Account and Price Item Derivation (for the Retention Type Claim Based Pricing Rule Type Category)

Once the Validate Transaction and Derive Price Item (C1-TXNIP) batch calls the primary pricing rule type specified in the transaction record type, it calls the related pricing rule types (if any) defined in the primary pricing rule type. Note that the related pricing rule types are called one by one in the specified sequence. Let us understand this with the help of an example.

Example 1: Related Pricing Rule Type Sequence

In the example 1, the system first calls the related pricing rule type with the highest sequence (i.e. 10) once the CLAIM pricing rule type is called. The system calls the related pricing rule type irrespective of whether the transaction legs are derived using the primary pricing rule type. Once the RETENTION TYPE CLAIM BASED pricing rule type is called, the system calls the related pricing rule type with the next sequence (i.e. 20). This process continues until all related pricing rule types defined in the primary pricing rule type are called one by one in the specified sequence.

If the eligibility rule type is defined for a related pricing rule type, the system considers the related pricing rule type for deriving the transaction legs when the eligibility rule is satisfied. If the eligibility rule is not satisfied, the system does not consider the related pricing rule type for deriving the transaction legs. Let us understand this with the help of an example.

Example 2: Related Pricing Rule Type Eligibility Criteria

In the example 2, the eligibility criteria is defined for the RETENTION TYPE CLAIM BASED and CLAIM FEE CHARGES pricing rule types. However, the eligibility criteria for the CLAIM FEE CHARGES pricing rule type was not satisfied, and therefore it is not used for deriving the transaction legs.

The Validate Transaction and Derive Price Item (C1-TXNIP) batch maps a claim transaction to one or more price item and price item parameters which are defined in the eligible related pricing rule type. This is possible when you attach an algorithm created using the C1_​ACCPRIDRV algorithm type to the Account and Price Item Derivation system event of the related pricing rule type.

This algorithm fetches the effective pricing rule for each price item and price item parameters combination specified in the related pricing rule type on the derivation date. The system considers the paid date as the derivation date. This algorithm first searches for the effective pricing rule for a price item and price item parameters combination which is defined for the policy at the bill group level. If the system does not find any effective pricing rule for a price item and price item parameters combination which is defined for the policy at the bill group level, it inherits the effective pricing rule for a price item and price item parameters combination from the parent customer level.

For example, if the system receives a claim transaction with the following details:

• UDF_​DATE_​1 is set to 15-01-2018

• Transaction Record Type is set to TR1

Example 3: Effective Pricing Rule Derivation

In the example 3, the system fetches C2P3 and C1P4 pricing rules for P3 and P4 respectively, which are effective on the paid date. Note that the effective pricing rule for P3 is derived at the bill group level, whereas the effective pricing rule for P4 is derived from the parent customer level.

While fetching the effective pricing rule, the system first searches for the exact match for the price item parameters at both the levels. For example, if the system receives a claim transaction with the following details:

• UDF_​CHAR_​1 is set to Western

• UDF_​CHAR_​2 is set to Active

• UDF_​DATE_​1 is set to 20-03-2018

• Transaction Record Type is set to TR4

Example 4: Exact Match for Price Item Parameters

In the example 4, the system fetches the C2P1 pricing rule for P1 because of the following reasons:

• The paid date (i.e. 20-03-2018) of the claim transaction falls within the date range (i.e. 01-01-2018 to 31-12-2018) of the C2P1 pricing rule which is defined at the bill group level.

• It contains the exact match for the price item parameters which are received in the transaction.

If the system cannot find the exact match for the price item parameters at both the levels, it searches for the best fit match for the price item parameters first at the bill group level and then at the parent customer level. For example, if the system receives a claim transaction with the following details:

• UDF_​CHAR_​1 is set to Western

• UDF_​CHAR_​2 is set to Active

• UDF_​CHAR_​3 is set to HR

• UDF_​CHAR_​4 is set to Indian

• UDF_​DATE_​1 is set to 07-06-2018

• Transaction Record Type is set to TR5

Example 5: Best Fit Match for Price Item Parameters

In the example 5, the system could not find the exact match for the price item parameters (i.e. Location = Western, Employee Status = Active, Employee Department = HR, and Nationality = Indian) in the effective pricing rule for P3. Therefore, the system searches for the best fit match. While searching for the best fit match, the system rules out the optional parameter with lowest priority (i.e. Nationality = Indian) and checks whether pricing is defined for the price item parameters (i.e. Location = Western, Employee Status = Active, and Employee Department = HR) in the effective pricing rule. If so, it considers C1P3 as the effective pricing rule for P3. If not, the system rules out the optional parameter with the next lowest priority (i.e. Employee Department = HR) and checks whether pricing is defined for the price item parameters (i.e. Location = Western and Employee Status = Active) in the effective pricing rule. If so, it considers C1P3 as the effective pricing rule for P3. If not, the status of the transaction is changed to Error.

