Functional views

The reporting views in this section are deprecated. They are replaced with the base views described in Base views.

Functional views provide in one view a combination of information from different source tables, that together fulfill a functional need. Functional views combine the following

• Regular table columns of underlying base table of the view

• Single valued dynamic fields. These are shown as regular columns of the view

• Multi language aspect of the data is resolved, the information is shown in one language.

• Look up columns. Information from lookup tables is shown using the code and description of the lookup

• Data access restrictions using the role of the user that uses the views

Some functional views will be similar to their base views. The reason for this is that it enables the granting of these views to the NonConfidential role. It would be harder to grant only a subset of the base views.

Propagation

Specifically the bill and claim line functional view will show both

• all the propagated columns in the same way as the UI and the integration points show them, which is identical to the object values

• all the columns without propagation, which is identical to the database values and base views.

Data access restrictions in the functional views.

Data access is implemented in the functional views, using a user context. Before data can be retrieved from the views the user that is using the views needs to be set. This is done using ohi_context_pkg. If the context is not set then only unrestricted data can be retrieved from the views to which access restrictions apply

Person access restriction

If the person is not restricted then every user can see the details of that person. If the person is restricted then only users with access to that restriction can see the details and data of that person.

The following information is not shown for restricted persons unless the user has an access grant that restriction code

• Claims

• Marital Statuses

• Person Titles

• Addresses

• Relation Tags

• Bank Account Numbers

• Associations

Data access group access restriction

If the data access group is not restricted, or the claim has no data access group then every user can see the claim. If the claim has a data access group and the data access group is restricted then only users with access to that restriction can see the claim and claim lines.

Payer access and Brand restriction.

This is similar to the data access group

Procedure access restriction

• If the procedure is not restricted then the procedure code and description are always shown

• If the procedure is restricted then the procedure code and description are only shown if the user has access to the restriction

Diagnosis access restriction

This is similar to the person access restriction

Combinations of restrictions

Claim and Authorization

A user only has access to a claim or authorization if either the

• person

• payer

• brand

• data access group

are not restricted or if the user has access to all each of the restricted ones.

Bill, Claim line, Coverages

A user has access to the bills, claim lines and coverages of the claims, to which he has access.

Limit Consumptions

No access restrictions.

Functional view columns

All functional views will be created with a FUN_ prefix.

Claim

Field/Field set description
For each of the following lookups Brand that the Claim is associated with Claim Form record Claimant Provider Claimant Relation Classification Scheme Classification Location Type Location Provider Payer Code record associated with this claim Payment Specification Receiver Provider Payment Specification Receiver Relation Payment Receiver Provider Payment Receiver Relation Payment Beneficiary Provider Payment Beneficiary Relation Primary Diagnosis Referring Provider Service Provider Serviced Entity Type Serviced Entity Servicing Specialty the following fields will be provided a code field a code definition field (if applicable) a name or description A code field (only) will be provided for the reference to currency for all amount fields: total allowed amount total claimed amount total covered amount
All fixed attributes of a claim.
All single valued, non time valid, flex attributes of a claim.
Access restrictions. The following access restrictions will be implemented in this functional view. Person: If a person is restricted then only users with an access grant can see the claims for that person. Diagnosis: If a diagnosis is restricted, then the diagnosis is not shown. The claim is visible to a user Brand: If a brand is restricted then only users with an access grant can see claims for that brand Data access group (group contract): Only users with an access grant to a restricted 'data access groups' can see the claim Payer: Only users with an access grant to a restricted 'payer' can see the claim For all access dimensions holds that when that dimension is not restricted that every user can see the claim. For instance for non restricted persons every user can see the claim.

Bill

Field/Field set description
For each of the following lookups Service Provider Location Provider Serviced Entity Type Serviced Entity Referring Provider Servicing Specialty Payment Receiver Provider Payment Receiver Relation Location Type the following fields will be provided a code field a code definition field (if applicable) a name or description
All fixed attributes of a bill
Access restrictions. The following access restrictions will be implemented in this functional view. Claim: Only if a user can see the claim then the user can see the bill. Person: If a person is restricted then only users with an access grant can see the claims for that person.

