Coverage Regimes

A Coverage Regime represents a benefit calculation. It consists of a sequence of rules that apply intermediate calculations steps, each rule passing on its results to the next rule. Each rule typically represents a specific type of liability such as a deductible, a copayment or a benefit limit.

The Coverage Regime enables a wide variety of calculations, including tiered calculations in which the sequence of rules that are apply can change based on rules based on prior charges for the same patient and service. For example, consider a benefit that covers the first ten office visits per year in full, covers the next five at 20% Coinsurance and denies every visit past the 15th.

This chapter explains the concepts of the Coverage Regime, Periods, Tranches, and Cover Withhold Rules using a bottom-up approach. The example scenarios show various typical configurations.

Cover Withhold Rules, Categories, and Labels

Cover Withhold Rules are liability calculation rules. They specify coverage limit, withhold limit, and which limits accumulate. A Cover Withhold Rule has the following fields:

Cover Withhold Rule

Table 1. Cover Withhold Rule
Field	Description
Sequence	The timing of execution of this rule, relative to other Cover Withhold Rules.
Action	Specifies whether this role withholds or covers an Amount. Typically, the payer is liable for the Covered Amount, and the serviced Person, or a Relation related to the serviced object, is liable for the Withheld Amount.
Amount per unit	The Amount per unit that is covered or withheld.
Amount per unit currency	The Currency of the Amount per unit. It sets automatically to the Currency that the Coverage Regime specifies.
Percentage	The percentage of the Amount that is covered or withheld.
Percentage based on	This field specifies the Amount that must be the basis of the calculation. Values are the Coverage Labels that: Represent the original (benefits input) Amount or the outcome of a preceding Cover Withhold Rule or have action type `INPUT`.
Result applied to	This field specifies the part of the benefits input amount that must apply calculation results. The values are: The remaining Covered Amount. The remaining Withheld Amount. The original benefits input amount. A specific Coverage Label. Business rule: It is important to select the third one on the first Cover Withhold Rule in a regime.
Coverage Label	The Coverage Label to which the result applies after selecting the fourth option.
Category	Specifies the category of the Cover Withhold Rule, which drives the labels that associate with the results. Typical categories are: Covered Coinsurance Copayment Deductible Penalty Benefit limit
Message	Specifies a message that shows with the Claim Line when applying this Cover Withhold Rule to the Claim Line, and the Covered (or withheld) Amount is greater than zero. Substitution parameters for the message: The Amount per unit Covered (or Withheld) is post-fixed by a space and the Currency display code of the Amount per unit. The Covered (or Withheld) Percentage. The type of rule (Action). The resulting Amount after the Cover Withhold Rule, before applying any limits post-fixed by a space and the Currency display code of the resulting Amount. Description of the Product. Description of the Benefit Specification. Benefit Specification Procedure Group 1 usage concatenated with the Procedure Group 1 Description or the Procedure Condition usage concatenated with the Procedure Condition Description (Procedure Group takes precedence when specifying both). Benefit Specification Diagnosis Group usage concatenated with the Diagnosis Group description or the Diagnosis Group Condition description. Benefit Specification Age From and Age To. Benefit Specification Gender description.

A Cover Withhold Rule specifies either an Amount or Percentage, both of which apply per rendered service unit. It is possible to omit both Amount and Percentage. This is how a benefits configuration user would set up the rule when he or she wants to configure parametrized coverage regimes.

Configuring the Amount or Percentage or setting Cover Withhold Rules during runtime through parametrization does not matter to explain how Cover Withhold Rules work. The rest of this chapter assumes that the Cover Withhold Rule contains the specification for the Amount or Percentage. Read the Product Definition Developer Guide for more details on this feature.

If there is over one rule, each rule is applied in the order specified by the sequence. If a Cover Withhold Rule specifies a Percentage, distinguish between the Amount on which the Percentage is based and the Amount on which the result is applied. To clarify this distinction, consider the following scenario:

A payer requires a $20 copay for doctor visits. Once the copay has been applied, the payer withholds an additional 10% based on the benefits input amount. Suppose a doctor visit Claim comes in for a benefits input amount of $100. The copay is applied first, splitting the amount up into two smaller amounts: the $20 copay that is withheld and the remaining $80. Next, the payer withholds 10% based on the benefits input amount. The original benefits input amount was $100, and therefore, the payer withholds an additional $10. However, that additional $10 withhold is not applied to the original Amount (which served as the basis for the percentage calculation), but rather to the $80 that remained after the copay was applied.

To clarify the purpose of the sequence, action, amount, percentage, percentage based on and result applied to, consider the following scenario:

Suppose that for a doctor’s visit a person has a $20 copay and a 20% Coinsurance. The copay is applied before the Coinsurance. Such a benefit would be specified by the following Cover Withhold Rules. The values within brackets represent the Cover Withhold Rule fields:

<Withhold> <$20> applied to the <original> amount.
<Withhold> <20%> of the <amount remaining after copay> applied to the <remaining covered> amount.

