Business Rules

Oracle Revenue Management and Billing facilitates you to calculate the premium for each individual membership differently based on various health product, health plan, membership, or member person attributes. You can define different set of business rules for the following categories:

• Binder Payment - If an individual membership meets the criteria of a binder payment business rule, the system derives the following information from the business rule:

  • Binder Payment Applicability

  • Threshold Percentage

  • Grace Days

  • Hold Billing

• Fully-Insured Pricing - If an individual membership meets the criteria of a fully-insured pricing business rule, the system derives the following information from the business rule:

  • Maximum Age Limit of Dependents

  • Dependent Order Priority

  • Age Calculation Date

  • Age Recalculation Date

  • Young Adult Applicability

  • Young Adult Max Age Limit

  • Member Relationship Derivation Date

• New Born - If an individual membership meets the criteria of a new born business rule, the system derives the following information from the business rule:

  • Gift Days Applicability

  • New Born Gift Days

• Rate Guarantee - If an individual membership meets the criteria of a rate guarantee business rule, the system derives the following information from the business rule:

  • Rate Guarantee Applicability

  • Rate Guarantee Period

• Refund/Write Off - If an individual membership meets the criteria of a refund/write-off business rule, the system derives the following information from the business rule:

  • Refund Threshold Amount

  • Defer Refund (in Days)

  • Write Off Threshold Amount

  • Defer Write Off (in Days)

• Delinquency Grace Period - If an individual membership meets the criteria of a delinquency grace period business rule, the system derives the following information from the business rule:

  • Criteria Description

  • Effective Date

  • Status

  • Grace Period (Days)

• Delinquency Event Attributes - If an individual membership meets the criteria of a delinquency event attributes business rule, the system derives the following information from the business rule:

  • Criteria Description

  • Effective Date

  • Status

  • Wait Days

  • Wait Month

  • Wait Day of Month

  • Send Membership Level Notification

• Delinquency Termination Date - If an individual membership meets the criteria of a delinquency termination date business rule, the system derives the following information from the business rule:

  • Criteria Description

  • Effective Date

  • Status

  • Termination Date Rule

• Delinquency Miscellaneous Options - If an individual membership meets the criteria of a delinquency miscellaneous options business rule, the system derives the following information from the business rule:

  • Criteria Description

  • Effective Date

  • Status

  • Trigger Date Recalculation On Hold Release

  • Trigger Date Recalculation On Resume

  • Trigger Termination Process

  • Immediate

  • Month End

  • After X Days

  • Termination Wait Days

  • Add Days to Coverage End Date

  • Add Days to Paid Through Date

  • Add Months to Paid Through Date

  • Add Days to Grace End Date

  • Add Days to Date of Processing of Termination Request

A business rule contains a criteria. If the criteria of the business rule is met, the information is derived from the business rule. This information is used while deriving the member relationship for a member person, subscription tier for an individual membership, and while deriving eligible member persons for premium calculation.

You can define criteria for a business rule using a set of parameters which are associated with a business rule type. The system enables you to associate only those parameters in a business rule type where the parameter usage is set to Business Rule Eligibility Criteria.

To implement the business rule feature, the following new screens are introduced in this release:

• Business Rule Type - Used to specify a list of parameters where the parameter usage is set to Business Rule Eligibility Criteria. You can then use the parameter while defining a criteria in the business rule.

• Business Rule - Used to search business rules of a particular category (i.e. Fully-Insured Pricing or New Born).

Parent topic: Individual Health Insurance Pricing