Benefit Passthrough Charges vs. Calculated Charges

Until now, the system enabled you to compare the calculated benefit amount against the externally priced (i.e. passthrough) benefit amount. And, if the calculated benefit amount was 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 created a To Do using the given To Do type and then added the To Do in the respective membership log.

Now, the system enables you to bill either the calculated benefit amount or passthrough benefit amount for a membership depending upon the business requirements. To implement this feature, the following changes are made to the system:

  • A new option named Compare Premium is introduced while defining or editing a benefit sub type.

  • A new characteristic type named C1BILLMD is introduced in this release.

  • A new algorithm named C1-BNFTENTY is attached to the Audit system event of the C1-IndMembership and C1-Benefits business objects.

To bill either the calculated benefit amount or passthrough benefit amount for a membership, you need to do the following:

  • Select the Compare Premium option in the respective benefit sub type.

  • Specify the price item (i.e. validate price item) in the respective benefit sub type. Here, you must specify the price item that is added in the primary pricing rule type (associated with the health plan) using which the premium is calculated for the membership.

  • Define the C1BILLMD characteristic type for the validate price item. You can set it to either of the following:

    • PREMIUM – Used when you want to bill the calculated benefit amount for the membership.

    • PASSTHROUGH - Used when you want to bill the passthrough benefit amount for the membership.

If the repricing entity detail record is created for the primary pricing rule type (used for calculating membership premium) and the repricing entity detail record does not exist for the benefit pricing rule type with the same effective date, then the C1-BNFTENTY algorithm creates the repricing entity detail record for the benefit pricing rule type, individual membership, and effective date combination in the CI_​REPRC_​ENTITY_​DTL table. The status of the benefit repricing entity detail record is set to Pending. This happens whenever the membership is audited, and the Compare Premium option is selected in the respective benefit sub type. Similarly, if the repricing entity detail record is created for the benefit pricing rule type (used for calculating membership benefit) and the repricing entity detail record does not exist for the primary pricing rule type with the same effective date, then the C1-BNFTENTY algorithm creates the repricing entity detail record for the primary pricing rule type, individual membership, and effective date combination in the CI_​REPRC_​ENTITY_​DTL table. The status of the premium repricing entity detail record is set to Pending. This happens whenever the membership benefit is audited, and the Compare Premium option is selected in the respective benefit sub type.

On executing the C1-REPC2 batch, the system updates the status of the following:

  • Premium repricing entity detail record to Invalid when the C1BILLMD characteristic on the validate price item is set to PASSTHROUGH

  • Benefit repricing entity detail record to Invalid when the C1BILLMD characteristic on the validate price item is set to PREMIUM

A new screen named Pricing Vs Passthrough Charges is introduced in this release. It is accessible from the Report and Inquiry menu. It enables you to view the difference (if any) between the calculated and passthrough benefit amount of a membership.