In the example 5, the system considers pricing defined for the price item parameters (i.e. Location = Western and Employee Status = Active) as the best fit match, and therefore fetches C1P3 as the effective pricing rule for P3. While fetching the effective pricing rule, the system considers only those price item parameters specified in the related pricing rule type for which the parameter usage is set to Pricing.

The system then derives the account with a particular invoice type (to which a price item must be billed) based on the priority which is defined for the respective price item in the related pricing rule type.

Example 6: Priority Based Account Derivation

In the example 6, while mapping the claim transaction to P3, the system checks whether an account where the Invoice Type (C1INVTYP) characteristic is set to Standard exists for the bill group. If so, it considers the standard account (A1) of the bill group for billing. However, if an account where the Invoice Type (C1INVTYP) characteristic is set to Standard does not exist for the bill group, the status of the transaction is changed to Error.

Similarly, while mapping the claim transaction to P4, the system checks whether an account where the Invoice Type (C1INVTYP) characteristic is set to Retention exists for the bill group. If so, it considers the retention account (A2) of the bill group for billing. However, if an account where the Invoice Type (C1INVTYP) characteristic is set to Retention does not exist for the bill group, the system checks whether an account where the Invoice Type (C1INVTYP) characteristic is set to Standard exists for the bill group. If so, it considers the standard account (A1) of the bill group for billing. If an account where the Invoice Type (C1INVTYP) characteristic is set to Standard does not exist for the bill group, the status of the transaction is changed to Error.

Once the account is derived, the system then checks whether the account has one active contract of the contract type which is associated with the price item. If so, it fetches the contract for further processing. Once the effective pricing rule, account, and active contract are derived, the transaction is mapped to the respective price item, price item parameters, and account. A transaction leg is created for each price item, price item parameters, and account combination. For example, if the system receives a claim transaction with the following details:

• UDF_​CHAR_​1 is set to Western

• UDF_​CHAR_​2 is set to Active

• UDF_​CHAR_​3 is set to HR

• UDF_​DATE_​1 is set to 03-01-2018

• Transaction Record Type is set to TR5

Example 7: Transaction Leg Derivation

In the example 7, the system maps the claim transaction to the following price item, price item parameters, and account combinations:

• Price Item: P1; Price Item Parameter: Location = Western, Employee Status = Active, and Employee Department = HR; and Account: A1

• Price Item: P2; Price Item Parameter: Location = Western, Employee Status = Active, and Employee Department = HR; and Account: A2

• Price Item: P3; Price Item Parameter: Location = Western, Employee Status = Active, and Employee Department = HR; and Account: A3

In the example 7, the system creates three transaction legs - TL1, TL2, and TL3 for the claim transaction. Once a transaction leg is created, the respective effective pricing rule is stamped against the transaction leg. In addition, the price item parameters of the transaction leg are grouped. In the example 7, the system creates one price item parameter group which contains the following price item parameters:

• Location = Western

• Employee Status = Active

• Employee Department = HR

A group is used to determine the price item pricing. A unique group ID is generated for each group. If a group with a set of price item parameters already exists in the system, a new group is not created. Instead, the existing group is used for determining the price item pricing.

If a pricing group is used while defining a pricing rule for a bill group, the system fetches the pricing rule for a claim transaction when the following conditions are met:

• The paid date of the claim transaction falls within the pricing rule's date range.

• The employee attributes specified in the claim transaction match the criteria defined in any one of the pricing group rule.

• The employee attributes specified in the claim transaction match the price item parameters defined within the satisfied rule.

Let us understand this with the help of an example. A claim transaction is received with the following details:

• UDF_​CHAR_​1 is set to X

• UDF_​CHAR_​2 is set to Western

• UDF_​CHAR_​3 is set to Indian

• UDF_​CHAR_​4 is set to HR

• UDF_​CHAR_​5 is set to Permanent

• UDF_​CHAR_​6 is set to Senior Manager

• UDF_​CHAR_​7 s set to BG1

• UDF_​DATE_​1 03-01-2018

• Transaction Record Type is set to TR6

Example 8: Effective Pricing Rule is Defined Using a Pricing Group

In the example 8, the system considers the PR1 pricing rule for PP1 because of the following reasons:

• The paid date (i.e. 03-01-2018) of the claim transaction falls within the PR1 pricing rule's date range (i.e. 01-01-2018 to 31-12-2018).

• The employee attributes specified in the claim transaction match the criteria defined in the Rule 1 (i.e. Source System = X, Parameter 1 = Western, Parameter 2 = Indian, Parameter 3 = HR, and Parameter 4 = Permanent).

• The employee attributes specified in the claim transaction match the price item parameters defined within the Rule 1.

