Policy Plans

A fully-insured group policy may cover various plans for medical, dental, or disability benefits. You can subscriber a person for one or more policy plans within or across policies. The system creates one membership for each person who is subscribed to the policy plan. You can then add dependent members in each membership whenever required.

While creating a policy plan, you need to specify either a price item or at least one pricing rule type. The price item given in the policy plan is used to create a pass-through billable charge for pre-calculated premium amount which is received in an inbound message.

Alternatively, you can associate a pricing rule type with a policy plan. You can only associate a pricing rule type where the pricing rule type category is set to Age Based, Tier Based, or Pass-Through Billable Charge. If you associate an age based pricing rule type with the policy plan, the system creates the SQI based billable charge whenever the membership premium is calculated for eligible members. If you associate a tier based pricing rule type with the policy plan, the system creates the SQI based billable charge whenever the premium is calculated for membership. However, if you associate a pass-through billable charge pricing rule type with the policy plan, the system creates an SQI based billable charge using the pass-through billable charge pricing rule type whenever the price item information is given, but the account information is not given in a health care inbound message. Note that if both the price item and account details are given in the billable charge information, the system directly creates the SQI based billable charge for the pre-calculated premium and does not refer the pass-through billable charge pricing rule type which is associated with the policy plan.