Claim line

Field/Field set description
For each of the following lookups Benefits Provider Claim Claim Line that is the original Claim Line for this Claim Line Claim Line that is the replacement Claim Line for this Claim Line Classification Classification Authorization Location Type Location Provider Payment Receiver Provider Payment Receiver Relation Price Individual Provider Price Organization Provider Primary Diagnosis (the claim line diagnosis with the lowest sequence number) Procedure Procedure2 Procedure3 Referring Provider Service Provider Serviced Entity Type Serviced Entity Servicing Specialty the following fields will be provided a code field a code definition field ( if applicable) a name or description A code field (only) will be provided for the reference to currency for all amount fields: allowed amount benefits input amount claimed amount covered amount preceding payer paid amount
All fixed attributes of a claim line.
All single valued flex attributes of a claim line
Access restrictions. The following access restrictions will be implemented in this functional view. Claim: Only if a user can see the claim then the user can see the claim line Person: If the serviced person is restricted then only users with an access grant can see the claimlines for that person. Diagnosis: If a diagnosis is restricted, then the diagnosis is not shown. The claim line is visible to the user. Procedure: If a procedure is restricted, then the procedure is not shown. The claim line is visible to the user.

Claim line coverages

Field	Description
Claim code	The code of the claim
Claim line code	The code of the claim line
Action	The action of the coverage (C/W for Cover/Withhold)
Coverage label code	The code of the coverage label that is used to define the meaning of the claim line coverage
Coverage label disp sequence	The display sequence of the coverage label
Display name	The display name of the claim line coverage
Number of units	The number of units that is covered or withheld
Amount	The amount that is covered or withheld
Amount curr	The currency code of the amount
Product	The product that provides the coverage

Limit consumptions

This report view shows limit consumptions in combination with information from the related limit, counter and counter period. It is possible that a single limit consumption counts towards multiple counter periods (for example carry over consumption). In that case multiple records are shown in this report for the different counter periods. It is also possible that a limit consumption does not count towards any counter period. In that case the counter period fields are empty. Note that in the counter period fields the current count and amount for the counter period are displayed and not the count and the amount at the time of the consumption. For more information on how consumption counts towards counter periods see Adjudication Limits in the Benefit Rules implementation guide.

Field/Field set	Description
Limit code	The code of the limit
Counter entity type	The entity type (display name) for which the counter is used, like Person, Car, House etc.
Counter entity code	The code of the person or object for which the counter is used
Counter entity name	The description of the person or object for which the counter is used
Counter adjudication case id	The id of the adjudication case
Counter adjudication case definition code	The code of the case definition for which the counter is used (picked up based on the adjudication case id if the adjudication case still exists)
Counter adjudication case definition descr	The description of the case definition for which the counter is used (picked up based on the adjudication case id if the adjudication case still exists)
Counter family code	The code of the family for which the counter is used
Counter Period Id	The id of the counter period
Counter Period aggregation level	The product aggregation level for which the counter period is used
Counter Period provider code def	The code definition of the code of the provider for which the counter period is used
Counter Period provider code	The code of the provider for which the counter period is used
Counter Period provider name	The name of the provider for which the counter period is used
Counter Period start date	The start date of the counter period
Counter Period end date	The end date of the counter period
Counter Period carry over start date	The carry over start date of the counter period
Counter Period other products carry over start date	The other products carry over start date of the counter period
Counter Period current number	The currently consumed number of units for the counter period
Counter Period current amount	The currently consumed amount for the counter period
Counter Period current amount currency	The currency code of the current amount
Counter Period current service days	The currently consumed number of service days for the counter period
Consumption maximum number	The maximum number of units against which the consumption adjudicated
Consumption maximum amount	The maximum amount against which the consumption adjudicated
Consumption maximum amount curr	The currency code of the maximum amount
Consumption maximum service days	The maximum number of service days against which the consumption adjudicated
Consumption entity type	he entity type (display name) for which the consumption was registered, like Person, Car, House etc
Consumption entity code	The code of the person or object for which the consumption was registered
Consumption entity name	The name of the person or object for which the consumption was registered
Consumption number of units	The consumed number of units for the consumption
Consumption amount	The consumed amount for the consumption
Consumption amount curr	The currency code of the consumed amount
Consumption aggregation level	The product aggregation level of the consumption
Consumption provider code def	The code definition of the code of the provider of the consumption
Consumption provider code	The code of the provider of the consumption
Consumption provider name	The name of the provider of the consumption
Consumption transaction date	The transaction date of the consumption
Consumption service date	The service date of the consumption
Consumption external id	The external id of the consumption
Consumption description	The description of the consumption
Consumption display name	The display name of the consumption
Consumption provider group status	The provider group status of the consumption
Consumption ind withdrawn	The indicator withdrawn of the consumption
Consumption ind exclude from carry over	The indicator exclude from carry over of the consumption

