Pricing Management

Oracle Revenue Management and Billing allows you to define prices for premiums, various fees, credits, discounts, and taxes that are defined as price items. Price for the price item may vary based on various attributes, which are defined as parameters in the system. Parameter values are derived either from transaction attributes (for example, for calculating claim based fees for a self-funded customer, pricing may vary based on claim transaction's health coverage class) or based on a field or characteristic of entities (for example, for calculating premium, pricing may vary based on member person's characteristic; whether a smoker or non-smoker). The system also supports deriving the pricing parameter through an algorithm, thereby enabling the custom derivation based on requirements.

Based on the line of business and the type of charge, you can define standard pricing which is common for multiple customers (for example, pricing defined for a health plan is applicable for all the subscribers subscribing to the health plan) or customer-specific pricing (for example, for fully-insured group customer, the pricing is specific to the group and you can define the policy plan level pricing in the system to achieve this. For more information about the fully-insured pricing, see Fully-Insured Pricing.

The system enables you to define pricing at various levels in a customer hierarchy (for example, for a self-funded group customer, the pricing can be defined at the bill group level as well as at the parent customer level). If pricing is defined at multiple levels for a customer, the precedence is given to the pricing based on the level while searching for the pricing. For example, if pricing is defined for a price item at the bill group level as well as the parent customer level, the bill group level pricing takes precedence over the parent customer level pricing. Also, the parent customer level pricing is inherited by all the bill groups.

The pricing is triggered based on the transactions to calculate various charges or credit amounts eligible for a transaction. For example, for a self-funded customer, claim amounts with additional fees and markups, claim based fees, stop loss is calculated for claim transactions, enrollment based retention fees are calculated based on enrollment transactions, and ancillary fees are calculated based on ancillary transactions. For more information about the self-funded pricing, see Self-Funded Pricing.

Transaction Based Pricing is invoked using the Transaction Feed Management module which processes different types of transactions (for example, claim, capitation, ancillary, enrollment, etc.) using the configurable validation and mapping rules to invoke the eligible pricing rules. For more information about the transaction feed management, see Transaction Feed Management.

Pricing can also be triggered based on qualifying life events (for example, premium is calculated when a new membership is added, or a new member is added to an existing membership, or every time the plan pricing is revised, etc.). The entity audit framework enables you to define various events for which pricing should be revised. For example, addition of a new membership, addition of a new member, updates to the plan pricing, or the membership attributes which you want to monitor for premium change, etc. The system enables you to define the algorithms to price the eligible events by invoking pricing rules. For more information about the entity audit framework, see Entity Audit.

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