Specific Stop-Loss (SSL) Pricing

Stop-Loss coverage provides liability limits on claims for individuals and for the employer group as a whole. Specific Stop-Loss (SSL) is the form of excess risk coverage that provides protection for the employer against a high claim on any one individual. This is protection against abnormal severity of a single member claim rather than abnormal frequency of claims in total. Specific stop-loss is also known as individual stop-loss. The specific stop-loss is calculated on the claim transactions received for an individual.

You can define a specific stop-loss pricing rule at the parent customer and bill group levels. The specific stop-loss pricing rule at the bill group level takes precedence over the specific stop-loss pricing rule at the parent customer level. You can define specific stop-loss pricing rules for parent customers and bill groups from the Customer 360° Information screen. You can define a specific stop-loss pricing rule using a specific stop-loss pricing rule type.

It is the specific stop-loss pricing rule type which helps the system to determine:

  • Business object using which the specific stop-loss pricing rule should be created in the system.

Note: The specific stop-loss pricing rule type is not a primary pricing rule type. It inherits the attributes from a claim pricing rule type where it is included as a related pricing rule type.

  • Algorithm which should be triggered while validating a transaction.

Note: An algorithm type for validating a transaction is not shipped from the product. You need to create a custom algorithm type, if required.

  • Algorithms which should be triggered while deriving account and price item for a transaction.

Note: You must create an algorithm using the C1_​ACCPRISL algorithm type and attach it to the Account and Price Item Derivation system event.

  • Post-processing algorithm which should be triggered once the specific stop-loss pricing rule is derived.

Note: A post-processing algorithm type is not shipped from the product. You need to create a custom algorithm type, if required.

  • Price items for which you can define specific stop-loss pricing rules using the specific stop-loss pricing rule type.

  • Rate options that you can use while defining the pricing for a price item.

  • Different type of account to which the price item should be billed based on the specified priority.

Note: Ideally, the price item parameters should not be specified in a specific stop-loss pricing rule type. The price item parameters which are specified in the claim pricing rule type are used for accumulating specific stop-loss.

  • Additional information, such as:

    • Identifier which helps to determine whether the specific stop-loss should be calculated for claim transactions which are received during the run-in period of the policy.

    • SSL billable charge line type using which you want to create specific stop-loss billable charges.

    • Domestic provider claim billable charge line type using which you want to create domestic provider claim calculation lines.

    • Markup or markdown billable charge line type using which you want to create markup or markdown calculation lines.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the line item is eligible for billing.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the markup or markdown calculation line is eligible for billing.

    • Transaction field which you want to use in the rules as the output parameter to determine whether the domestic provider claim calculation line is eligible for billing.

Once a specific stop-loss pricing rule type is defined, you can create specific stop-loss pricing rules using the specific stop-loss pricing rule type. While defining a specific stop-loss pricing rule for a parent customer, you need to specify the following:

  • Price item for which you want to define the pricing.

  • Pricing date range during which the pricing is effective.

  • Rate option which you want to use while defining the specific stop-loss pricing.

  • Whether the specific stop-loss pricing rule must be used for only pricing or for pricing and billing.

  • Whether the specific stop-loss must be accumulated at the member or main subscriber level.

  • Settlement frequency which helps to determine the bill after date. The valid values are:

    • Immediately - If you select this option from the list, the bill after date is not calculated. The specific stop-loss billable charge is billed immediately in the next bill cycle.

    • Manually (At Required Intervals) - If you select this option from the list, the bill after date which is specified in the Manual Settlement Bill After Date parameter while executing the C1-BCSSL batch is stamped on the specific stop-loss billable charge.

    • Never - If you select this option from the list, the bill after date which is specified in the Manual Settlement Bill After Date parameter while executing the C1-BCSSL batch is stamped on the specific stop-loss billable charge.

    • Yearly - If you select this option from the list, the bill after date in the specific stop-loss billable charge is set to the pricing end date.

  • Accumulation parameters (such as incurred start date, incurred end date, paid start date, paid end date, etc.) based on which you want to accumulate the specific stop-loss for the claim transactions which are processed in the run-in or active period of the policy.

  • The maximum limit defined for specific stop-loss at the member or main subscriber level.

  • Settlement days which helps to calculate the settlement date (i.e. pricing end date, incurred end date, or paid end date whichever is later + settlement days)

  • Whether the Aggregate Specific Stop-Loss (ASSL) should be calculated during the C1-BCSSL batch run for each bill group

  • The ASSL limit indicating that the aggregate specific stop-loss amount beyond this limit will be paid by the insurance company to the ASSL credit account.

  • Whether any member, main subscriber, or provider is excluded during the specific stop-loss calculation Different SSL limit (i.e. lasered amount) for a member, main subscriber, or provider who are expected to have higher claim amount.

However, while defining a specific stop-loss pricing rule for a bill group, you need to specify the following:

  • The status of the policy for which you want to define the specific stop-loss pricing rule.

  • Price item for which you want to define the pricing.

  • Parent customer's SSL pricing rule from which you want to inherit the accumulation parameters and exclusion and lasering information.

Note: The pricing date range is derived from the parent customer's specific stop-loss pricing rule because the specific stop-loss pricing rules for parent customer and bill group should have the same date range.

  • Rate option which you want to use while defining the specific stop-loss pricing.

  • Whether the specific stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.

  • The SSL limit indicating that the specific stop-loss amount beyond this limit will be paid by the insurance company.

  • The maximum specific stop-loss limit defined for the member when the claim transactions are received in the run-in period of the policy.

  • Whether line items in a claim pricing rule are eligible for specific stop-loss

Note: By default, the line items where the pricing rule type category is set to Specific Stop-Loss appear in the Line Items section. If you want to set specific stop-loss eligibility for the line items which belong to a particular claim pricing rule, you must select the respective claim pricing rule.

  • Whether certain percentage of SSL should be excluded while calculating specific stop-loss for domestic provider claim.

You can also specify a pricing group while defining a specific stop-loss pricing rule for a bill group. If you specify a pricing group while defining a stop-loss pricing rule for a bill group, you will have to define the following details for each rule defined in the pricing group:

  • Whether the specific stop-loss calculated for the claim transactions which are mapped to the specified price items and price item parameters should be accumulated.

  • The SSL limit indicating that the specific stop-loss amount beyond this limit will be paid by the insurance company.

  • The maximum specific stop-loss limit defined for the member when the claim transactions are received in the run-in period of the policy.

  • Whether line items in a claim pricing rule are eligible for specific stop-loss.

Note: By default, the line items where the pricing rule type category is set to Specific Stop-Loss appear in the Line Items section. If you want to set specific stop-loss eligibility for the line items which belong to a particular claim pricing rule, you must select the respective claim pricing rule.

  • Whether certain percentage of SSL should be excluded while calculating specific stop-loss for domestic provider claim.

Once a specific stop-loss pricing rule is defined for a parent customer and bill group, the system creates one price assignment, one price list, and one price list assignment.

Related Topics

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Pricing Rule Type screen Pricing Rule Type

Parent Topic: Self-Funded Pricing