Aggregate Stop-Loss (ASL) Pricing

ASL provides a ceiling on the eligible expenses that an employer would pay, in total for all members or subscribers, during a contract period. The amount that exceeds this limit will be paid by the insurance company.

You can define an aggregate stop-loss pricing rule at the parent customer and bill group levels. The aggregate stop-loss pricing rule at the bill group level takes precedence over the aggregate stop-loss pricing rule at the parent customer level. You can define aggregate stop-loss pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define an aggregate stop-loss pricing rule using an aggregate stop-loss pricing rule type. It is the aggregate stop-loss pricing rule type which helps the system to determine:

  • Business object using which the aggregate stop-loss pricing rule should be created in the system.

Note: The aggregate stop-loss pricing rule type is not a primary pricing rule type. It inherits the attributes from a claim pricing rule type where it is included as a related pricing rule type.

  • Algorithm which should be triggered while validating a transaction.

Note: An algorithm type for validating a transaction is not shipped from the product. You need to create a custom algorithm type, if required.

  • Algorithms which should be triggered while deriving account and price item for a transaction.

Note: You must create an algorithm using the C1_​ACCPRISL algorithm type and attach it to the Account and Price Item Derivation system event.

  • Post-processing algorithm which should be triggered once the aggregate stop-loss pricing rule is derived.

Note: A post-processing algorithm type is not shipped from the product. You need to create a custom algorithm type, if required.

  • Price items for which you can define aggregate stop-loss pricing rules using the aggregate stop-loss pricing rule type.

  • Rate options that you can use while defining the pricing for a price item.

  • Different type of account to which the price item should be billed based on the specified priority.

Note: Ideally, the price item parameters should not be specified in an aggregate stop-loss pricing rule type. The price item parameters which are specified in the claim pricing rule type are used for accumulating aggregate stop-loss.

  • Additional information, such as:

    • Identifier which helps to determine whether the aggregate stop-loss should be calculated for claim transactions which are received during the run-in period of the policy.

    • ASL billable charge line type using which you want to create aggregate stop-loss billable charges.

    • Domestic provider claim billable charge line type using which you want to create domestic provider claim calculation lines.

    • Markup or markdown billable charge line type using which you want to create markup or markdown calculation lines.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the line item is eligible for billing.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the markup or markdown calculation line is eligible for billing.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the domestic provider claim calculation line is eligible for billing.

    • ASL limit price item whose effective retention type enrollment based pricing should be used to calculate the enrollment based limit when the ASL Limit (During Policy Period) or ASL Limit (During Settlement Period) field is set to Enrollment Based Limit, Enrollment Based or Minimum ASL Limit (Whichever is Greater), or Percentage of Enrollment Based Limit in the aggregate stop-loss pricing rule which is defined for a parent customer.

Once an aggregate stop-loss pricing rule type is defined, you can create aggregate stop-loss pricing rules using the aggregate stop-loss pricing rule type. While defining an aggregate stop-loss pricing rule for a parent customer, you need to specify the following:

  • Price item for which you want to define the pricing.

  • Parent customer's SSL pricing rule from which you want to inherit the settlement frequency, settlement days, accumulation parameters (such as incurred start date, incurred end date, paid start date, and paid end date).

Note: The pricing date range is derived from the parent customer's specific stop-loss pricing rule because the specific stop-loss and aggregate stop-loss pricing rules for a parent customer should have the same date range.

  • Rate option which you want to use while defining the aggregate stop-loss pricing.

  • Settlement frequency which helps to determine the bill after date. The valid values are:

    • Immediately - If you select this option from the list, the bill after date is not calculated. The aggregate stop-loss billable charge is billed immediately in the next bill cycle.

    • Manually (At Required Intervals) - If you select this option from the list, the bill after date which is specified in the Manual Settlement Date parameter while executing the C1-BCASL batch is stamped on the aggregate stop-loss billable charge.

    • Monthly - If you select this option from the list, the bill after date which is specified in the Manual Settlement Date parameter while executing the C1-BCASL batch is stamped on the aggregate stop-loss billable charge.

    • Yearly - If you select this option from the list, the bill after date in the aggregate stop-loss billable charge is set to the pricing end date.

  • Account in which the aggregate stop-loss amount should be credited.

  • Accumulation parameters (such as incurred start date, incurred end date, paid start date, paid end date, etc.) based on which you want to accumulate the aggregate stop-loss for the claim transactions which are processed in the run-in or active period of the policy.

  • The maximum limit defined for aggregate stop-loss at the parent customer level.

  • Settlement days which helps to calculate the settlement date (i.e. pricing end date, incurred end date, or paid end date whichever is later + settlement days)

  • Whether the ASL limit should be set to either of the following during the policy period:

    • Policy Based Limit

    • Enrollment Based or Minimum ASL Limit (Whichever is Greater)

    • Enrollment Based Limit

    • Percentage of Enrollment Based Limit

  • Whether the ASL limit should be set to either of the following during the settlement period:

    • Policy Based Limit

    • Enrollment Based or Minimum ASL Limit (Whichever is Greater)

    • Enrollment Based Limit

However, while defining an aggregate stop-loss pricing rule for a bill group, you need to specify the following:

  • The status of the policy for which you want to define the aggregate stop-loss pricing rule.

  • Price item for which you want to define the pricing.

  • Parent customer's ASL pricing rule from which you want to inherit the pricing date range.

Note: The pricing date range is derived from the parent customer's aggregate stop-loss pricing rule because the aggregate stop-loss pricing rules for parent customer and bill group should have the same date range.

  • Rate option which you want to use while defining the aggregate stop-loss pricing.

  • Whether the aggregate stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.

  • Whether line items in a claim pricing rule are eligible for aggregate stop-loss.

Note: By default, the line items where the pricing rule type category is set to Aggregate Stop-Loss appear in the Line Items section. If you want to set aggregate stop-loss eligibility for the line items which belong to a particular claim pricing rule, you must select the respective claim pricing rule.

  • Whether certain percentage of ASL should be excluded while calculating aggregate stop-loss for domestic provider claim.

You can also specify a pricing group while defining an aggregate stop-loss pricing rule for a bill group. If you specify a pricing group while defining an aggregate stop-loss pricing rule for a bill group, you will have to define the following details for each rule defined in the pricing group:

  • Whether the aggregate stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.

  • Whether line items in a claim pricing rule are eligible for aggregate stop-loss.

Note: By default, the line items where the pricing rule type category is set to Aggregate Stop-Loss appear in the Line Items section. If you want to set aggregate stop-loss eligibility for the line items which belong to a particular claim pricing rule, you must select the respective claim pricing rule.

  • Whether certain percentage of ASL should be excluded while calculating aggregate stop-loss for domestic provider claim.

Once an aggregate stop-loss pricing rule is defined for a parent customer and bill group, the system creates one price assignment, one price list, and one price list assignment.

Related Topics

For more information on... See...
Pricing Rule Type screen Pricing Rule Type

Parent Topic: Self-Funded Pricing