Pricing Rule Type

The Pricing Rule Type zone displays the details of the pricing rule type for claim, aggregate stop-loss, specific stop-loss, retention type enrollment based, retention type claim based, one-time flat fee, bill period based recurring flat fee, and frequency based recurring flat fee. This zone contains the following sections:

• Main - This section provides basic information about the pricing rule type. It contains the following fields:

  Field Name	Field Description
  Pricing Rule Type	Displays the pricing rule type.
  Description	Displays the description for the pricing rule type.
  Detailed Description	Displays additional information about the pricing rule type category.
  Pricing Rule Business Object	Indicates the pricing rule business object. In addition, a context menu appears corresponding to this field which helps in navigating to other screens in the application. The valid values are: Claim Pricing Rule Aggregate Stop-Loss (ASL) Pricing Rule Specific Stop-Loss (SSL) Pricing Rule Retention Type Claim Based Pricing Rule Retention Type Enrollment Based Pricing Rule Flat Fee Pricing Rule Ancillary Pricing Rule Discount Arrangement Pricing Rule Level Funded (LF) Pricing Rule Minimum Premium Program Pricing Rule Note: It has a link. On clicking the link, the Business Object screen appears where you can view the details of the respective business object.
  Business Object	Indicates the pricing rule type business object. In addition, a context menu appears corresponding to this field which helps in navigating to other screens in the application. The valid values are: Claim Pricing Rule Type Aggregate Stop-Loss (ASL) Pricing Rule Type Specific Stop-Loss (SSL) Pricing Rule Type Retention Type Claim Based Pricing Rule Type Retention Type Enrollment Based Pricing Rule Type Flat Fee Pricing Rule Type Ancillary Pricing Rule Type Discount Arrangement Pricing Rule Type Level Funded (LF) Pricing Rule Type Minimum Premium Program Pricing Rule Type Note: It has a link. On clicking the link, the Business Object screen appears where you can view the details of the respective business object.
  Status	Indicates the status of the pricing rule type. The valid values are: Active Inactive
  Primary	Displays whether the pricing rule type is primary or not.
  Pricing Rule Type Category	Indicates the pricing rule type category for the pricing rule type. The valid values are: Claim Aggregate Stop-Loss Specific Stop-Loss Retention Type Claim Based Retention Type Enrollment Based Flat Fees Ancillary Discount Arrangement Level Funded Minimum Premium Program

• Related Pricing Rule Types - This section lists the pricing rule types which are related to the parent pricing rule type. It contains the following columns:

  Column Name	Column Description
  Sequence	Displays the order in which pricing rule type is executed.
  Pricing Rule Type	Displays the related pricing rule type for the parent rule type. Note: It has a link. On clicking the link, the Pricing Rule Type screen appears where you can view the details of the respective pricing rule type.
  Eligibility Rule Type	Indicates the rule type eligibility for the related pricing rule type. Note: It has a link. On clicking the link, the Rule Type screen appears where you can view the eligibility details of the respective pricing rule type.

  Note: This section appears when the pricing rule type is a primary pricing rule type.

• Transaction Field Mapping - This section displays the transaction related data mapped to the pricing rule type. It contains the following fields:

  Field Name	Field Description
  Source System	Displays the external system from where the transaction data is mapped.
  Parameter 1 ... Parameter 4	Displays the parameters mapped for the transactions.
  Incurred Date	Displays the date incurred for transaction.
  Paid Date	Displays the transaction paid date.
  Source of Funds	Displays the source of funds used to make the payment.
  Composite	Displays the composite transaction data.
  Claim Disposition	Displays the disposition of the claims transaction.
  Provider's Tax Identification Number	Displays the tax identification number of the provider.
  Member ID	Displays the member ID.
  Main Subscriber ID	Displays the customer ID.
  Run-in Identifier	Displays the run-in identifier.
  Runout Identifier	Displays the runout identifier.
  Coverage Start Date	Displays the transaction coverage start date.
  Coverage End Date	Displays the transaction coverage end date.
  Retroactivity Indicator	Displays information of the retroactivity indicator.

  Note: This section appears when the pricing rule type is a primary pricing rule type.