Products

Field	Description
Code	The code of the product
Description	The description of the product
Aggregation level	The product aggregation level, used for limits that aggregate per product
Priority code	The code of the priority of the product when multiple products need to be evaluated for the benefits of one claim line.
Priority description	The description of the priority of the product when multiple products need to be evaluated for the benefits of one claim line.
Product line code	The code of the product line
Product line descr	The description of the product line
Product family code	The code of the product family
Product family desc	The description of the product family
Funding arrangement code	The code of the funding arrangement
Funding arrangement desc	The description of the funding arrangement
Claim time limit	The amount of units for the limit until when a claim can be submitted for adjudication.
Claim time limit uom	The unit of the Claim time limit (D/M/Y for Days/Months/Years)
Currency code	The code of the steering currency of the product
Dynamic fields	All single valued flex attributes of a product

Product benefit specifications

Field	Description
Product code	The code of the product
Product description	The description of the product
Benefit specification code	The code of the benefit specification that is linked to the product
Benefit specification descr	The description of the benefit specification that is linked to the product
Start date	The start date of the product benefit specification
End date	The end date of the product benefit specification
Enabled?	Is the product benefits specification enabled?
Dynamic fields	All single valued flex attributes of a product benefit specification

Benefit specifications

Field	Description
Code	The code of the benefit specification
Description	The description of the benefit specification
Subtype	The type of specification, allowable values: WPSP for waiting period, AUSP for authorization, COSP for Coverage, POSP for Post Benefits
Service Option Service Code	The service option service code from which the benefit specification was generated in OHI Product Definition
Claim form type code	The code of the claim form type
Claim form type display name	The display name of the claim form type
Age from	The start age
Age to	The end age (up to and including)
Priority code	The code of the priority of the benefit specification when multiple benefit specifications need to be evaluated for the benefits of one claim line
Priority description	The description of the priority of the benefit specification when multiple benefit specifications need to be evaluated for the benefits of one claim line
Procedure group 1 usage	Is the procedure group in scope or not in scope?
Procedure group 1 code	The code of the procedure group
Procedure group 1 description	The description of the procedure group
Procedure group 2 usage	Is the second procedure group in scope or not in scope?
Procedure group 2 code	The code of the second procedure group
Procedure group 2 description	The description of the second procedure group
Procedure group 3 usage	Is the third procedure group in scope or not in scope?
Procedure group 3 code	The code of the third procedure group
Procedure group 3 description	The description of the third procedure group
Procedure condition usage	Is the procedure condition in scope or not in scope?
Procedure condition code	The code of the dynamic logic condition that is used to define the procedures to which this benefit specification is applicable
Procedure condition description	The description of the dynamic logic condition that is used to define the procedures to which this benefit specification is applicable
Diagnosis group usage	Is the diagnoses group in scope or not in scope?
Diagnosis group	The code of the associated diagnosis group
Diagnosis group description	The description of the associated diagnosis group
Diagnosis condition code	The code of the dynamic logic condition that is used to define the diagnoses to which this benefit specification is applicable
Diagnosis condition description	The description of the dynamic logic condition that is used to define the diagnoses to which this benefit specification is applicable
Diagnosis type code	The code of the associated diagnosis type
Diagnosis type description	The description of the associated diagnosis type
Gender	The specific gender to which the regime applies
Regime Code	The code of the associated regime
Regime description	The description of the associated regime
Case definition code	The code of the associated case definition
Case definition description	The description of the associated case definition
Person country region usage	The usage (in/not in) of the person country region
Person country region code	The code of the associated country region for the person
Person country region description	The description of the associated country region for the person
Provider country region usage	The usage (in/not in) of the provider country region
Provider country region code	The code of the associated country region for the provider
Provider country region description	The description of the associated country region for the provider
Employer country region usage	The usage (in/not in) of the employer country region
Employer country region code	The code of the associated country region for the employer
Employer country region description	The description of the associated country region for the employer
Product provider group scope	The scope of the provider groups of the product
Specific provider group scope	The scope of the specific provider groups
Ind authorization missing	Does the benefit specification apply only when an authorization is missing? (applicable for subtype COVE: Coverage Specification)
Ind consume authorization	If this indicator is unchecked, then the claim line on which the benefit specification is applied will not write consumption on returned authorizations (applicable for subtype AUTH: Authorization Specification)
Dynamic fields	All single valued flex attributes of a product benefit specification
Location Type Usage	The usage (in/not in) of the location types
Modifier Usage	The usage (in/not in) of the modifiers
Specialty Usage	The usage (in/not in) of the specialties