The system then stores the pricing group rule which is satisfied against a parameter which is defined in the Pricing Group Rule Parameter option type of the C1-ASOBLLNG feature configuration. In such case, the price item parameter group contains the price item parameters and the pricing group rule parameter. For example, Group A contains Designation = Senior Manager, Employee Group = BG1, and Pricing Group Rule Parameter = Rule 1.

In the example 8, the system could find the exact match for pricing parameters defined in the pricing group rule. However, if the exact match is not available, the system finds the effective pricing rule using the best fit match for the pricing parameters defined in the pricing group rule. Note that the system searches for the exact match in the effective pricing rules at both the bill group and parent customer levels. If the exact match is not available at both the levels, the system finds the effective pricing rule using the best fit match for the pricing parameters (defined in the pricing group rule) first at the bill group level and then at the parent customer level.

Let us understand this with the help of an example. A claim transaction is received with the following details:

• UDF_​CHAR_​1 is set to X

• UDF_​CHAR_​2 is set to Western

• UDF_​CHAR_​3 is set to Indian

• UDF_​CHAR_​4 is set to HR

• UDF_​CHAR_​5 is set to Permanent

• UDF_​CHAR_​6 is set to Senior Manager

• UDF_​CHAR_​7 is set to BG1

• UDF_​DATE_​1 is set to 31-05-2018

• Transaction Record Type is set to TR6

Example 9: Effective Pricing Rule Derivation Using Best Fit Match for Pricing Parameters

In the example 9, the system could not find the exact match for the pricing parameters (i.e. Source System = X, Parameter 1 = Western, Parameter 2 = Indian, Parameter 3 = HR, and Parameter 4 = Permanent) in the effective pricing rule for PP1. Therefore, the system searches for the best fit match. While searching for the best fit match, the system rules out the optional parameter 4 (i.e. Parameter 4 = Permanent) and then checks whether the pricing group rule where Source System = X, Parameter 1 = Western, Parameter 2 = Indian, and Parameter 3 = HR exists in the effective pricing rule. If so, it considers the pricing group rule for further processing. If not, the system then rules out the optional parameter 3 (i.e. Parameter 3 = HR) and then checks whether the pricing group rule where Source System = X, Parameter 1 = Western, and Parameter 2 = Indian exists in the effective pricing rule. If so, it considers the pricing group rule for further processing. If not, the system then rules out the optional parameter 2 (i.e. Parameter 2 = Indian) and then checks whether the pricing group rule where Source System = X and Parameter 1 = Western exists in the effective pricing rule. If so, it considers the pricing group rule for further processing. If not, the status of the transaction is changed to Error.

In the example 9, the system considers Rule 1 where Source System = X and Parameter 1 = Western as the best fit match in the PR1 pricing rule for PP1. In addition, the employee attributes in the claim transaction satisfy the price item parameters (i.e. Designation = Senior Manager and Employee Group = BG1) defined within the Rule 1. Therefore, the system fetches PR1 as the effective pricing rule for PP1. In addition, the system fetches PR2 as the effective pricing rule for PP2. The system creates two price item parameter groups - One contains Designation = Senior Manager, Employee Group = BG1, and Pricing Group Rule Parameter = Rule 1 and another contains Designation = Senior Manager, Employee Group = BG1, and Pricing Group Rule Parameter = Rule 2. Once the price item parameter group is created, the system creates the aggregation parameter group. An aggregation parameter group contains all price item parameters included in the related pricing rule type for which the parameter usage is set to Aggregation.

If the effective pricing rule is not derived for a price item and price item parameters combination or if the account or active contract for the account is not derived, the system does not create a transaction leg for the respective price item.

Example 10: No. of Transaction Legs Derived

In the example 10, the system could not find the effective pricing rule for PP11 and PP16, the required account for PP13 and PP15, and the active contract for PP14 on A2. Therefore, in this case, the system creates two transaction legs - TL11 and TL12 for the transaction.

If the eligibility rule type is defined for a price item, the system maps the transaction to the price item when the eligibility rule is satisfied. If the eligibility rule is not satisfied, the system does not consider the price item for billing.

Example 11: Price Item Eligibility for Transaction Leg Derivation

In the example 11, the eligibility criteria is defined for the RETENTION TYPE CLAIM BASED and CLAIM FEE CHARGES pricing rule types. However, the eligibility criteria for the CLAIM FEE CHARGES pricing rule type was not satisfied, and therefore it is not used for deriving the transaction legs. The eligibility criteria for PE1 and PE5 was satisfied, but the eligibility criteria for PE3 and PE6 was not satisfied. Further, the system could not find the required account for PE5 and the active contract for PE2 on A2. Therefore, in this case, the system creates two transaction legs (i.e. TL1 and TL2) for the claim transaction. For more information about the related pricing rule type eligibility and price item eligibility features, refer to the Related Pricing Rule Type Eligibility and Price Item Eligibility sections, respectively.

Once a transaction leg is created, the derivation date is set as the processing date corresponding to the transaction leg.