Pricing Rules
The self-funded plan may offer various services to the employer, such as claim administration, reinsurance or stop-loss, discount or level funding arrangement, and so on. Oracle Revenue Management and Billing enables you to define pricing rules for various services offered in the self-funded plan. The below table lists the pricing rules which you can define for the following services offered in the self-funded plan:
| Service | Pricing Rule | Created for.... |
|---|---|---|
| Claim Administration | Claim | Parent Customer |
| Claim Administration | Claim | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Claim Administration | Retention Type Claim Based | Parent Customer |
| Claim Administration | Retention Type Claim Based | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Claim Administration | Discount Share | Parent Customer |
| Claim Administration | Discount Guarantee | Parent Customer |
| Claim Administration | One-Time Flat Fees | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Claim Administration | Bill Period Based Recurring Flat Fees | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Claim Administration | Frequency Based Recurring Flat Fees | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Enrollment | Retention Type Enrollment Based | Parent Customer |
| Enrollment | Retention Type Enrollment Based | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Ancillary, such as Laboratory, Radiology, Pharmacy, Physical Therapy, or Preventive Care | Ancillary | Parent Customer |
| Ancillary, such as Laboratory, Radiology, Pharmacy, Physical Therapy, or Preventive Care | Ancillary | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Stop-Loss | Specific Stop-Loss | Parent Customer |
| Stop-Loss | Specific Stop-Loss | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Stop-Loss | Aggregate Stop-Loss | Parent Customer |
| Stop-Loss | Aggregate Stop-Loss | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Level Funding Arrangement | Enrollment Based Premium | Parent Customer |
| Level Funding Arrangement | Enrollment Based Premium | Bill Group's Policy where the Parent Customer is the Policy Holder |
| Level Funding Arrangement | Flat Rate Based Premium | Parent Customer |
| Level Funding Arrangement | Flat Rate Based Premium | Bill Group's Policy where the Parent Customer is the Policy Holder |
You can create the above mentioned self-funded pricing rules for a parent customer or for the policy of the bill group from the user interface and not through a health care inbound message.
The system creates a price assignment for each pricing rule. In case of the retention type claim and enrollment based pricing rules, the system creates multiple price assignments when different claim based or enrollment based fee is offered for employees with different set of employee attributes.
The system first searches for the pricing rule of a price item (i.e. service) at the bill group level. If the effective pricing rule for a price item is available at the bill group level, the system uses it for deriving the price assignment. However, if the effective pricing rule for a price item is not available at the bill group level, the system searches for the pricing rule of a price item at the parent customer level. If the effective pricing rule for a price item is available at the parent customer level, the system uses it for deriving the price assignment. However, if the effective pricing rule for a price item is not available at the bill group or parent customer level, the system does not consider the respective price item for billing.