Product Building Blocks Integration Point
A number of entities have their system of record in Claims but are used as product building blocks in Oracle Health Insurance Product Definition. To make sure that Oracle Health Insurance Product Definition is aware of the available building blocks, this integration point publishes the inventory of building blocks available in Claims.
The operations in this integration point are called through a dedicated user interface page in the application. Upon request, Claims assembles the up-to-date inventory and stores it in a (internal database) repository. This inventory is then available for import to Oracle Health Insurance Product Definition.
The following pseudo code describes the structure of the XML that contains the inventory of building blocks
<dataset>
<transactionSourceCode
code=
/>
<executionRank
rank=
>
...
</executionRank>
...
</dataset>
The <dataset> element includes a single optional <transactionSourceCode> element that contains the transaction source code and one or more elements. Items are ordered using <executionRank> elements, such that dependent items can be processed in the correct order. An element has a generic structure and can contain one of the building blocks. An element has one of the following types:
-
AUTHORIZATION_REGIME
-
BRAND
-
CASE_DEFINITION
-
CLAIM_FORM_TYPE
-
CONDITION
-
COUNTRY_REGION
-
COVER_WITHHOLD_CATEGORY
-
COVERAGE_REGIME
-
DIAGNOSIS_GROUP
-
DIAGNOSIS_TYPE
-
LIMIT
-
LOCATION_TYPE
-
MODIFIER
-
POST_BENEFITS_REGIME
-
PROCEDURE_GROUP
-
PROVIDER_GROUP
-
RESERVATION_REGIME
-
SPECIALTY
-
WAITING_PERIOD_REGIME
All building blocks that exist at the time that the payload is built are included.
Authorization Regimes
Authorization regimes are used to indicate specific charge thresholds before an authorization is required, e.g., an authorization is only required after the 10th office visit within a calendar year.
<content>
<authorizationRegime
uuid
code
description
indActive
/>
...
/>
Brands
A brand is a commercial label placed on a product. Brands can be used to restrict access to claims. This section describes the content of the response message for brands that is created upon request.
<content>
<brand
uuid
code
description
indActive
/>
...
/>
Case Definitions
A case definition prescribes the criteria by which a new case can be identified as well as closed. This section describes the content of the response message that is created upon request.
<content>
<caseDefinition
uuid
code
description
indActive
/>
...
/>
Claim Form Types
Claim form types are used to designate a set of forms that have a common structure. For example, both the claim form 837I and UB04 are of the type "Institutional"
<content>
<claimFormType
uuid
code
displayName
/>
...
/>
Conditions
Conditions are a type of user configurable logic where one or more objects are used as a input with a result that is either true or false. The signature of a condition specifies which objects are required. Three different types of dynamic logic conditions can be attached to a benefit specification. Each of the types has a different signature: 'Diagnosis', 'Procedure' and 'Benefit Specification (Other)'. The dynamic logic with the signature 'Benefit specification (Other)' is created and maintained in Claims. This section describes the content of the response message that is created upon request.
<content>
<condition
uuid
code
description
logic
indActive
/>
...
/>
Note that the logic itself is also included in the payload. This enables a user of Oracle Health Insurance Product Definition to review the logic.
Country Regions
Country regions are officially recognized subdivisions of countries, like in geography books such as provinces and states. This section describes the content of the response message that is created upon request.
<content>
<countryRegion
uuid
code
countryCode
displayCode
indActive
/>
...
/>
Cover Withhold Categories
Cover withhold categories are used in Oracle Health Insurance Product Definition to create accumulation rules and parameter amounts and percentages.
<content>
<coverWithholdCategory
uuid
code
/>
...
/>
Coverage Regimes
Coverage regimes are used in Oracle Health Insurance Product Definition as a cost share template that can be linked to a particular service.
<content>
<coverageRegime
uuid
code
description
indActive
>
<coverageRegimeParameters
<coverageRegimeParameter
coverWithholdCategoryCode
/>
...
/>
...
/>
The <coverageRegime> element is built up as follows:
1) The integration point selects all the regimes present in Claims.
2) Per coverage regime, all cover withhold categories in the distinct set of used cover withhold categories (regime > period > tranche > cover withhold rules > cover withhold category) are added as a <coverageRegimeParameter>
So if a regime included multiple cover withhold rules with the cover withhold category "DEDUCTIBLE", e.g., because it includes multiple tranches, only one <coverageRegimeParameter> element is included for the "DEDUCTIBLE".
<coverageRegime
uuid "112234455"
code "CI_DEDUC"
description "Coinsurance followed by deductible"
indActive "Y"
<coverageRegimeParameters
<coverageRegimeParameter
coverWithholdCategoryCode "COINSURANCE"
/>
<coverageRegimeParameter
coverWithholdCategoryCode "DEDUCTIBLE"
/>
...
/>
/>
Diagnosis Groups
Diagnosis groups are bundled diagnoses to signify a group that can become part of a specific benefit specification. This section describes the content of the response message that is created upon request.
<content>
<diagnosisGroup
uuid
code
description
/>
...
/>
Diagnosis Types
Diagnosis types are used to specify the type of diagnoses, as may be specified on claims, claim lines and/or bills.
<content>
<diagnosisType
uuid
code
description
/>
...
/>
Limits
Limits are used in Oracle Health Insurance Product Definition to create accumulation rules and to connect the maximum amount, days or units to that limit.
Limits that have action Reserve are not included in the selection.
<content>
<limit
uuid
code
description
displayName
type
/>
...
/>
Location Types
Location types are used to specify the type of facility or place of service in which a particular benefit applies (or does not apply). This section describes the content of the response message that is created upon request.
<content>
<locationType
uuid
code
claimFormTypeCode
description
indActive
/>
...
/>
Modifiers
Modifiers are a further specification of a service code and is typically used to recognize a generic service code as belonging to a specific type of care.
<content>
<modifier
uuid
code
description
indActive
/>
...
/>
Post Benefits Regimes
Post benefits regimes are used for coordination of benefits.
<content>
<postBenefitsRegime
uuid
code
description
indActive
/>
...
/>
Procedure Groups
Procedure groups are bundled procedures to signify a group that can become part of a specific benefit specification. This section describes the content of the response message that is created upon request.
<content>
<procedureGroup
uuid
code
description
/>
...
/>
Provider Groups
Provider groups are groups of medical service providers that are used as a part of a product or benefit specification in Oracle Health Insurance to signify if a group of providers is eligible for that product or specific benefit specification. This section describes the content of the response message that is created upon request.
<content>
<providerGroup
uuid
code
description
indActive
/>
...
/>
Reservation Regimes
Reservation regimes are used to indicate that an actual claim needs to look for a reservation claim.
<content>
<reservationRegime
uuid
code
description
indActive
/>
...
/>