• Algorithms - This section displays the algorithms used for the pricing rule type. It contains the following columns:

  Column Name	Column Description
  System Event	Indicates the system event on which the algorithm must be executed. The valid values are: Account and Price Item Derivation Account and Price Item Derivation Post-Processing Accumulation Billable Charge Post-Processing Accumulation Billable Charge Pre-Processing Accumulation Post-Processing Accumulation Pre-Processing Bill After Date Determination Bill Group Derivation Billable Charge Creation Post-Processing Billable Charge Creation Pre-Processing Final Settlement Derivation New Born Waiver Calculation Premium Calculation Pricing Rule Derivation Pricing Rule Post-Processing Pricing Rule Pre-Processing Pricing Rule Proration Amount Calculation Skip Month Premium Calculation Transaction Validation
  Sequence	Displays the order in which the algorithms for each system event must be executed.
  Algorithm	Displays the algorithm. Note: It has a link. On clicking the link, the Algorithm screen appears with the details of the respective algorithm.

• Additional Data - This section displays the additional information about the pricing rule type. It contains the following fields:

  Field Name	Field Description
  Eligible for Level Funding	Indicates whether the pricing rule type is eligible for level funding or not. The valid values are: Yes No
  Eligible for Specific Stop-Loss	Indicates whether the pricing rule type is eligible for specific stop-loss or not. The valid values are: Yes No Note: This field appears when the option selected for the Pricing Rule Type Category is Claim, Retention Type Claim Based, or Retention Type Enrollment Based.
  Eligible for Minimum Premium Program	Indicates whether the pricing rule type is eligible for minimum premium program or not. The valid values are: Yes No Note: This field appears when the option selected for the Pricing Rule Type Category is
  Run-in Identifier Value	Displays the value for run-in identifier.
  Runout Identifier Value	Displays the value for runout identifier.

  Note: This section does not appear when the pricing rule type category is flat fees.

• Price Items - This section displays the price items assigned to the pricing rule type. It contains the following columns:

  Column Name	Column Description
  Price Item	Displays the price item information. Note: It has a link. On clicking the link, the Price Item screen appears where you can view the details of the respective price item.
  Rate Option	On clicking the Add () icon, the following column appears: Column Name Column Description Rate Option Indicates the rate option for the price item. Note: This column does not appear when the pricing rule type category is flat fees.
  Bill To Account	On clicking the Add () icon, the following columns appear: Column Name Column Description Priority Displays the order in which the invoice type was considered while defining a price item. Invoice Type Displays the invoice type for the price item.
  Eligibility Rule Type	Indicates the rule type which indicates the rules that should be executed to determine whether the price item is eligible for billing. Note: It has a link. On clicking the link, the Rule Type screen appears where you can view the eligibility details of the respective pricing rule type.

• Price Item Parameters - This section displays the price item parameters in the pricing rule type. It contains the following columns:

  Column Name	Column Description
  Price Item Parameter	Displays the parameter associated with the price item. Note: It has a link. On clicking the link, the Parameter screen appears where you can view the details of the respective parameter.
  Transaction Field	Displays the additional transaction data. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective transaction field. This column does not appear when the pricing rule type category is flat fees.
  Eligible for Specific Stop-Loss	Displays the parameter eligible for Specific Stop-Loss when the eligibility checkbox was checked. Note: This field appears only when the option selected for the Pricing Rule Type Category is Claim, Retention Type Claim Based, or Retention Type Enrollment Based.
  Eligible for Level Funding	Displays the parameter eligible for level funding when the eligibility checkbox was checked.

• Characteristics - This section displays the pricing rule type characteristics. It contains the following columns:

  Column Name	Column Description
  Characteristic Type	Indicates the characteristic type.
  Characteristic Value	Displays the value for the characteristic type.

• Event Management - This section displays the audit event details. It contains the following columns:

  Column Name	Column Description
  Audit Event Type	Displays the audit event type which you can use while adding elements for audit in a fully-insured benefit pricing rule type.
  Element Type	Indicates the type of audit element for a fully-insured benefit pricing rule type. The valid values are: Business Object Status Characteristic Field
  Element Name	Displays the element name for a fully-insured benefit pricing rule type.
  Element Value	Displays the value for an element name.

• Claim Templates - This section list the pricing rule type for claim template. It contains the following field:

  Field Name	Field Description
  Claim Template	Indicates the claim template.

  Note: This section appears when the Business Object is Claim Pricing Rule Type.

• Claim-Specific Additional Data - This section displays the claim specific additional data. It contains the following fields:

  Field Name	Field Description
  Rule Based Billing Eligibility Field	Displays whether the rule based field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Rule Based Markup or Markdown Eligibility Field	Displays whether the rule based markup or markdown field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Markup or Markdown Billable Charge Line Type	Displays the markup or markdown billable charge line type.

  Note: This section appears when the Business Object is Claim Pricing Rule Type.

