Off-Process Request

There might be situations in the Administrative Services Only (ASO) business wherein the insurance company or health insurance customer (i.e. Employer) would like to change agreed limits or funds within the policy period. For example, a need may arise to change the ASL limit, minimum or maximum discount limit, or settlement or runout funds. This will impact the stop-loss, discount arrangement, and level funding calculation, respectively. In addition, there might be situations wherein the aggregated amount might require a change due to corrections in the claim transactions or due to migration of customers for whom the stop-loss is pre-accumulated and billed in the legacy system.

Oracle Revenue Management and Billing provides a mechanism through which the agreed limits, funds, or calculated amounts can be amended within the policy period.

The system enables you to amend the above mentioned accumulation field values through an off-process request. As its name suggests, an off-process request is an adhoc request to create an adjustment or billable charge through which the system can amend the above mentioned accumulation field values.

While creating an off-process request, you need to specify an off-process request type using which you want to create the off-process request. It is the off-process request type which helps the system to determine:

• The business object using which the off-process request should be created in the system

• Whether the system should create an adjustment or billable charge to amend the above mentioned accumulation field values

• Whether the approval is required for the off-process request

• The accumulation categories whose field values can be amended through the respective off-process requests

• The accumulation fields whose values can be amended through the respective off-process requests

• The default adjustment type using which the adjustment should be created when the amendment mode is set to Adjustment

• The default billable charge line type using which the billable charge should be created when the amendment mode is set to Billable Charge

• The type of contract against which the adjustment or billable charge should be created for the account

Once you specify the off-process request type, you need to specify the following:

• The parent customer (i.e. person whose person type is set to Parent Customer) for which you want to create an off-process request

• The accumulation category whose field value you want to amend through the off-process request

• The accumulation field whose value you want to amend through the off-process request

  Note: Here, you can select only those accumulation categories and fields for which the contract type and adjustment type or billable charge line type information is available in the respective off-process request type.

• The accumulation group for which the changes should be reflected in the system

  Note: If the accumulation category is set to Specific Stop-Loss, you can only select the accumulation group defined at the bill group level. However, if the accumulation category is set to Aggregate Stop-Loss, Discount Arrangement, or Level Funded, you can only select the accumulation group defined at the parent customer level.

• The account for which the adjustment or billable charge should be created in the system

• The amount which you want amend through the off-process request

• The adjustment type using which the adjustment should be created when the amendment mode is set to Adjustment in the respective off-process request type

• The billable charge line type using which the billable charge should be created when the amendment mode is set to Billable Charge in the respective off-process request type

• The member or main subscriber for whom the field value should be amended in the system

  Note: You need to specify the member or main subscriber when the accumulation category is set to Specific Stop-Loss.

• The date (i.e. effective date) when the field value should be amended in the system

  Note: If the amendment mode is set to Adjustment, the above date is stamped as the accounting date. However, if the amendment mode is set to Billable Charge, the above date is stamped as the billable charge start and end dates.

• The coverage period for which the amendment is applicable

  Note: The coverage period is stored for the informational purposes only and is not considered during accumulation.

Once an off-process request is created in the Draft status, you can edit, delete, or submit the off-process request. On submitting an off-process request, the system creates the adjustments or billable charges to amend the accumulation field values. Finally, the status of the off-process request is changed to Processed.

You can optionally configure the approval process for the off-process request. If the Approval Required flag is set to Yes in the off-process request type, the status of the off-process request is changed to Approval In Progress when you submit the off-process request. Once the approver approves the off-process request, the status of the off-process request is changed to Approved. The system then creates the adjustments or billable charges to amend the accumulation field values. Finally, the status of the off-process request is changed to Processed. However, if the approver rejects an off-process request, the status of the off-process request is changed to Rejected.

These adjustments or billable charges are then considered in the accumulation run when the adjustment date or billable charge start and end dates fall within the accumulation cycle. Depending on the accumulation category, the adjustment or billable charge is considered when the C1-ACSSL, C1-ACASL, C1-ACDA, or C1-ACLF batch is executed.

For more information on how to setup the off-process request feature, see Prerequisites.

Related Topics

Parent Topic: Oracle Revenue Management and Billing Insurance Business Processes