Scenarios
This paragraph presents a number of use cases to clarify the interaction between Claims and an enrollment system. The purpose of these use cases is to illustrate the expected response to a given request. The situations that are described reflect the situations in an arbitrary enrollment system. To avoid unnecessary complexity, some simplifications are applied:
-
The identifiers are assumed to be the same in Claims and the enrollment system.
-
To improve readability, the relations are identified by a name rather than a code.
-
Dates are all in the format YYYY-MM-DD
External enrollment system, policy products
Serviced Person | Product code | Enrollment Status | Start date | End date |
---|---|---|---|---|
Mrs. Jones |
EXTRA |
Active |
2007-01-01 |
n/a |
Mrs. Jones |
BASIC |
Active |
2007-01-01 |
n/a |
Junior 1 |
BASIC |
Active |
2007-01-01 |
2008-12-31 |
Jane Mills |
BASIC |
Active |
2008-01-01 |
n/a |
Dale Cooper |
BASIC |
Active |
2008-01-01 |
n/a |
External enrollment system, policy families
Serviced Person | Family | Start date | End date |
---|---|---|---|
Mrs. Jones |
FAM01 |
2007-01-01 |
n/a |
Junior 1 |
FAM01 |
2007-01-01 |
n/a |
Jane Mills |
FAM45 |
2008-01-01 |
2008-05-31 |
Jane Mills |
FAM67 |
2008-06-01 |
n/a |
Dale Cooper |
FAM33 |
2008-01-01 |
n/a |
Scenario 1
Claim 1234 is processed and the serviced person is Mrs. Jones. Within the claim, the claim line service dates span from 2008-02-25 through 2008-02-28. Mrs.Jones is subscribed to products BASIC and EXTRA. Claims sends out the request and receives the following response:
The enrollment system responds:
<enrollment > <families> <family code="FAM01" startDate="2007-01-01" /> </families> <products> <product code="BASIC" contractDate="2007-01-01" startDate="2007-01-01" /> <product code="EXTRA" contractDate="2007-01-01" startDate="2007-01-01" /> </products> </enrollment>
The following information is stored in Claims:
-
Claims, Policy Products*
Claim | Serviced Person | Product | Subscription | Start | End |
---|---|---|---|---|---|
1234 |
Mrs Jones |
BASIC |
2007-01-01 |
2008-02-25 |
2008-02-28 |
1234 |
Mrs Jones |
EXTRA |
2007-01-01 |
2008-02-25 |
2008-02-28 |
Claims, Policy families
Claim | Serviced Person | Family | Start | End |
---|---|---|---|---|
1234 |
Mrs Jones |
FAM01 |
2008-02-25 |
2008-02-28 |
Note that Claims stores only the policy product and family information for the requested period. So even if the enrollment system responds by sending the full policy product history, Claims stores only the information valid within the request period.
Scenario 2
A claim is processed for serviced person Junior 1. The claim has a single line with service date 2009-02-25. Rather than sending the full policy product history, the enrollment system is set up to respond only with the policy enrollment products valid in the request period. The request time period is set to have a start date of 2009-01-01 and end date of 2009-12-31.
In this particular use case there are no policy enrollment products for the person in the request time period, so Claims expects HTTP Response code 204 (No Content).
Scenario 3
Claim 6555 comes in with serviced person being Jane Mills. The claim line service dates span a period from 2008-05-25 through 2008-07-03. This use case reflects the situation where a person has multiple family codes over time, for example, due to marriage
The response:
<enrollment> > <families> <family code="FAM45" startDate="2008-05-25" endDate="2008-05-31" /> <family code="FAM67" startDate="2008-06-01" endDate="2008-07-03" /> </families> <products> <product code="BASIC" contractDate="2008-01-01" startDate="2008-01-01" /> </products> </enrollment>
The following information is stored in Claims:
Claims, Policy Products
Claim | Serviced Person | Product | Subscription | Start | End |
---|---|---|---|---|---|
6555 |
Jane Mills |
BASIC |
2008-01-01 |
2008-01-01 |
n/a |
Claims, Policy Families
Claim | Serviced Person | Family | Start | End |
---|---|---|---|---|
6555 |
Jane Mills |
FAM45 |
2008-05-25 |
2008-05-31 |
6555 |
Jane Mills |
FAM67 |
2008-06-01 |
2008-07-03 |
Scenario 4
This scenario clarifies how to sent in dynamic field values through the enrollment response. Consider a scenario where the CLA_POLICY_PRODUCTS table has been extended by the dynamic field "studentStatus". The value domain for this field is defined by the flex code definition STUDENT_STATUS. The definition allows the values "NO STUDENT", "IN STATE" and "OUT OF STATE".
Claim 8444 comes in with serviced person Dale Cooper. The claim has five lines, all with service date 2008-04-04. Dale is an OUT OF STATE student.
The request can be started by posting a GET request to:
https://<context:root>/api/enrollments?insurableEntityType="PERSON"&insurableEntityCode="Dale Cooper"& lineOfBusinessCode="HEALTH_INSURANCE"&startDate="2008-04-04"&endDate="2008-04-04"
The response:
<enrollment> <families> <family code="FAM33" startDate="2008-04-04" /> </families> <products> <product code="BASIC" contractDate="2008-01-01" startDate="2008-01-01" studentStatus="OUT OF STATE" /> </product> </products> </enrollment>
The following information is stored in Claims:
Claims, Policy Products | Dynamic field | |||||
---|---|---|---|---|---|---|
Claim |
Serviced Person |
Product |
Subscription |
Start |
End |
Student Status |
8444 |
Dale Cooper |
BASIC |
2008-01-01 |
2008-01-01 |
n/a |
OUT OF STATE |
Claims, Policy Families
Claim | Serviced Person | Family | Start | End |
---|---|---|---|---|
8444 |
Dale Cooper |
FAM33 |
2008-04-04 |
2008-04-04 |