Functional Views (Deprecated)
The reporting views in this section are deprecated. They are replaced with the base views described in Overview. |
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
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Regular table columns of underlying base table of the view
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Single valued dynamic fields. These are shown as regular columns of the view
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Multi language aspect of the data is resolved, the information is shown in one language.
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Look up columns. Information from lookup tables is shown using the code and description of the lookup
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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
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all the propagated columns in the same way as the UI and the integration points show them, which is identical to the object values
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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
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Claims
-
Marital Statuses
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Person Titles
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Addresses
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Relation Tags
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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.
Procedure Access Restriction
-
If the procedure is not restricted then the procedure code and description are always shown
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If the procedure is restricted then the procedure code and description are only shown if the user has access to the restriction
Combinations of Restrictions
Claim and Authorization
A user only has access to a claim or authorization if either the
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person
-
payer
-
brand
-
data access group
are not restricted or if the user has access to all each of the restricted ones.
Claim
Field or Field Set Description |
---|
For each of the following lookups
the following fields will be provided
A code field (only) will be provided for the reference to currency for all amount fields:
|
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.
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 or Field Set Description |
---|
For each of the following lookups
the following fields will be provided
|
All fixed attributes of a bill |
Access restrictions. The following access restrictions will be implemented in this functional view.
|
Claim line
Field or Field Set Description |
---|
For each of the following lookups
A code field (only) will be provided for the reference to currency for all amount fields:
|
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 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" page in the Benefit Rules chapter of the Configuration Guide.
Field or 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 Oracle Health Insurance 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 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.
|
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 |