Sample Health Product and Plan Inbound Message for Health Plan Pricing Rules Setup
Using the below example, you can do the following:
-
Create the age-based pricing rule for the RET_DENT health plan -
The following table provides sample data for an age-based pricing rule of the health plan: Base Rate Pricing Parameter Modifier Information Health Plan Pricing Rule Type Base Fee Lower Age Limit Upper Age Limit Parameter Parameter Value Modifier Modifier Value Modifier Rate RET_DENT AGE_BASED 100 1 20 TOBAC Y SMOKER N 10 300 1 40 TOBAC Y SMOKER N 20 500 1 60 TOBAC Y SMOKER N 30 -
Create the discount charge pricing rule for the RET_DENT health plan -
The following table provides sample data for a discount charge pricing rule of the health plan: Health Plan Pricing Rule Type Base Fee Modifier Modifier Value Modifier Rate RET_DENT DISCOUNT_CHARGE 50 VP_BAND VP1 10 70 M_BAND M1 20 90 IC_BAND IC1 30
<schema>
<bo>C1-HCProdHlthPlnInbound</bo>
<messageType>C1-HCPRODHLTHPLN-INB-MSG-TYPE</messageType>
<sourceSystem>NSC</sourceSystem>
<externalTransactionId>889977</externalTransactionId>
<externalBatchId>737373</externalBatchId>
<externalSourceId>373737</externalSourceId>
<healthPlanData>
<healthProductCode>HPROD_505</healthProductCode>
<healthPlanCode>RET_DENT</healthPlanCode>
<description>RETIREE DENTAL HEALTH PLAN</description>
<charitablePlan>N</charitablePlan>
<standardPlan>Y</standardPlan>
<acaQhp>Y</acaQhp>
<grandFatherPlan>Y</grandFatherPlan>
<ancillaryBenefits>Y</ancillaryBenefits>
<riderBenefits>N</riderBenefits>
<addOnPlan>N</addOnPlan>
<hiosId></hiosId>
<startDate>2021-01-01</startDate>
<endDate>2021-12-31</endDate>
<status>ACTIVE</status>
<healthPlanCharacteristics>
<characteristicType>ZZ-BNBLA</characteristicType>
<characteristicValue>DRCT</characteristicValue>
<effectiveDate>2021-01-01</effectiveDate>
</healthPlanCharacteristics>
<healthPlanPricingRuleTypes>
<pricingRuleType>AGE_BASED</pricingRuleType>
</healthPlanPricingRuleTypes>
<healthPlanPricingRuleTypes>
<pricingRuleType>DISCOUNT_CHARGE</pricingRuleType>
</healthPlanPricingRuleTypes>
</healthPlanData>
<healthPlanPricingRuleData>
<sequence>1</sequence>
<entityIdentifiers>
<entityIdentifiersList>
<entityIdentifierType>HLPN</entityIdentifierType>
<entityIdentifierValue>RET_DENT</entityIdentifierValue>
</entityIdentifiersList>
</entityIdentifiers>
<pricingRuleType>AGE_BASED</pricingRuleType>
<priceItemCd>AGE</priceItemCd>
<status>ACTIVE</status>
<startDate>2021-01-01</startDate>
<endDate>2021-31-01</endDate>
<rateOption>ZZAGE</rateOption>
<pricingType>FLAT</pricingType>
<modifierApplicability>Y</modifierApplicability>
<modifierMethod>EXPT</modifierMethod>
<baseRate>
<sequence>1</sequence>
<baseFee>100</baseFee>
<lowerAgeLimit>1</lowerAgeLimit>
<upperAgeLimit>20</upperAgeLimit>
<pricingParameter>
<sequence>1</sequence>
<parameterCode>TOBAC</parameterCode>
<parameterValue>Y</parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>SMOKER</parameterCode>
<parameterValue>N</parameterValue>
<rate>10</rate>
</modifierInformation>
</baseRate>
<characteristics>
