C1-BC-FIDER

This algorithm validates the following:

  • Either the account ID or account identifier type and account identifier is specified in the record.

  • Start and end dates are specified in the record.

  • Price item is specified in the record.

  • Either the contract ID or source system, policy number, and plan number is specified in the record for the fully insured group business.

  • Either the contract ID or health plan code is specified in the record for the fully insured individual business.

If the account ID is not specified in the record, it derives the account ID using the respective account identifier type and account identifier combination. Once the account ID is derived, the corresponding record is updated in the C1_​UPLOAD_​REQ_​DTLS table. If the system could not derive the account ID using the account identifier type and account identifier combination, the status of the record in the C1_​UPLOAD_​REQ_​DTLS table is changed to Invalid.

If the Plan Based Contract Creation Eligibility option type of the C1-ASOBLLNG feature configuration is not set to Yes and if the contract ID is not specified in the record, the system derives an active contract of the account for the coverage period using the contract type specified in the price item. However, if the Plan Based Contract Creation Eligibility option type of the C1-ASOBLLNG feature configuration is set to Yes and if the contract ID is not specified in the record, the system derives policy plan or health plan specific contract of the account for the coverage period depending on the information given in the record. Before deriving the contract for the fully insured group business, the system derives the policy plan ID using the source system, policy number, and plan number combination. Once the policy plan is derived, the corresponding record is updated in the C1_​UPLOAD_​REQ_​DTLS table.

This algorithm then derives the active contract for the policy plan using the contract type (associated with the price item), policy plan ID, and coverage period combination. However, in case of the fully insured individual business, the system derives the active contract for the health plan using the contract type (associated with the price item), health plan code, and coverage period combination. Once the contract ID is derived, the corresponding record is updated in the C1_​UPLOAD_​REQ_​DTLS table. If the system could not derive the policy plan ID or contract ID, the status of the record in the C1_​UPLOAD_​REQ_​DTLS table is changed to Invalid. In addition, if any of the above validations fail, the status of the record in the C1_​UPLOAD_​REQ_​DTLS table is changed to Invalid.

This algorithm also checks whether the characteristic type specified in the Membership ID Characteristic for Billable Charge option type of the C1-ASOBLLNG feature configuration is available in the record. If so, the system derives the membership ID from the specified characteristic in the record. However, if the required characteristic is not available in the record, this algorithm tries to derive the group or individual membership using either of the following combinations:

  • Subscriber Identifier Type and Subscriber Identifier

  • External Membership ID

  • Membership Type, External Membership ID, Subscriber Identifier Type and Subscriber Identifier

Once the membership ID is derived, the corresponding record is updated in the C1_​UPLOAD_​REQ_​DTLS table.

This algorithm sets the recurring flag to BP and the adhoc bill flag to N for each record in the upload request. It also derives the fields which can be used as search filters based on the mapping defined in the respective upload request type.