Associate Plan Coverages with Classes

Ensure that plan containing the required segments or coverages are in Active Status.

To associate plan coverages, follow these steps:

1. On the Classes tab, select the required class.
2. Navigate to Plan Coverages > Associate.
3. Move the required segments from Plan Coverages box to Associate box.
4. Enter the Effective Date and click OK.

   

   Associate Plan Coverages

   Note:

   Ensure that you associate required plan coverages with parent and child classes.

When you have completed all the class details, click the Submit icon to update the Record Status of the Class Group to Active.

Active Class Group

Step 11: Add a Relationship

To add a relationship for a group customer, follow these steps:

1. On the Left Entity Navigation list, click Relationships. The Downstream Relationships tab opens.
2. Select the Employment from the Add Relationship Type drop-down.
3. Click Add New Relationship.
4. Select Relationship Sub Type as Full Time.
5. Click . The Client page appears with Find Client and Add Client tabs.
6. Use Find Client to search an existing client or use Add Client to create a new client.
7. Enter Effective Date and then, click Save.
8. Use > to expand the required relationship.
9. Under the Action column, click the Submit icon. The relationship is now Active.

   

   Active Relationship

Step 12: Process EvaluateMembership Activity

To process EvaluateMembership activity at client level, follow these steps:

1. For the newly added relationship, hover over the Ellipsis icon, and then click Go To Client. The Client screen appears.
2. On the Client screen, in the Left Navigation list, click Activities. The Activity page appears.
3. Click + Add Activity icon. The Add Activity page appears.
4. In the Select Activity drop-down, select EvaluateMembership activity.
5. Enter Effective Date and Effective Until and then, click OK.
6. In the Action column, click the Process icon. The activity is processed successfully.

   

   Evaluate Membership Activity

On successful processing, the client becomes the member of the required child class. This can be observed on the Class Membership tab of the activity.

Class Membership

You can also observe that client is added as a member under the Members tab of a child class.

Child Class Membership

Step 13: Process EnrollmentPrototype Activity

To process EnrollmentPrototype activity at client level, follow these steps:

1. On the Client screen, in the Left Navigation list, click Activities. The Activity page appears.
2. Click + Add Activity icon. The Add Activity page appears.
3. In the Select Activity drop-down, select EnrollementPrototype activity.
4. Enter Effective Date, New Policy Name, Issue State, and Coverage etc. and then, click OK.
5. In the Action column, click the Process icon. The activity is processed successfully.

   

   Active Enrollment Activity

On successful processing, a new policy is created in Pending state. This policy is for the Group Plan that we created for the Group Customer.

New Policy

Activate activity is added in Pending state for the newly created policy. To make the policy Active, in the Action column, click the Process icon. The policy becomes Active.

Step 14: Process GenerateBillDetail

To Process GenerateBillDetail, follow these steps:

1. On the Policy screen, in the Left Navigation list, click Activities. The Activity page appears.
2. Click + Add Activity icon. The Add Activity page appears.
3. In the Select Activity drop-down, select GenerateBillDetail activity.
4. Enter Effective Date, Bill Due Date, Bill Due Amount, Bill Group Type, Bill Entity Type, and Policy.

   

   GenerateBillDetail Activity Details

5. Click OK.
6. In the Action column, click the Process icon. The activity is processed successfully.

Step 15: Process GenerateBill

To Process GenerateBill, follow these steps:

1. On the Group Customer screen, in the Left Navigation list, click Activities. The Activity page appears.
2. Click + Add Activity icon. The Add Activity page appears.
3. In the Select Activity drop-down, select GenerateBill activity.
4. Enter Effective Date, Billing Detail Start Date, Billing Detail End Date, Bill Owner Type, Bill Detail Minimum Threshold Amount and Bill Detail Maximum Threshold Amount.

   

   GenerateBill Activity Details

5. Click OK.
6. In the Action column, click the Process icon. The activity is processed successfully.

Note the Bill Reference ID appearing under the Billing tab of the Activity Results.

Bill Reference ID

Step 16: Reconcile the bill

To reconcile bill amount, follow these steps:

1. On the Unified Search, select Group/list bill in the Find drop-down and then enter the Bill Reference ID.The Group/List Bill Reconciliation page appears.

   

   Group List Bill

2. Click Link Suspense. The Link Suspense page appears.

   

   Link Suspense with the Bill

3. Select OIPA Suspense Ticket in the Type of Suspense drop-down.
4. Use Suspense Search Criteria to link the required Suspense. The suspense is linked and it appears as shown below.

   

   Suspense Linked with the Bill

5. Use to edit the Amount For Reconciliation and then click to save the bill reconciliation details. The warning message appears, click OK.

   

   Warning Message

   Another message appears, This may take few minutes. Click OK to continue. Click OK. The Bill Details are saved.

   

   Bill Details Saved

   The Reconciliation activity is added in the Pending state for the policy.

   

   Reconciliation Activity Added

6. In the Action column, click the Process icon. The activity is processed successfully. On successful processing, the amount is reconciled.

   

   Bill Amount is Reconciled

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Title and Copyright Information

Group Customer - Manual

F89508-01

November 2023

Copyright © 2021, 2023, Oracle and/or its affiliates. 

How to enroll members and reconcile bills for a Group Customer without Data Intake

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