Bill Group Derivation

The Validate Transaction and Derive Price Item (C1-TXNIP) batch derives the bill group, parent customer, and policy for the claim, enrollment, and ancillary transactions. This is possible only when an algorithm created using the C1_​TXNBGDRV algorithm type is attached to the Bill Group Derivation system event of the primary pricing rule type. The derived bill group is used for billing the following (if any):

  • Claim Charges

  • Claim Based Fees

  • Specific Stop-Loss (SSL) Credits

  • Aggregate Stop-Loss (ASL) Credits

  • Retroactive Enrollment Fees

  • Non-retroactive Enrollment Fees

  • One-time or Recurring Fees

  • Ancillary Charges

To derive a bill group, the system first determines the derivation date. The paid date is considered as the derivation date while processing the claim transactions. The coverage end date is considered as the derivation date while processing the retroactive enrollment transactions. And, the coverage start date is considered as the derivation date while processing the non-retroactive enrollment transactions. If the system cannot determine the derivation date, the status of the transaction is changed to Error.

Depending on the transaction fields which are mapped to source system, parameter 1, parameter 2, parameter 3, and parameter 4 in the primary pricing rule type, the system derives the data from the transaction. For example, if the source system is mapped to the External System field, parameter 1 is mapped to the Location field, parameter 2 is mapped to the Designation field, parameter 3 is mapped to the Employee Group field, and parameter 4 is mapped to the Nationality field, the system derives these details from the transaction. Based on the data available in the transaction, the system derives a bill group using the derivation and pricing parameters which are defined for the bill group. Note that the system considers the derivation and pricing parameters which are effective on the derivation date. For example, if the following derivation and pricing parameters are defined for the Bill Group 1 and Bill Group 2:

Bill Group Name Sort ID Effective Date Source System Parameter 1 Parameter 2 Parameter 3 Parameter 4
Bill Group 1 123 01-01-2018 X Eastern Senior Manager BG1 Indian
Bill Group 1 132 01-04-2018 X Western Senior Manager - -
Bill Group 1 156 01-07-2018 Y Eastern Senior Manager BG1 Indian
Bill Group 1 163 01-10-2018 Y Western Senior Manager - -
Bill Group 2 172 01-01-2018 Y Eastern - - -
Bill Group 2 181 01-04-2018 Y Western - - -
Bill Group 2 122 01-07-2018 X Eastern - - -
Bill Group 2 112 01-10-2018 X Western - - -

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

  • External System is set to X

  • Location is set to Western

  • Designation is set to Senior Manager

  • Paid Date is set to 12-05-2018

In this example, the derivation and pricing parameters defined for the Bill Group 1 and 132 (sort ID) combination are effective on the paid date, and therefore the system derives Bill Group 1 for billing the claim transaction. Let us take another example where the system receives a retroactive enrollment transaction with the following details:

  • External System is set to X

  • Location is set to Eastern

  • Designation is set to Senior Manager

  • Employee Group is set to BG1

  • Nationality is set to Indian

  • Coverage Start Date is set to 01-01-2018

  • Coverage End Date is set to 31-03-2018

In this example, the derivation and pricing parameters defined for the Bill Group 1 and 123 (sort ID) combination are effective on the coverage end date, and therefore the system derives Bill Group 1 for billing the retroactive enrollment transaction.

In the above two examples, the system could find the exact match for the bill group in the system. However, if the exact match is not available, the system finds the bill group using the best fit match. For example, if the system receives a claim transaction with the following details:

  • External System is set to Y

  • Location is set to Western

  • Designation is set to Senior Manager

  • Employee Group is set to BG2

  • Nationality is set to Indian

  • Paid Date is set to 01-06-2018

In this example, the system could not find the effective derivation and pricing parameters with exact match (i.e. Source System = Y, Location = Western, Designation = Senior Manager, Employee Group = BG2, and Nationality = Indian) on the paid date. Therefore, it searches for the best fit match.

While searching for the best fit match, the system first rules out the optional parameter 4 (i.e. Nationality = Indian) and then checks whether the effective derivation and pricing parameters, where Source System = Y, Location = Western, Designation = Senior Manager, and Employee Group = BG2, are available on the paid date. If so, it considers the derivation and pricing parameters and accordingly derives the bill group. If not, the system then rules out the optional parameter 3 (i.e. Employee Group = BG2) and then checks whether the effective derivation and pricing parameters, where Source System = Y, Location = Western, and Designation = Senior Manager, are available on the paid date. If so, it considers the derivation and pricing parameters and accordingly derives the bill group. If not, the system then rules out the optional parameter 2 (i.e. Designation = Senior Manager) and then checks whether the effective derivation and pricing parameters, where Source System = Y and Location = Western, are available on the paid date. If so, it considers the derivation and pricing parameters and accordingly derives the bill group. If not, the status of the transaction is changed to Error.

In this example, the derivation and pricing parameters, where Source System = Y and Location = Western, defined for the Bill Group 2 and 181 (sort ID) combination are considered as the best fit match. Therefore, the system derives Bill Group 2 for billing the claim transaction. Let us take another example where the system receives a non-retroactive enrollment transaction with the following details:

  • External System is set to Y

  • Location is set to Eastern

  • Designation is set to Senior Manager

  • Employee Group is set to BG1

  • Nationality is set to Indian

  • Coverage Start Date is set to 01-01-2018

  • Coverage End Date is set to 31-03-2018

In this example, the system could not find the effective derivation and pricing parameters with exact match (i.e. Source System = Y, Location = Eastern, Designation = Senior Manager, Employee Group = BG1, and Nationality = Indian) on the coverage start date. Therefore, it searches for the best fit match. The derivation and pricing parameters, where Source System = Y and Location = Eastern, defined for the Bill Group 2 and 172 (sort ID) combination are considered as the best fit match. Therefore, the system derives Bill Group 2 for billing the non-retroactive enrollment transaction.

Once the bill group is derived, the system derives the parent customer of the bill group. Once the parent customer is derived, the system derives the policy for the transaction in the following manner:

If the transaction is a... Then...
Claim Transaction The system checks whether the paid date of the claim transaction falls within the policy start date and runout end date of any policy where:

  • The bill group is associated with the policy using the policy person role which is specified in the Bill Group Policy Person Role option type of the C1-ASOBLLNG feature configuration.

  • The status of the policy is set to either of the following:

    • In Force/Active

    • Runout

    • Post Runout
Retroactive Enrollment Transaction The system checks whether the coverage end date falls within the policy start date and policy end date of any policy where:

  • The bill group is associated with the policy using the policy person role which is specified in the Bill Group Policy Person Role option type of the C1-ASOBLLNG feature configuration.

  • The status of the policy is set to In Force/Active.
Non-retroactive Enrollment Transaction The system checks whether the coverage start date falls within the policy start date and policy end date of any policy where:

  • The bill group is associated with the policy using the policy person role which is specified in the Bill Group Policy Person Role option type of the C1-ASOBLLNG feature configuration.

  • The status of the policy is set to In Force/Active.

If the system cannot derive the policy for the transaction, the status of the transaction is changed to Error.