Hold Repricing
Until now, the system calculated the premium and benefit (if applicable) charges immediately through the Repricing feature whenever an individual membership is added, updated, canceled, terminated, or reinstated in ORMB. In the individual health insurance business, there might be situations wherein approved premium rates are not available for the future enrollment period, frequent updates are received for the memberships, or the data flow is delayed due to some maintenance activity in the source system. In all such situations, you may want to hold the repricing for the membership for a particular period.
Oracle Revenue Management and Billing enables you to capture the repricing after date for a membership. This helps you to hold the repricing for the membership until the specified date. Note that the hold repricing feature is offered and certified only for the fully insured individual business and not for the fully insured group business. To implement the hold repricing feature, the following changes are made in the system:
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A new field named REPRC_AFTER_DT is added in the CI_MEMBERSHIP table.
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A new tag named repriceAfterDate is introduced in the C1-IndMembership and C1-HCInboundMessage business object schema.
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A new tag named repriceAfterDate is introduced in the C1-MembershipRepricing business service schema.
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The C1-HCINPROC and C1-INVRDTCIM algorithm types are enhanced to support the hold repricing feature.
You can specify the repricing after date for an individual membership only through a health care inbound message or through the membership repricing inbound web service and not from the user interface (i.e. through the Membership screen). The repriceAfterDate tag is not mandatory. If the value for the repriceAfterDate tag is received while creating an individual membership, the system checks whether the repricing after date of the individual membership is earlier than the inbound message processing date. If so, the system throws an appropriate message indicating that the repricing after date of the individual membership cannot be earlier than the inbound message processing date. However, if the repricing after date of an individual membership is equal to or later than the inbound message processing date, the system checks whether the repricing after date of an individual membership is later than the membership end date. If so, the system throws an appropriate message indicating that the repricing after date of the individual membership cannot be later than the membership end date. However, if the repricing after date of an individual membership is earlier than the membership end date, the system adds the individual membership to the health plan. The repricing after date (if any) is then shown in the Main section of the Membership screen. In addition, a log entry is created for the individual membership indicating that the repricing for the membership is on hold till a particular date. You can view the log entry in the Log tab of the Membership screen.
If the value for the repriceAfterDate tag is received while updating a membership, the system checks whether the repricing after date of the individual membership is earlier than the inbound message processing date. If so, the system throws an appropriate message indicating that the repricing after date of the individual membership cannot be earlier than the inbound message processing date. However, if the repricing after date of an individual membership is equal to or later than the inbound message processing date, the system checks the status of the individual membership. If the status of the individual membership is not set to Canceled, the system checks whether there is any invoice request created for the respective account in the non-final status (i.e. in a status other than Processed or Canceled). If so, the system checks whether the repricing after date is later than the invoice request processing date. If so, the system sets the invoice request processing date to repricing after date + 1. In addition, a log entry is created for the invoice request indicating that the invoice request is on hold till a particular date. You can view the log entry in the Log tab of the Invoice Request screen.
However, if the repricing after date is earlier than or equal to the invoice request processing date, the system does not override the invoice request processing date.
On executing the C1-REPC1 batch, the system considers the repricing after date specified for the individual membership while processing the respective repricing entity detail records. If the repricing after date is equal to or later than the batch business date, the system considers only those repricing entity detail records of the individual membership where the category of the pricing rule types is set to Benefit and accordingly creates the repricing requests for the benefit specific price items. Only when the repricing after date is earlier than the batch business date, the system considers all the repricing entity detail records of the respective individual membership which are in the Pending status and accordingly creates a repricing request for each individual membership, pricing rule, and effective date combination.