Prorate Membership Benefit and Corresponding Sponsor Charges
Until now, the system prorated the group and individual membership premium charges when the membership was enrolled or terminated in middle of the billing cycle. For the fully insured group business, the system prorated the membership premium using the proration rules defined on the fully insured policy plan. However, for the fully insured individual business, the system prorated the membership premium using the daily proration mechanism.
Now, Oracle Revenue Management and Billing also enables you to prorate the membership benefit charges on the eligible account and their corresponding benefit sponsor charges on the sponsor account. For the fully insured group business, the system allows you to prorate the membership premium benefit charges using the proration rules defined on the fully insured policy plan and prorate the membership non-premium benefit charges using the daily proration mechanism. A new option named Premium Benefit is introduced while defining and editing a benefit sub type. If the Premium Benefit option is selected in a benefit sub type, the system will consider the benefits created using the benefit sub type as the membership premium benefits and will prorate the membership premium benefits (if required) using the proration rules defined on the fully insured policy plan. Note that if the proration rules are not defined on the fully insured policy plan, the system will prorate the membership premium benefits using the daily proration mechanism.
However, if the Premium Benefit option is not selected in a benefit sub type, the system will consider the benefits created using the benefit sub type as the membership non-premium benefits and will prorate the membership non-premium benefits (if required) using the daily proration mechanism. While defining a benefit sub type, by default, the Premium Benefit option is not selected. If you select the Premium Benefit option, then the Charge Benefit Sponsor option is removed from the user interface. This is because the group membership premium benefits are not sponsored by a health insurance exchange. If the Premium Benefit option is not selected and the Charge Benefit Sponsor option is selected, the system will prorate the benefit sponsor charges using the daily proration mechanism.
For the fully insured individual business, the system will prorate the membership benefit charges and their corresponding benefit sponsor changers using the daily proration mechanism.
The Premium Benefit option in the Benefit Sub Type screen is applicable only for the fully insured group business.
The end date of benefit should be sent through a health care inbound message or through a membership repricing request whenever the group or individual membership is terminated.
The system decides whether to prorate the membership premium or non-premium benefit charges of a price item using the Proration Required option defined corresponding to the price item in the respective benefit pricing rule type. If the Proration Required option is selected corresponding to a price item, the system will prorate the charges of the respective price item whenever required during membership enrolment or termination. However, if the Proration Required option is not selected corresponding to a price item, the system will not prorate the charges of the respective price item during membership enrolment or termination.
Note that if you select the Proration Required option corresponding to any price item in a benefit pricing rule type, you need to attach an algorithm created using the C1-BNFTPRCF algorithm type to the Pricing Rule Proration Amount Calculation system event of the benefit pricing rule type.