Membership Benefit Billing

Once the repricing entity detail records are created for the membership benefits which are added or updated, you need to execute the following batches in the given sequence:

  • Identify Entities for Repricing (C1-REPC1)

  • Process Repricing Request (C1-REPC2)

  • Fully Insured Billable Charge Creation (C1-FIBCR)

Before executing the above batches, you need to set the Medicare preference in the Medicare option type of the C1-ASOBLLNG feature configuration. This preference is used to derive the membership benefit pricing while creating charges for Medicare Part D LIS and Medicare Part D LEP. You can define a Medicare preference using the Medicare preference category through the Field Mapping screen. While defining a Medicare preference, you must set the following attributes in a Medicare preference:

  • Late Enrollment Penalty - Used to indicate the benefit sub type for Medicare Part D LEP.

  • Low Income Subsidy - Used to indicate the benefit sub type for Medicare Part D LIS.

  • Medicare Prescription Drug Coverage - Used to indicate the benefit sub type for Medicare Part D.

For more information about the Medicare preference, refer to Medicare Preference

If the reverse charge is to be created for a membership benefit on the benefit sponsor account, the system does the following during the respective batch execution:

  • C1-REPC1 - This batch checks whether the benefit sponsor account or sponsor account derivation algorithm is specified in the benefit sub type. If the sponsor account derivation algorithm is specified in the benefit sub type, the C1-REPC1 batch invokes the sponsor account derivation algorithm which derives the benefit sponsor account for the individual membership. It then creates two repricing requests - one for benefit price item and another for benefit sponsored price item.

  • C1-REPC2 - This batch derives the amount for the benefit repricing request and benefit sponsored repricing request from the C1_​BENEFITS table.

  • C1-FIBCR - This batch creates the billable charges for benefit price item as well as benefit sponsored price item. A characteristic is stamped on the benefit charge which is created using the benefit sponsored price item on the benefit sponsor account. This characteristic indicates that the benefit charge is a reverse charge on the benefit sponsor account. While defining the characteristic, the system fetches the characteristic type which is specified in the Sponsored Switch Characteristic for Billable Charge option type of the C1-ASOBLLNG feature configuration.

If the Validate External Price option is selected in the benefit sub type of a membership benefit, the system invokes the C1-PRLBCVLD algorithm which is attached to the Billable Charge Creation Post-Processing system event of the respective benefit pricing rule type. It is used to calculate the benefit charge using the validate price item and then compare it against the externally priced benefit charge. If there is a mismatch in the benefit start date, benefit end date, and benefit amount, the system creates a To Do using the given To Do type and then adds the To Do in the respective membership log. However, if the benefit start date and end dates match, but the benefit amount does not match, the system uses the threshold amount to determine whether the To Do should be created for the membership. If the calculated benefit amount is within the minimum amount (i.e. received benefit amount - threshold amount) and maximum amount (i.e. received benefit amount + threshold amount) range, the system will not create a To Do for the membership when there is mismatch in the calculated benefit amount (priced in ORMB) and received pre-calculated benefit amount (i.e. priced externally). However, if the calculated benefit amount is not within the minimum amount (i.e. received benefit amount - threshold amount) and maximum amount (i.e. received benefit amount + threshold amount) range, the system creates a To Do using the given To Do type and then adds the To Do in the respective membership log.

The C1-PRLBCVLD algorithm contains the following parameters:

  • To Do Type - Used to indicate the To Do type using which you want to create a To Do. The C1-PRBCV To Do type is shipped with the product. This parameter is mandatory.

  • To Do Role - Used to indicate that users with the specified To Do role must receive the To Do notification. This parameter is optional. If you do not specify this parameter, the system considers the default To Do role associated with the To Do type.

  • Threshold Amount - Used to specify the threshold amount which is used to calculate the minimum and maximum amount range for benefit amount comparison. This parameter is mandatory.

You can view the benefit price item billable charges generated for a membership benefit from the Billable Charges zone of the Contracts and Charges tab in the Membership screen. Similarly, you can view the benefit sponsored price item billable charges (i.e. reverse charges which are created for a membership benefit on the benefit sponsor account) from the Sponsor Billable Charges zone of the Contracts and Charges tab in the Membership screen. In the Sponsor Billable Charges zone, the system displays the billable charges where the characteristic type specified in the Sponsored Switch Characteristic for Billable Charge option type of the C1-ASOBLLNG feature configuration is defined. Therefore, if you want to create a reverse charge for a membership benefit on the benefit sponsor account, it is mandatory to set the Sponsored Switch Characteristic for Billable Charge option type of the C1-ASOBLLNG feature configuration.