Ancillary Pricing

The Administrative Services Only (ASO) provider may process some adhoc charges with respect to preventive care, vaccination, diagnostic, and so on. These adhoc charges may also occur due to some corrections in the claim transactions which are already billed to the customer. Oracle Revenue Management and Billing enables you to process and bill these ancillary transactions to the self-funded employer.

The system enables you to create an ancillary charge in either of the following ways:

  • Create a pass through charge without markup or markdown (i.e. flat charge).

  • Create a pass through charge with a flat or percentage based markup or markdown.

  • Create a rate based charge using the rate defined in the ancillary pricing and the service quantity specified in the ancillary transaction. You can also apply markup or markdown to a rate based charge.

You can use any custom mechanism or the file upload utility in ORMB to upload the ancillary transactions. The pricing for the ancillary transactions can be defined using the ancillary pricing rules. You can define an ancillary pricing rule at the parent customer and bill group levels. The ancillary pricing rule at the bill group level takes precedence over the ancillary pricing rule at the parent customer level. You can define the ancillary pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define an ancillary pricing rule using an ancillary pricing rule type. It is the ancillary pricing rule type which helps the system to determine:

  • Business object using which the ancillary pricing rule should be created in the system.

  • Whether it is the primary pricing rule type from where the related pricing rule types will inherit the transaction field mapping details.

    Note: You must select the Primary option while defining an ancillary pricing rule type. On selecting the Primary option, the Related Pricing Rule Types and Transaction Field Mapping sections appear in the Ancillary Pricing Rule Type screen.

  • Rule type which indicates the rules that should be executed to determine whether the related pricing rule type is eligible for deriving the transaction legs.

  • Transaction fields from where the data from the ancillary transaction should be stored in the respective fields (for example, the data from the UDF_​CHAR_​1 transaction field must be stored in the Parameter 1 field which will be used for deriving the bill group and pricing).

  • Algorithm which should be triggered for validating an ancillary transaction.

    Note: An algorithm type for validating an ancillary transaction is not shipped with the product. You can create a custom algorithm type, if required.

  • Algorithm which should be triggered for deriving the bill group, parent customer, and policy for an ancillary transaction.

    Note: You must create an algorithm using the C1_​TXNBGDRV algorithm type and attach it to the Bill Group Derivation system event.

  • Algorithm which should be triggered for deriving the account and price item for an ancillary transaction.

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

  • Algorithm which should be triggered for determining the bill after date.

    Note: You must create an algorithm using the C1_​BAFTDRV algorithm type and attach it to the Bill After Date Determination system event.

  • Pricing rule post-processing algorithm which should be triggered once the effective ancillary pricing rule is derived.

    Note: A pricing rule post-processing algorithm type is not shipped with the product. You can create a custom algorithm type, if required.

  • Additional generic information, such as:

    • Whether the price items included in the ancillary pricing rule type are eligible for specific stop-loss and aggregate stop-loss.

    • Whether the price items included in the ancillary pricing rule type are eligible for level funding.

    • Whether the ancillary charges should be written off when the bill is generated in the post runout period of the policy. In this case, a write-off adjustment is created against the respective bill segment during the post bill completion. The write-off adjustment is created using the post runout write-off adjustment type which is specified in the ancillary pricing rule type.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the price item should be considered for billing.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the related pricing rule type should be considered for deriving the transaction legs.

    • Value which the output parameter in the rule should return when the price item and related pricing rule type in the ancillary pricing rule type should be considered for processing.

  • Price items for which you can define ancillary pricing rules using the ancillary pricing rule type.

  • Rate options that you can use while defining the pricing for the ancillary price items.

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

  • Rule type which indicates the rules that should be executed to determine whether the price item is eligible for billing.