Regimes

Authorization Regime

Field	Description
Code	The code of the authorization regime
Description	The description of the authorization regime
Type	The type of authorization for which the regime applies
Ind active	Is the authorization regime still in use?
Ind repetitive	Should the rules repeat after the end of the period(s)?
Reference	The code of the reference for the start of the period(s)
Currency code	The code of the steering currency of the authorization regime
Authorization matching function code	The code of the dynamic logic function that is used for matching an authorization
Authorization matching function description	The description of the dynamic logic function that is used for matching an authorization
Authorization detail matching function code	The code of the dynamic logic function that is used for matching the details of an authorization
Authorization detail matching function description	The description of the dynamic logic function that is used for matching the details of an authorization
Label (exceeded)	The coverage label (exceeded)
Label (denied)	The coverage label (denied)
Label (not found)	The coverage label (not found)
Message code (not met)	The code of the message (not met)
Message (not met)	The text of the message (not met)
Message severity (not met)	The severity of the message (not met)
Message code (met)	The code of the message (met)
Message (met)	The text of the message (met)
Message severity (met)	The severity of the message (met)
Message code (met and exceeded)	The code of the message (met and exceeded)
Message (met and exceeded)	The text of the message (met and exceeded)
Message severity (met and exceeded)	The severity of the message (met and exceeded)
Message code (exceeded benefit)	The code of the message (exceeded, other benefit)
Message (exceeded benefit)	The text of the message (exceeded, other benefit)
Message severity (exceeded benefit)	The severity of the message (exceeded, other benefit)
Message code (exceeded no benefit)	The code of the message (exceeded, no other benefit)
Message text (exceeded no benefit)	The text of the message (exceeded, no other benefit)
Message severity (exceeded no benefit)	The severity of the message (exceeded, no other benefit)
Message code (denied benefit)	The code of the message (denied, other benefit)
Message text (denied benefit)	The text of the message (denied, other benefit)
Message severity (denied benefit)	The severity of the message (denied, other benefit)
Message code (denied no benefit)	The code of the message (denied, no other benefit)
Message text (denied no benefit)	The text of the message (denied, no other benefit)
Message severity (denied no benefit)	The severity of the message (denied, no other benefit)
Message code (not found benefit)	The code of the message (not found, other benefit)
Message text (not found benefit)	The text of the message (not found, other benefit)
Message severity (not found benefit)	The severity of the message (not found, other benefit)
Message code (not found no benefit)	The code of the message (not found, no other benefit)
Message text (not found no benefit)	The text of the message (not found, no other benefit)
Message severity (not found no benefit)	The severity of the message (not found, no other benefit)
Dynamic fields	All single valued flex attributes of an authorization regime

Waiting Period Regime

Field	Description
Code	The code of the waiting period regime
Description	The description of the waiting period regime
Ind active	Is the waiting period regime still in use?
Period	The period (quantity)
Period unit of measure	The unit of the period (D/M/Y for Day/Month/Year)
Message code	The code of the message that is attached to the claim line when the waiting period is violated
Message	The text of the message
Message severity	The severity of the message
Start date function code	The code of the dynamic logic function that is used to derive the start date used to measure the waiting period
Start date function description	The description of the dynamic logic function that is used to derive the start date used to measure the waiting period
Dynamic fields	All single valued flex attributes of a waiting period regime

Coverage Regime

Field	Description
Code	The code of the coverage regime
Description	The description of the coverage regime
Ind active	Is the coverage regime still in use?
Ind repetitive	Should the period(s) repeat?
Reference	The code of the reference for the start of the period(s)
Currency code	The code of the steering currency of the coverage regime
Dynamic fields	All single valued, non time valid flex attributes of a coverage regime

Procedure groups

Field	Description
Code	The code of the procedure group
Description	The description of the procedure group

Diagnosis groups

Field	Description
Code	The code of the diagnosis group
Description	The description of the diagnosis group

