Fully-Insured Pricing Business Rules

Oracle Revenue Management and Billing enables you to define business rules for fully-insured pricing. A new category named Fully-Insured Pricing Business Rule is introduced in this release. The premium calculation process for an individual membership is described as follows:

  • If you want to calculate the premium for an individual membership using an Age Based Pricing rule, the system derives the rate for each eligible member person. Once the rate is derived, the system identifies members that are eligible for premium calculation using the fully-insured pricing business rules. On creating or editing an individual membership through a health care inbound message or membership repricing inbound web service, the system determines the fully-insured pricing business rules which are applicable for the individual membership. If an individual membership meets the criteria of the fully-insured pricing business rule, the system then stamps the fully-insured pricing business rule corresponding to the individual membership.

  • If you want to calculate the premium for an individual membership using a Tier Based Pricing rule, the system derives the subscription tier using the fully-insured pricing business rules. Once the premium is calculated for an individual membership, the system creates a billable charge for the premium. If the account is defined for the individual membership using the characteristic types specified in the Account Identifier Type Char Type and Account Identifier Value Char Type option types of the C1-ASOBLLNG feature configuration, the system uses the account to bill the charge for the premium. However, if these characteristics are not defined for the individual membership, the system considers the account of the financially responsible member person to the charge for the premium.

    Note: While deriving a business rule of the Fully-Insured Pricing Business Rule category, the system considers the respective business rules which are effective on the audit event's effective date.

You can define, edit, and delete a fully-insured pricing business rule through the Business Rule screen. While defining a fully-insured pricing business rule, you need to set its category to Fully-Insured Pricing Business Rule. The fully-insured pricing business rule enables you to define the following parameters:

  • Maximum Dependents - Used to specify the maximum number of children which are eligible for premium calculation.

  • Dependent Max Age Limit - Used to specify the maximum age limit for children eligible for premium calculation.

  • Dependent Order Priority - Used to indicate the order priority of the dependent during premium calculation.

  • Age Calculation Date - Used to indicate whether the member person's age should be calculated using the member person's enrollment date or policy's start or renewal date.

  • Age Recalculation Date - Used to indicate whether the member person's age should be recalculated using the member person's enrollment date or policy's start or renewal date.

  • Young Adult Applicability - Used to indicate that the child or dependent enrolling in the membership becomes the young adult in the enrollment period.

  • Young Adult Max Age Limit - Used to specify the maximum age limit for young adults which are eligible for premium calculation.

  • Member Relationship Derivation Date - Used to indicate the member relationship for a member person.

You can view the fully-insured pricing business rules through the Business Rule screen.

Parent topic: Business Rules