<characteristicsList>
<characteristicType>ZZ-DISP</characteristicType>
<characteristicValue>DRCT</characteristicValue>
<effectiveDate>2021-04-01</effectiveDate>
</characteristicsList>
</characteristics>
<pricingRuleEligibility>
<sequence>1</sequence>
<priceParmCode>ORA_EMP</priceParmCode>
<priceParmVal>Y</priceParmVal>
</pricingRuleEligibility>
<pricingRuleEligibility>
<sequence>2</sequence>
<priceParmCode>MEMSTATE</priceParmCode>
<priceParmVal>NY</priceParmVal>
</pricingRuleEligibility>
</healthPlanPricingRuleData>
<healthPlanPricingRuleData>
<sequence>2</sequence>
<entityIdentifiers>
<entityIdentifiersList>
<entityIdentifierType>HLPN</entityIdentifierType>
<entityIdentifierValue>RET_DENT</entityIdentifierValue>
</entityIdentifiersList>
</entityIdentifiers>
<pricingRuleType>AGE_BASED</pricingRuleType>
<priceItemCd>AGE</priceItemCd>
<status>ACTIVE</status>
<startDate>2021-01-01</startDate>
<endDate>2021-12-31</endDate>
<rateOption>ZZAGE</rateOption>
<pricingType>FLAT</pricingType>
<modifierApplicability>Y</modifierApplicability>
<modifierMethod>EXPT</modifierMethod>
<baseRate>
<sequence>1</sequence>
<baseFee>300</baseFee>
<lowerAgeLimit>1</lowerAgeLimit>
<upperAgeLimit>40</upperAgeLimit>
<pricingParameter>
<sequence>1</sequence>
<parameterCode>TOBAC</parameterCode>
<parameterValue>Y</parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>SMOKER</parameterCode>
<parameterValue>N</parameterValue>
<rate>20</rate>
</modifierInformation>
</baseRate>
<characteristics>
<characteristicsList>
<characteristicType>ZZ-BLAGM</characteristicType>
<characteristicValue>BRCT</characteristicValue>
<effectiveDate>2021-01-01</effectiveDate>
</characteristicsList>
</characteristics>
<pricingRuleEligibility>
<sequence>1</sequence>
<priceParmCode>ORA_EMP</priceParmCode>
<priceParmVal>Y</priceParmVal>
</pricingRuleEligibility>
<pricingRuleEligibility>
<sequence>2</sequence>
<priceParmCode>MEMSTATE</priceParmCode>
<priceParmVal>TX</priceParmVal>
</pricingRuleEligibility>
</healthPlanPricingRuleData>
<healthPlanPricingRuleData>
<sequence>3</sequence>
<entityIdentifiers>
<entityIdentifiersList>
<entityIdentifierType>HLPN</entityIdentifierType>
<entityIdentifierValue>RET_DENT</entityIdentifierValue>
</entityIdentifiersList>
</entityIdentifiers>
<pricingRuleType>AGE_BASED</pricingRuleType>
<priceItemCd>AGE</priceItemCd>
<status>ACTIVE</status>
<startDate>2021-01-01</startDate>
<endDate>2021-12-31</endDate>
<rateOption>ZZAGE</rateOption>
<pricingType>FLAT</pricingType>
<modifierApplicability>Y</modifierApplicability>
<modifierMethod>EXPT</modifierMethod>
<baseRate>
<sequence>1</sequence>
<baseFee>500</baseFee>
<lowerAgeLimit>1</lowerAgeLimit>
<upperAgeLimit>60</upperAgeLimit>
<pricingParameter>
<sequence>1</sequence>
<parameterCode>TOBAC</parameterCode>
<parameterValue>Y</parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>SMOKER</parameterCode>
<parameterValue>N</parameterValue>
<rate>30</rate>
</modifierInformation>
</baseRate>
<characteristics>
<characteristicsList>
<characteristicType>ZZ-TESGM</characteristicType>
<characteristicValue>TRCT</characteristicValue>