The benefits input amount for the doctor’s visit is $100. The first rule withholds $20 of the original $100, leaving a covered running total of $80. The second rule is calculated on the basis of the amount that remains after the copay has been applied, that is, 20% of $80 adds up to $16. The result of the second rule is applied to the covered running total of $80. Whatever is left after the second rule is applied, that is, $64, is covered by the payer.

Now suppose that the payer wants to provide the claimant with a specification of the applied benefits. In the given example, it would not suffice to simply inform the claimant that he will be reimbursed for $64. The claimant would want to know where the other $36 has gone. A benefit specification would at least have to state:

Benefits input amount $100
Withheld $20 due to "Copay"
Withheld $16 due to "Coinsurance"
To be paid: $64

To be able to provide such a specification, each of the Cover Withhold Rules needs to have a label, such as "Copay" or "Coinsurance". In Claims, such labels are assigned through the cover withhold category associated with the cover withhold rule. When a Cover Withhold Rule is processed, regardless of the applied action, the benefits input amount is split into two parts: the amount covered, and the amount withheld. The cover withhold category specifies labels for both of these parts:

Cover Withhold Category

Table 2. Cover Withhold Category
Field	Description
Code	Identifier of the category.
Label Covered Amount	After a Cover Withhold Rule with this cover withhold category has been applied, this is the label that is associated with that part of the amount that is covered.
Label Withheld Amount	After a Cover Withhold Rule with this cover withhold category has been applied, this is the label that is associated with that part of the amount that is withheld.

Suppose the payer has set up two Cover Withhold Categories:

Category <Copay> with:
- Withhold label <Copay withheld>
- Cover label <Amount after copay>
Category <Coinsurance> with:
- Withhold label <Coinsurance withheld>
- Cover label <Amount after Coinsurance>

Now suppose the payer sets up the following Cover Withhold Rule, including a reference to the cover withhold category:

<Withhold>`<20%>` of the <original> applied to the <original> as category <Coinsurance>.

Given a benefits input amount of $100, the benefit specification would state:

$100 benefits input amount
$20 <Coinsurance withheld>
$80 <Amount after Coinsurance>
$80 to be paid

In this simple scenario the benefits input amount is split up into a Covered ($80) and Withheld Amount ($20). Both Amounts are tagged with their corresponding labels. Now consider the inverse cover rule, which is functionally identical:

<Cover> <80%> of the <original> applied to the <original> amount as category <Coinsurance>

Given the same benefits input amount, this rule would yield the exact same benefit specification, due to the fact that the same cover withhold category, that is, <Coinsurance>, is used.

Now let us consider a slightly more complex example. Define an additional subsequent rule, so that:

<Withhold> <$20> applied to the <original> amount as category <Copay>
<Withhold> <20%> of the <Amount after Copay> amount, applied to the <remaining covered> Amount as category <Coinsurance>.

Given a benefits input Amount of $100, the Benefit Specification would state:

$100 benefits input Amount
$20 <Copay withheld>
$16 <Coinsurance withheld>
$64 <Amount after Coinsurance>
Pay $64

What is important to notice is that the $80 <Amount after copay> that is a result from the first rule no longer exists, due to the fact that it is considered intermediate result. After the second rule has been processed, those $80 have been split up into two other amounts, that is $16 <Coinsurance withheld> and $64 <Amount after Coinsurance>.

It is important to use Cover Withhold Categories for assigning coverage labels. How those labels and the pertaining amounts are persisted in Claims is explained later in the section on Claim Line Coverage Rules.

In essence, labels allow us to put a name to the resulting Amounts of a Cover Withhold Rule. As such, an amount becomes tangible: put a name to each amount to use that amount in subsequent Cover Withhold Rules. Another purpose of coverage labels is to allow for reinsurance: an amount that is withheld in a primary product is reinsured (that is, covered) in a supplementary product.

Consider the following scenario:

A person is subscribed to two products: one basic product and one supplementary product. The basic product states that the person has a $20 copay and a 40% Coinsurance for doctor visits. The supplementary product states that 100% of all copays as specified in the basic product is reinsured by the payer.

This scenario implies that the supplementary product is somehow able to distinguish the part of the benefits input amount that was withheld (in the basic product) due to copay from the part that was withheld due to Coinsurance. Such a thing is possible through the use of coverage labels. Before discussing how reinsurance across products can be accomplished, first take a closer look at a coverage label:

Coverage Label

Table 3. Coverage Label
Field	Description
Code	Identifier of the label.
Display Name	The display name of the coverage label.
Action	The nature of the amount on which this label can be applied. `<covered>`: Amounts that result from a calculation `<withheld>`: Amounts that result from a calculation `<original>`: The default input amount (typically the allowed amount) `<input>`: An input amount derived from other data elements on the claim line. This option is used when the calculation re-insures liabilities taken by the preceding payer.
Display Sequence	The display order of coverage labels on the claims page.
Reinsures (label)	Another coverage label that is reinsured by this label. This field must specify a label with the `<withhold>` action. This field may only be specified by `<cover>` labels.
Gets input through	Specifies a function dynamic logic that supplies the value for this label.