  • Price item parameters based on which you want to define the price item pricing. Two price item parameters are mandatory in the ancillary pricing rule type - one which stores the billable charge line type from the ancillary transaction and another which stores the pricing arrangement from the ancillary transaction. The following pricing arrangements are supported in the ancillary pricing rule:

    • Pass Through Charge Without Markup and Markdown

    • Pass Through Charge With Markup and Markdown

    • Rate Based Charge Without Markup and Markdown

    • Rate Based Charge With Markup and Markdown

    Note: The price item parameters (for example, BCHGLINETYPE and PRICINGARRANGEMENT) which you include in the ancillary pricing rule type must be defined in the Billable Charge Line Type Parameter and Pricing Arrangement Parameter option types of the C1-ASOBLLNG feature configuration, respectively.

  • Additional ancillary-specific information, such as:

    • Identifiers which help to determine whether the ancillary transaction is eligible for billing for not.

    • 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.

    • Billable charge line type using which you want to create billable charges for markup and markdown.

    • Rule type which indicates the rules which should be executed to determine whether the markup or markdown calculation line is eligible for billing.

    • How the system should interpret the value stored in the pricing arrangement price item parameter (i.e. whether the value means the ancillary charge should be a pass through charge without markup or markdown, pass through charge with markup or markdown, or rate based charge with or without markup or markdown). Accordingly, the system will search for the pricing in the effective ancillary pricing rule where:

      • Billable charge line type matches the one specified in the ancillary transaction

      • Line defined for the billable charge line type has the pricing arrangement as mentioned in the ancillary transaction

    • Line item which indicates the SQI using which the ancillary charge should be created. You need to specify the line item for each pricing arrangement which is defined in the ancillary pricing rule type.

Once an ancillary pricing rule type is defined, you can create ancillary pricing rules using the ancillary pricing rule type. While defining an ancillary pricing rule for a parent customer and bill group, you need to specify the following:

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

  • Pricing date range during which the pricing is effective.

  • Rate option which you want to use while defining the ancillary pricing.

  • Whether you want to define the pricing for a pass through charge without markup or markdown. If you select the Pass Through without Markup or Markdown option, you cannot define the pricing for a pass through charge with markup or markdown and the pricing for rate based charge with or without markup or markdown in the ancillary pricing rule. However, if the Pass Through without Markup or Markdown option is not selected, you can define pricing for different billable charge line types which can be with markup or markdown or which can be rate based with or without markup or markdown. In addition, if the Pass Through without Markup or Markdown option is not selected, by default, the system will define the pricing for a pass through charge without markup or markdown. Depending on the billable charge line type and pricing arrangement information in the ancillary transaction, the system will accordingly fetch the appropriate pricing for billing the ancillary charge. For example, if the ancillary transaction contains BCLT1 as the billable charge line type and PASSMK as the pricing arrangement and the effective ancillary pricing rule contains the following pricing:

    Ancillary Pricing Billable Charge Line Type Pricing Arrangement Rate Pricing Strategy Markup Amount Markdown Amount
    AP1 BCLT0 Pass Through with Markup or Markdown - Markup $10 -
    AP2 BCLT1 Pass Through with Markup or Markdown - Markdown - $5
    AP3 BCLT2 Rate Based without Markup or Markdown $5 - - -
    AP4 BCLT3 Rate Based with Markup or Markdown $5 Markup $10 -
    AP5 BCLT4 Rate Based with Markup or Markdown $5 Markdown - $5
    AP6 - Pass Through without Markup or Markdown - - - -

    In this case, the system will use the AP2 pricing defined in the ancillary pricing rule. The system will markdown the SQI with the specified amount (i.e. $5).

  • Whether the billable charge line type is eligible for billing or not. Accordingly, the system will create billable charge for the ancillary transaction.

In addition, while defining an ancillary pricing rule for a bill group, you need to indicate the policy status for which the ancillary pricing rule is applicable. You can also specify a pricing group while defining an ancillary pricing rule for a bill group. Once an ancillary pricing rule is created, the system creates multiple price assignments in a price list and assigns the price list to the bill group.

Related Topics

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

Parent Topic: Self-Funded Pricing