Episode Details

Field	Description
Episode
Insurable entity type code	The code the insurable entity type
Insurable entity code	The code the the insurable entity
Insurable entity name/desc	The last name of the person or description of the insurable object
Episode definition code	The code of the episode definition
Episode definition description	The description of the episode definition
All fixed attributes of an episode
All single valued, non time valid, flex attributes of an episode
Episode Details
Type	The type of the episode detail - Trigger, New or Include
Priced?	Is the claim line priced?
Episode category code	The code of the episode category
Episode category description	The description of the episode category
Claim Line
Allowed amount	The allowed amount
Allowed amount currency code	The currency of the allowed amount
Claim code	The code of the claim
Claim line code	The code of the claim line
Claim payer code	The code of the payer
Claim payer description	The description of the payer
Claim brand code	The code of the brand
Claim brand description	The description of the brand
Claimed amount	The claimed amount
Claimed amount currency code	The currency code of the claimed amount
Contract reference code	The code of the contract reference
Contract reference description	The description of the contract reference
Price individual provider code	The code of the price individual provider
Price individual provider definition code	The definition code of the price individual provider
Price individual provider name	The name of the price individual provider
Price organization provider code	The code of the price organization provider
Price organization provider definition code	The definition code of the price organization provider
Price organization provider name	The name of the price organization provider
Primary diagnosis code	The code of the claim line diagnosis with the lowest sequence number
Primary diagnosis definition code	The definition code of the diagnosis
Primary diagnosis description	The description of the diagnosis
Procedure code	The code of the procedure
Procedure definition code	The definition code of the procedure
Procedure description	The description of the procedure
Procedure 2 code	The code of the procedure 2
Procedure 2 definition code	The definition code of the procedure 2
Procedure 2 description	The description of the procedure 2
Procedure 3 code	The code of the procedure 3
Procedure 3 definition code	The definition code of the procedure 3
Procedure 3 description	The description of the procedure 3
Provider Pricing Clause (type reimbursement method) referenced by claim line provider pricing clause
Reimbursement method code	The code of the reimbursement method
Reimbursement method description	The description of the reimbursement method
Access restrictions The following access restrictions will be implemented in this functional view. Claim: Only if a user can see the claim then the user can see the episode details Person: If the insurable entity type is person and the person is restricted then only users with an access grant can see the episode details for that person. Diagnosis: If a diagnosis is restricted, then the diagnosis is not shown. The claim line is visible to the user. Procedure: If a procedure is restricted, then the procedure is not shown. The claim line is visible to the user.

Claim Line not in any Episode

A view providing insight into claim lines not being part of a episode that belong to persons or objects for whom episodes exist which overlap in time validity with the claim lines.

Field	Description
Episode
Insurable entity type code	The code the the insurable entity type
Insurable entity code	The code the the insurable entity
Insurable entity name/desc	The last name of the person or desc of the insurable object
Episode definition code	The code of the episode definition
Episode definition description	The description of the episode definition
All fixed attributes of a episode
All single valued, non time valid, flex attributes of a episode
Claim Line
Allowed amount	The allowed amount
Allowed amount currency code	The currency of the allowed amount
Claim code	The code of the claim
Claim line code	The code of the claim line
Claim payer code	The code of the payer
Claim payer description	The description of the payer
Claim brand code	The code of the brand
Claim brand description	The description of the brand
Claimed amount	The claimed amount
Claimed amount currency code	The currency code of the claimed amount
Contract reference code	The code of the contract reference
Contract reference description	The description of the contract reference
Price individual provider code	The code of the price individual provider
Price individual provider definition code	The definition code of the price individual provider
Price individual provider name	The name of the price individual provider
Price organization provider code	The code of the price organization provider
Price organization provider definition code	The definition code of the price organization provider
Price organization provider name	The name of the price organization provider
Primary diagnosis code	The code of the claim line diagnosis with the lowest sequence number
Primary diagnosis definition code	The definition code of the diagnosis
Primary diagnosis description	The description of the diagnosis
Procedure code	The code of the procedure
Procedure definition code	The definition code of the procedure
Procedure description	The description of the procedure
Procedure 2 code	The code of the procedure 2
Procedure 2 definition code	The definition code of the procedure 2
Procedure 2 description	The description of the procedure 2
Procedure 3 code	The code of the procedure 3
Procedure 3 definition code	The definition code of the procedure 3
Procedure 3 description	The description of the procedure 3
Provider Pricing Clause (type reimbursement method) referenced by claim line provider pricing clause
Reimbursement method code	The code of the reimbursement method
Reimbursement method description	The description of the reimbursement method
Access restrictions The following access restrictions will be implemented in this functional view. Claim: Only if a user can see the claim then the user can see the claim line Person: If the insurable entity type is person and the person is restricted then only users with an access grant can see the details for that person. Diagnosis: If a diagnosis is restricted, then the diagnosis is not shown. The claim line is visible to the user. Procedure: If a procedure is restricted, then the procedure is not shown. The claim line is visible to the user.

Generic fields

All reporting views will contain the following generic logging fields:

Field	Description
Created by	The user who created this record
Created by date	Date and time of creation of this record
Last updated by	The user who last updated of this record
Last updated by date	Date and time of the last update of this record