Price Item (Health Insurance Business)

The various charges that are to be charged to the customer (for example, premium or optional administration fees to a fully-insured group customer and claim based fees or enrollment based fees to a self-funded customer) are defined as price items in the system. Similarly, various charges credited to the customer are also defined as price items. Stop-loss arrangements for a self-funded customer (for example, specific stop-loss that is calculated and credited to customer) is represented using a price item in the system.

Once you define a price item, you can also define the pricing for the price item at various levels using pricing rules based on the requirements. For a fully-insured group customer, the pricing is defined at the policy plan level. Whereas, for a self-funded customer, the pricing can be defined either at the bill group policy level or at the parent customer level. For more information about the fully-insured pricing, see Fully-Insured Pricing. And, for more information about the self-funded pricing, see Self-Funded Pricing.

The system enables you to create price items which can be used for pricing and billing. It means that pricing can be defined for the price item and charges can be created against it in the system. The system enables you to create the following type of price items:

• Fees Based Price Items - The fees based services would include services on which fees is charged to the customers either annually or at regular intervals (for example, for the administrative services offered to the self-funded customer, the admin fees will be charged). You can create fees based price items which can be used for pricing and billing in the system.

You need to associate a contract type with a price item. The system allows you to create a charge (i.e. billable charge) for a price item on an account when a contract of the contract type which is associated with the price item is already present on the account.

You can create price items which can be assigned to any price list except global price list or which can assigned to only global price lists. For more information about global price list, see Price List.

You can associate one or more parameters where the parameter usage is set to Price Item with a price item. These parameters can then be used for:

• Aggregating transactions which are mapped to the price item

• Defining multi parameter based pricing for the price item

If the parameter usage is set to Aggregation while associating a parameter with a price item, the parameter is only used for aggregating transactions which are mapped to the price item. However, if the parameter usage is set to Pricing while associating a parameter with a price item, the parameter is used for aggregating transactions as well as for defining multi parameter based pricing for the price item.

You can associate a price item to one or more divisions. In addition, you can do the following when a price item is associated to a division:

• Associate the Service Quantity Identifiers (SQIs) with the Price Item for the Division

• Define the Division-Specific Characteristics for the Price Item

Related Topics

Parent Topic: Pricing Management