Defining a Policy

Oracle Revenue Management and Billing enables you to define a policy for the fully-insured and self-funded health insurance business. You can define a fully-insured group policy using a policy type where the policy category is set to Fully-Insured Group or Fully-Insured Individual. However, you can define a self-funded policy using a policy type where the policy category is set to Self-Funded.

Note: At present, the Fully-Insured Individual policy category is not supported in the system.

Prerequisites

To define a policy, you should have:

  • Policy types defined in the application

  • Values defined for the C1-SourceSystemLookup extendable lookup

    Note: This prerequisite is applicable only when you want to define a fully-insured group policy.

  • Values defined for the RUNOUT_​ADM_​OPT_​FLG lookup field

    Note: This prerequisite is applicable when you want to define a self-funded policy.

Procedure

To define a policy:

  1. Click the Menu link in the Application toolbar.
    A list appears.
  2. From the Main menu, select Customer Management and then click Policy.
    A sub-menu appears.
  3. Click the Add option from the Policy sub-menu.

    The Select Policy Type screen appears. It contains the following field:

    Field Name Field Description Mandatory (Yes or No)
    Policy Type Used to indicate the policy type using which you want to create a policy.
    Note: If you want to create a fully-insured group policy, you must select a policy type where the policy category is set to Fully-Insured Group or Fully-Insured Individual. However, if you want to create a self-funded policy, you must select a policy type where the policy category is set to Self-Funded.
    		 Yes
    Tip: Alternatively, you can access this screen by clicking the Add button in the Page Title area of the Policy screen.
  4. Select the required policy type from the respective field.
  5. Click OK.

    The Policy screen appears. It contains the following sections:

    • Main - Used to specify the basic details about the policy.

    • Persons - Used to associate persons with the policy.

    • Characteristics - Used to define the characteristics for the policy.

    The Main section contains the following fields:

    Field Name Field Description Mandatory (Yes or No)
    Policy Type Indicates the policy type using which you are defining the policy. Not applicable
    Policy Number Used to specify the policy number. Yes
    Description Used to specify the description for the policy. Yes
    Source System Used to indicate the external system from where the policy is originated.
    Note: This field appears when you are defining a policy using a policy type where the policy category is set to Fully-Insured Group or Fully-Insured Individual.
    		 Yes
    Start Date Used to specify the date from when the policy is effective.
    Note: The policy start date cannot be later than the policy end date.
    		 Yes
    End Date Used to specify the date till when the policy is effective.
    Note: The policy end date cannot be earlier than the policy start date.
    		 Yes
    Runout End Date Used to specify the date when the runout period of the self-funded policy ends.
    Note:

    The runout end date cannot be earlier than or equal to the policy end date.

    This field appears when you are defining a policy using a policy type where the policy category is set to Self-Funded.

    		 No
    Runout Administration Fees Used to indicate whether the administration fees must be charged when the claim transaction for the self-funded policy is processed in the runout period. The valid values are:

    • None

    • Percentage of Claim

    Note:

    At present, this field is used only for the informational purposes and is not considered during the billable charge creation for the claim transactions which are received in the runout period of the policy.

    This field appears when you are defining a policy using a policy type where the policy category is set to Self-Funded.

    		 No
    Advance Level Funding Eligibility Indicates whether the self-funded policy is eligible for the advance billing feature of level funding.
    Note:

    This is a read-only field. By default, the value is set to No. You can edit the advance level funding eligibility only through a health care inbound message.

    This field appears when you are defining a policy using a policy type where the policy category is set to Self-Funded.

    		 Not applicable
    Advance Deposit Applicability Used to indicate whether the advance deposit is applicable for the policy.
    Note:

    This field is required only when the advance deposit level of the respective policy holder (i.e., parent customer) is set to POLI. However, this field is not mandatory.

    This field appears only when you create a policy using a policy type where the policy category is set to Fully-Insured Group.

    		 No
    Advance Deposit Amount Used to specify the advance deposit amount.
    Note:

    You must specify a positive value in this field.

    This field appears only when you create a policy using a policy type where the policy category is set to Fully-Insured Group.

    		 Yes (Conditional)
    Note: This field is required when the Advance Deposit Applicability option is selected.
    Advance Deposit Grace Days Used to specify the grace days. The system then uses the grace days to derive the grace period within which the advance deposit should be received from the group customer for the policy. While calculating the grace period, the system considers the policy start date as the grace start date. Once the grace start date is derived, the system calculates the grace end date (i.e., grace start date + grace days). For example, if a parent customer is the policy holder of the P1 policy (01-Jan-2022 to 31-Dec-2022) and advance deposit grace days is set to 6 days, then the system considers 01-Jan-2022 as the grace start date and sets the grace end date to 07-Jan-2022.
    Note:

    You must specify an integer value in this field.

    This field appears only when you create a policy using a policy type where the policy category is set to Fully-Insured Group.

    		 Yes (Conditional)
    Note: This field is required when the Advance Deposit Applicability option is selected.
    Advance Deposit Account Used to indicate the account of the parent customer where the advance deposit is parked for the policy.
    Note:

    This field appears only when you create a policy using a policy type where the policy category is set to Fully-Insured Group.

    You must specify an account with the account relationship type that is specified in the Advance Deposit Account Relationship Type attribute of the delinquency process preference. The system considers the delinquency process preference which is specified in the Delinquency Process Field Mapping option type of the DELINPROC feature configuration. For more information about the feature configuration, see Setting the DELINPROC Feature Configuration.

    The Search (The Search Icon) icon appears corresponding to the Advance Deposit Account field. On clicking the Search icon, the Account Search window appears.

    		 Yes (Conditional)
    Note: This field is required when the Advance Deposit Applicability option is selected.
  6. Enter the required details in the Main section.
  7. Associate the required persons with the policy.
    Note: While defining a policy, you must associate a person who is the main customer of the policy.
  8. Define the characteristics for the policy, if required.
  9. Click Save.
    The policy is defined and its status is set to Pending.

Related Topics

For more information on... See...
Policy screen Policy (Used for Viewing)
How to associate a person with a policy Associating a Person with a Policy
How to define a characteristic for a policy Defining a Characteristic for a Policy