<effectiveDate>2021-01-01</effectiveDate>
</characteristicsList>
</characteristics>
<pricingRuleEligibility>
<sequence>1</sequence>
<priceParmCode>ORA_EMP</priceParmCode>
<priceParmVal>Y</priceParmVal>
</pricingRuleEligibility>
<pricingRuleEligibility>
<sequence>2</sequence>
<priceParmCode>MEMSTATE</priceParmCode>
<priceParmVal>OH</priceParmVal>
</pricingRuleEligibility>
</healthPlanPricingRuleData>
<healthPlanPricingRuleData>
<sequence>4</sequence>
<entityIdentifiers>
<entityIdentifiersList>
<entityIdentifierType>HLPN</entityIdentifierType>
<entityIdentifierValue>RET_DENT</entityIdentifierValue>
</entityIdentifiersList>
</entityIdentifiers>
<pricingRuleType>DISCOUNT_CHARGE</pricingRuleType>
<priceItemCd>DISCOUNT_1</priceItemCd>
<status>ACTIVE</status>
<startDate>2021-01-01</startDate>
<endDate>2021-12-31</endDate>
<rateOption>ZZ_CAPPCT_PK</rateOption>
<pricingType>PCNT</pricingType>
<modifierApplicability>Y</modifierApplicability>
<modifierMethod>EXPT</modifierMethod>
<baseRate>
<sequence>1</sequence>
<baseFee>50</baseFee>
<lowerAgeLimit></lowerAgeLimit>
<upperAgeLimit></upperAgeLimit>
<pricingParameter>
<sequence></sequence>
<parameterCode></parameterCode>
<parameterValue></parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>VP_BAND</parameterCode>
<parameterValue>VP1</parameterValue>
<rate>10</rate>
</modifierInformation>
</baseRate>
<baseRate>
<sequence>2</sequence>
<baseFee>70</baseFee>
<lowerAgeLimit></lowerAgeLimit>
<upperAgeLimit></upperAgeLimit>
<pricingParameter>
<sequence></sequence>
<parameterCode></parameterCode>
<parameterValue></parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>M_BAND</parameterCode>
<parameterValue>M1</parameterValue>
<rate>20</rate>
</modifierInformation>
</baseRate>
<baseRate>
<sequence>3</sequence>
<baseFee>90</baseFee>
<lowerAgeLimit></lowerAgeLimit>
<upperAgeLimit></upperAgeLimit>
<pricingParameter>
<sequence></sequence>
<parameterCode></parameterCode>
<parameterValue></parameterValue>
</pricingParameter>
<modifierInformation>
<sequence>1</sequence>
<parameterCode>IC_BAND</parameterCode>
<parameterValue>IC1</parameterValue>
<rate>30</rate>
</modifierInformation>
</baseRate>
<characteristics>
<characteristicsList>
<characteristicType>ZZ-TESGM</characteristicType>
<characteristicValue>TRCT</characteristicValue>
<effectiveDate>2021-01-01</effectiveDate>
</characteristicsList>
</characteristics>
<pricingRuleEligibility>
<sequence>1</sequence>
<priceParmCode>ORA_EMP</priceParmCode>
<priceParmVal>Y</priceParmVal>
</pricingRuleEligibility>
<pricingRuleEligibility>
<sequence>2</sequence>
<priceParmCode>MEMSTATE</priceParmCode>
<priceParmVal>OH</priceParmVal>
</pricingRuleEligibility>
</healthPlanPricingRuleData>
</schema>Note: We have given the above sample to illustrate how the tags should
be nested while sending an inbound message from the external system.
However, you should not seamlessly use this sample in your environment
because the required pre-requisite data may not be available in your
environment. In such case, the system will give erroneous results.