• ASL-Specific Additional Data - This section displays the Aggregated Stop-Loss specific additional data. It contains the following fields:

  Field Name	Field Description
  ASL Billable Charge Line Type	Displays the Aggregated Stop-Loss billable charge line type.
  Domestic Provider Claim Billable Charge Line Type	Displays the claim billable charge line type for domestic provider.
  Rule Based Domestic Provider Claim Eligibility Field	Displays the rule based domestic provider for claim eligibility field.
  ASL Limit Price Item	Displays the Aggregated Stop-Loss limit price item.
  Rule Based Billing Eligibility Field	Displays whether the rule based field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Rule Based Markup or Markdown Eligibility Field	Displays whether the rule based markup or markdown field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Markup or Markdown Billable Charge Line Type	Displays the markup or markdown billable charge line type.

  Note: This section appears when the Business Object is Aggregate Stop-Loss (ASL) Pricing Rule Type.

• Enrollment-Specific Additional Data - This section displays the enrollment specific additional data. It contains the following fields:

  Field Name	Field Description
  Retroactivity Indicator Value	Displays the value for the retroactivity indicator.

  Note: This section appears when the Business Object is Retention Type Enrollment Based Pricing Rule Type.

• Claim Disposition Details - This section displays the details of claim disposition. It contains the following columns:

  Column Name	Column Description
  Claim Disposition	Indicates the claim disposition.
  Disposition Mode	Indicates the claim disposition mode. The valid values are: Align Signage Zero Out

  Note: This section appears when the Business Object is Retention Type Claim Based Pricing Rule Type.

• SSL-Specific Additional Data - This section displays the Specific Stop-Loss additional data. It contains the following fields:

  Field Name	Field Description
  SSL Billable Charge Line Type	Displays the Specific Stop-Loss billable charge line type.
  Domestic Provider Claim Billable Charge Line Type	Displays the claim billable charge line type for domestic provider.
  Rule Based Domestic Provider Claim Eligibility Field	Displays the rule based domestic provider for claim eligibility field.
  Rule Based Billing Eligibility Field	Displays whether the rule based field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Rule Based Markup or Markdown Eligibility Field	Displays whether the rule based markup or markdown field is eligible for billing or not. Note: It has a link. On clicking the link, the Field screen appears where you can view the details of the respective field.
  Markup or Markdown Billable Charge Line Type	Displays the markup or markdown billable charge line type.

  Note: This section appears when the Business Object is Specific Stop-Loss (SSL) Pricing Rule Type.

• Billable Charge Line Types - This section list the billable charge line type. It contains the following column:

  Column Name	Column Description
  Billable Charge Line Type	Indicates the billable charge line type.

  Note: This section appears when the Business Object is Flat Fees Pricing Rule Type.

• Flat Fees - Specific Additional Data - This section displays the recurring flat fee that is specific and considered as additional data. It contains the following fields:

  Field Name	Field Description
  Bill Segment Cancel Reason	Indicates the reason for cancelling the bill segment.
  Recurring Fee	Displays whether the recurring flat fee is required or not.
  Recurring Method	Indicates the recurring method if recurring fee is required. The valid values are: Bill Period Frequency Note: This field appears when the checkbox for Recurring Fee field is selected.

  Note: This section appears when the Business Object is Flat Fees Pricing Rule Type.

  This section contains the following sub-section:

  • Bill Periods - This section displays the bill period for the recurring flat fee. It contains the following column:

    Column Name	Column Description
    Bill Period	Indicates the bill period.

    Note: This section appears when the Recurring Method is Bill Period.

• Additional Fee Indicator - This section displays the additional fees which are applicable to one or more line items in the claim pricing rule. It contains the following fields:

  Column Name	Column Description
  Fee	Indicates the charge type category for the claim pricing rule.
  Claim Additional Fee Indicator	Indicates the charge type sub category for the claim pricing rule.

  Note: This section appears when the Business Object is Claim Pricing Rule Type.

• Minimum Premium Program - Specific Additional Data -

  Column Name	Column Description

• Record Actions - This section contains the following buttons:

  Button Name	Button Description
  Edit	Used to edit the details of the pricing rule type.
  Delete	Used to delete the pricing rule type.

• Record Information - This section contains the following fields:

  Field Name	Field Description
  Business Object	Indicates the business object using which the extendable lookup value for pricing rule type is created. In addition, a context menu appears corresponding to this field which helps in navigating to other screens in the application. Note: It has a link. On clicking the link, the Business Object screen appears with the details of the respective business object.

  By default, the Pricing Rule Type zone does not appear in the Pricing Rule Type screen. It appears when you click the Broadcast () icon corresponding to the pricing rule type in the Pricing Rule Type List zone.

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