Select Policy Products
Per claim line, the system filters the person’s products returned in the enrollment response on date. The system only uses policy products that are valid on or before the claim line start date and that are not suspended, for benefit specification selection[1].
The system does not select policy products for claim lines that meet one of the following conditions:
-
Lines with a checked "Keep Benefits" indicator;
-
Lines with a checked "Locked" indicator;
-
Lines with a product independent fatal message (attached to the line itself or the bill or claim to which the line belongs) of the following origins: SANITY CHECKS, ENROLLMENT, RESERVATION, PAYMENT STATUS.
In case of fatal messages of other origins, it is desirable to do the selection of policy products, in order to determine the person’s or object’s product (if any) and consequent eligibility for coverage. This information can be used in determining whether a denied claim line files under provider liability or under adjudication liability.
A claim line can specify an overriding coverage regime or overriding coverage specification in combination with an overriding product, subscription date and/or family code. If the line does not specify a product and none of the policy products returned in the enrollment response are valid on the claim line start date, the following claim line message is applied:
| Code | Sev | Text |
|---|---|---|
CLA-FL-BENS-001 |
Fatal |
No policy product found for insurable entity {code} on date {claim line start date} |
If the claim line specifies an overriding product, but not an overriding family code, then the family code that is returned in the enrollment response is used instead. If the line does not specify a family code and none was returned by the enrollment response, the following claim line message is applied:
| Code | Sev | Text |
|---|---|---|
CLA-FL-BENS-035 |
Fatal |
No policy family found for insurable entity {code} on date {claim line start date} |
The outcome is a list of time valid policy products. This list serves as input for the selection of waiting period specifications, authorization specifications, reservation specifications, coverage regime specifications and post benefits specifications, if no overriding coverage regime or overriding coverage specification was specified on the claim line. If an overriding coverage regime or overriding coverage specification was specified this list only serves as input for the selection of post benefits specifications.