C1-FICRETBC

Prerequisites

  • Define the values for the option types CTME (Characteristic Type For Membership Id) and PRSQ (Proration SQI) in the C1-ASOBLLNG feature configuration.

  • Define the price item which is passed (as a billable charge data) through a health care inbound message.

  • Define the pass-through billable charge pricing rule type on the policy plan.

This algorithm is invoked to create SQI (Service Quantity Identifier) based billable charges for fully-insured services. This algorithm creates the following set of SQI based billable charges:

  • Pre-calculated Premium Amount - SQI based billable charges which are created for pre-calculated premium amount received through a healthcare inbound message.

  • Calculated Premium Amount - Price items for which the SQI based billable charges are created using the pricing rules defined on the policy plan level.

This algorithm also performs the following operations:

  • Creation of the new billable charges.

  • Cancellation of the existing billable charges.

  • End Date modification of the existing billable charges.

This algorithm is invoked in the following scenarios:

If... Then...
A billable charge exists for a specific date range where the Billable Charge Status field is set to Billable option which is yet to be processed with the same start date, price item, and membership information The algorithm modifies only the end date information of that specific billable charge.
The membership is in the Pending Effectuation status and the status reason is Awaiting Binder Payment, where the status reason is mapped with the attribute value of the Membership Status Reason Hold / Awaiting Binder Payment attribute field in Field Mapping screen The algorithm retrieves the values of the binder payment applicability and hold billing switch from the CI_​MEMBERSHIP table. If the binder payment applicability and the hold billing switch is set to Y, the algorithm updates the bill after date information on the billable charge to 31-Dec-2099.
The billable charge for a particular price item and membership appear in the proposed date range and either of them have a different start date or amount The algorithm cancels the billable charge.
Note:

Billable charges which are created or updated for calculated charges, are updated accordingly in the PriceCalculationDetail entity in the CI_​PRCE_​CALC table. Further, those billable charge entries are marked as Completed. The Pricing rule type corresponding to the price item (during the processing of the inbound billable charge information) is fetched from the PricingRuleTypePriceitem entity in the C1_​PRC_​RULE_​TYPE_​PRICEITEM table on the first found basis.

The inbound billable charge information is processed as per the latest billable charge data. Once the inbound message is invoked, the algorithm assumes the following conditions:

  • The billable charge line characteristics are not available.

  • Every billable charge line has the same currency code.

In the case of modification or cancellation of the existing billable charges, its corresponding bill segments go through the following conditions:

  • If the billable charge end date is updated, the algorithm checks for all the bill segments where the date range exceeds the billable charge end date. If the date range exceeds the billable charge end date, then only those billable charges are either canceled or deleted based on the status of the bill segment.

  • If the billable charge is canceled, then all the bill segments within that billable charge are either canceled or deleted based on the status of the bill segment.

Finally, the billable charges are stamped with the following information:

  • Price Item

  • SQI (derived from the C1-ASOBLLNG feature configuration)

  • Pass-through billable charge entries in the MEMO ONLY state.

  • Aggregated amount is stamped as service quantity.

  • Additional information, if any...

It contains the following parameter:

  • Bill To Type Flag - This flag is used when the Contract ID is added in the MEMBERSHIP_​SA table.