Individual Health Insurance Billing

While calculating the premium for an individual membership using an age based pricing rule, the system derives the rate for each eligible member person. The system identifies members which are eligible for premium calculation using the fully-insured pricing and new born 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 and new born business rules which are applicable for the individual membership. The system enables you to define business rules of the following categories:

  • Fully-Insured Pricing

  • New Born

While determining the business rules which are applicable for an individual membership, the system executes the business rules of each category which are effective on the inbound processing date based on the priority of the business rule. If an individual membership meets the criteria of the business rule, the system stamps the respective business rule corresponding to the individual membership. In this way, the system derives two business rules - one fully-insured pricing business rule and another new born business rule.

While calculating the premium for an individual membership using a tier based pricing rule, the system derives the subscription tier using the fully-insured pricing and new born 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.

Parent topic: Oracle Revenue Management and Billing Insurance Business Processes