Regime Counters
Regime counters keep track of authorization, waiting period and coverage regime tranches. They are used to evaluate which tranche applies to a specific claim when evaluating the regime.
When setting up coverage regime tranches, the following attributes can be specified:
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maximum amount insurable entity
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maximum number insurable entity
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maximum service days insurable entity
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maximum amount family
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maximum number family
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maximum service days family
When setting up authorization regime tranches, the following attributes can be specified:
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maximum amount
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maximum number
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maximum service days
If no maximum is specified, then the tranche is not bounded by any maximum and no consumptions (and counters) are registered for that tranche.
The consumption that is registered by a reservation line will have indicator reserved set to Y(es) and expiration date set to the expiration date of the reservation.
The available room for a claim line that does not refers to reservation line is, the difference of the finalized and non expired consumption (current) of the counter (if existing) and the maximum on the regime tranche.
The claim line that refers to a reservation line will look for reserved consumption in all the tranches and take those consumptions. It will both register 1) consumption that it needs to take and 2) an offset negative consumption equal to the reserved quality that is consumes. The indicator reserved is set to Y(es) and the expiration date is set to the expiration date of the reservation for the offset consumption.
The maximum consumption (available room) that can be registered by a claim that refers to a reservation is the sum of:
1) available room within the counter (unconsumed amount, number of units or number of service days) - This is the difference of the finalized and non expired consumption (current)of the counter (if existing) and the maximum on the regime tranche.
2) available room on the reservation - This is the sum of the non expired consumption reserved by the reservation line and non expired offset consumption (negative consumption) taken by the claim lines referring the same reservation line under the counter (for a claim line referring to a reservation line, it is always guaranteed to have access to the reserved consumption even if the maximum on the tranche has reached)
The absolute value of the offset consumption (for amount and units) depends on the available reserved room. It is possible that the claim line takes more consumption than what is reserved for it. This is possible when the reserved consumption is for a lesser value and the tranche maximum has not been reached. In this case the absolute value of the offset will be less (but equal to the reserved room present) than the consumption taken by the claim line. The offset’s absolute value also depends on the indicator release (on the reservation regime). If it is set to Y(es); then the offset consumption offsets the entire reserved value in the tranche. In this case it is possible that the absolute value of the offset is more than the consumption taken by the claim line. If the limit is in service days, the offset consumption is created with the service date as on the reserved consumption and the withdrawn indicator is set to Y(es). When the withdrawn indicator is checked, the consumption represents a decrement of the number of service days (provided that the specified date was counted for earlier.
Note that when the released indicator is configured to Y(es) the excess reserved consumption is only released from the regime counter where the actual consumption is being registered.
The current (amount, unit, service days) on the counter takes into account all the non-expired consumptions under the counter. This is calculated every time a claim line (irrespective of reservation line or claim line referring a reservation or not) registers a consumption.
If both a maximum on insurable entity level and on family level are specified on a coverage regime tranche, then the tranche ends when one of the maximums is reached.
Regime counter
A regime counter holds the count of the total usage for a insurable entity i.e. serviced person/object or for a family. The regime counter keeps track of the regime period start and end date and the actual count.
| Field | Description |
|---|---|
Regime |
The code of the regime |
Period sequence |
The sequence of the regime period |
Tranche sequence |
The sequence of the regime period tranche |
Insurable Entity |
The person or object (insurable entity) to which this counter applies. |
Family code |
The code of the the family to which this counter applies. |
Case definition |
The identification of the case definition to which this counter applies |
Start date |
The start date of the period to which the counter applies. |
End date |
The end date of the period over which the counter applies. |
Current amount |
The current counted amount. This equals the sum of all benefits input amounts for this counter. |
Current amount currency |
The currency of the current amount. |
Current number |
The current counted number of units. This equals the sum of all allowed numbers for this counter [1]. |
Current service days |
The current counted number of service days. This equals the sum of all claimed service dates for this counter. |
Regime consumption
A regime consumption consists of the following fields:
| Field | Description |
|---|---|
Counter |
The counter to which the consumption is linked |
Counter Version |
The version of the counter at the time of writing this consumption. |
Claim Line |
The claim line that is the source for the consumption |
Claim |
The claim that the claim line that generated this consumption belongs to |
Descr |
The description of the external consumption |
Amount |
The amount that has been used. |
Amount currency |
The currency of the amount. |
Number of units |
The number of units that has been used |
Service date |
The start date of the specified claim line |
Insurable Entity |
The person or object (insurable entity) for which the consumption was registered |
Expiration Date |
The date after which the consumption expires. The claim receipt date is used as the as-of date. If the receipt date is not specified on the claim; the entry date of the claim is used as the as-of date |
Reserved Indicator |
Is the consumption reserved? |
Marked For Reversal Indicator |
Is this consumption marked for reversal (through unfinalize)? |
Reversed Indicator |
Is this consumption reversed? |
Preliminary Indicator |
Is this consumption linked to a non-finalized claim line? |
Withdrawn Indicator |
If checked, this consumption decrements a service day based counter. |
Reversal Date-time |
The date and time on which this consumption was logically deleted (due to reprocessing) |
Transaction Date-time |
The date and time of the consumption |
The consumed amount (or number) is always based on the benefits input amount or allowed number of units [2], rather the amount that is actually covered. Note that, contrary to limit counters, regime consumptions cannot originate from the counters integration point, i.e., they always originate from a claim line.
[1]
[2]