Pre-requisites

To setup the Self-Funded Billing feature, you need to do the following:

• Define the parent customers and bill groups in the system.

• Define the required pricing rule types for different pricing rule type categories, such as Claim, Specific Stop-Loss, Aggregate Stop-Loss, Retention Type Claim Based, Retention Type Enrollment Based, Flat Fees, and Ancillary.

• Map the transaction fields appropriately in the primary pricing rule types.

• Attach an algorithm created using the C1_​TXNBGDRV algorithm type to the Bill Group Derivation system event of the pricing rule type where the pricing rule type category is set to Claim or Retention Type Enrollment Based.

• Attach an algorithm created using the C1_​ACCPRIDRV algorithm type to the Account and Price Item Derivation system event of the pricing rule type where the pricing rule type category is set to Claim, Retention Type Claim Based, Retention Type Enrollment Based, or Ancillary.

• Attach an algorithm created using the C1_​ACCPRISL algorithm type to the Account and Price Item Derivation system event of the pricing rule type where the pricing rule type category is set to Specific Stop-Loss or Aggregate Stop-Loss.

• Attach an algorithm created using the C1_​BAFTDRV algorithm type to the Bill After Date Determination system event of the pricing rule type where the pricing rule type category is set to Claim, Retention Type Claim Based, Retention Type Enrollment Based, or Ancillary.

• Attach an algorithm created using the SA_​DERV_​POPC algorithm type to the TFM - Contract Derivation algorithm spot of the required divisions.

• Attach an algorithm created using the C1-VRPR_​POPC algorithm type to the TFM - Verify Pricing Post-Processing algorithm spot of the required divisions.

• Attach an algorithm created using the C1_​BCHG_​POPC algorithm type to the TFM - Billable Charge Post-Processing algorithm spot of the required divisions.

• Map each transaction record type to either the required rule type or primary pricing rule type.

• Define the pricing groups for the required bill groups.

• Define the required pricing rules for the parent customer and bill groups.

• Define the rate schedules with the following calculation algorithms for different price items:

  Price item related to....	Calculation Algorithm
  Claim	C1-CLAIMCALC
  Specific Stop-Loss	C1-SSLRTCALC
  Aggregate Stop-Loss	C1-ASLRTCALC
  Retention Type Enrollment Based	None
  Flat Fees	None
  Ancillary	C1-ANCICALC

• Attach an algorithm created using the C1-RETFLAT algorithm type to the TFM - Rate Pre-Processing algorithm spot of the required divisions.

• Define the TFM information in the rating option for different price items in the following manner:

  The following table lists the TFM information which must be defined in the rating option for the respective type of price items:

  Price item related to....	Rate Option
  	Aggregate Transaction	Aggregation Schedule	Ignore Transaction	Rating Criteria
  Claim	Yes	As Required	No	RITA
  Specific Stop-Loss	No	-	Yes	RITX
  Aggregate Stop-Loss	No	-	Yes	RITX
  Retention Type Claim Based	Yes	As Required	No	RITA
  Retention Type Enrollment Based	Yes	As Required	No	RITA
  Ancillary	Yes	As Required	No	RITA

• Define the derivation and pricing parameters for each bill group.

• Set the following option types in the C1-ASOBLLNG feature configuration:

  • Person Relationship Type

  • Bill Group Policy Person Role

  • Invoice Type Characteristic Type

  • Pricing Group Rule Parameter

  • Billable Charge Line Type Parameter

  • Pricing Arrangement Parameter

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