In the event that a Cover Withhold Rule specifies a cover withhold category in which the <cover> label reinsures another <withhold> label, the Cover Withhold Rule fields "Percentage based on" and "Result applied to" are no longer used: the calculation is both based upon and applied to the amount that is reinsured.

Consider the following scenario.

The payer from the previous scenario wants to configure Claims in such a way that the supplementary product fully reinsures all copays withheld by the basic product. The payer sets up the following six coverage labels, two for copay, two for Coinsurance and two for copay reinsurance.

<Withhold> label <Copayment>
<Withhold> label <Coinsurance>
<Withhold> label <NOT REINSURED>
<Cover> label <AMOUNT AFTER Copayment>
<Cover> label <AMOUNT AFTER Coinsurance>
<Cover> label <REINSURED Copayment> This label reinsures <Copayment>.

The payer sets up three cover withhold categories:

Category <Copayment>
- With withhold label <Copayment>
- And cover label `<AMOUNT AFTER Copayment
Category <Coinsurance>
- With withhold label <Coinsurance>
- And cover label <AMOUNT AFTER Coinsurance>
Category <Copayment REINSURANCE>
- With withhold label <NOT REINSURED>
- And cover label <REINSURED Copayment>

The basic product contains the following rule for doctor visits:

<Withhold> <$20> applied to the <original> amount as category <Copayment>.
<Withhold> <40%> of the <AMOUNT AFTER Copayment> applied to the <remaining covered> amount as category <Coinsurance>.

The supplementary product contains the following rule for doctor visits:

<Cover> <100%> of <Copayment> on <Copayment> as <Copayment REINSURED>.

The products are set up in such a way that the basic product benefits are applied before the supplementary product benefits. How this is done is specified in another chapter.

Now suppose a doctor visit claim line comes in for a benefits input amount of $100. First the basic product Cover Withhold Rules are applied resulting in the following breakdown: $20 <Copay withheld>, $32 <Coinsurance withheld > and $48 <Amount after Coinsurance>.

Subsequently, the Cover Withhold Rule in the supplementary product is processed. Because the rule specifies the category <Copay reinsurance> Claims derives that the label <Copay reinsured> applies. This label is set up to reinsure the label <Copay withheld>. As a consequence, the Cover Withhold Rule checks to see if an amount with the label <Copay withheld> in the resulting labels of the preceding Cover Withhold Rule exists. The rule then finds an amount of $20 <Copay withheld> and so it derives that an additional $20 is covered.

The result:

$100 benefits input amount
- $20 <Copayment>
- $32 <Coinsurance>
- $48 <Amount after Coinsurance>
- $20 <Copayment reinsured>
$68 to be paid

Note that the order in which the coverage labels are stated depends on the display sequence of the coverage label. It is also worth noting that it is possible for two or more Cover Withhold Rules to make use of the same cover withhold category, hence, the same coverage labels. In such an event, after all the Cover Withhold Rules are processed, the amounts associated with those labels are simply added up. Examples of this are discussed in the section on claim line coverage rules and claim line coverages.

Each time a Cover Withhold Rule is processed (other than the first one) a coverage label that represents an intermediate amount is replaced by one or more 'new' coverage labels. The amounts of these new coverage labels have to add up to the exact same amount of the intermediate amount label that is replaced. Likewise, the amounts of the coverage labels that are the result of the very first Cover Withhold Rule must always add up to the benefits input amount. This restriction prevents Cover Withhold Rules from covering (or withholding) more than the original benefits input amount. Consider the following scenario:

A payer has set up the following rules:

<Withhold> <10%> of the <original> amount, applied to the <original> amount as category Coinsurance
<Cover> <$20> applied to the <remaining withheld> amount as category`<Coverage>`

The category <Coverage> has a cover label <Covered>. A claim comes in for a benefits input amount of $100. The result of the first rule is $10 <Coinsurance withheld> and $90 <Amount after Coinsurance>. The second rule would replace the $10 <Coinsurance withheld>, which is the <remaining withheld amount>, with a $20 <Covered> label. Here is a restriction: if this replacement would be allowed, then the total covered amount would add up to $110, which is more than the initial benefits input amount. Therefore, the amount of the new label “<Covered>” is restricted to the amount specified on the label that is being replaced, that is the $10 <Coinsurance withheld>. As a result of this restriction only $10 is labeled <Covered> rather than the $20 specified by the cover withhold rule.

The end result:

$100 benefits input amount
$90 <Amount after Coinsurance>
$10 <Covered>
$100 to be paid

Counting Towards Limits

A limit represents the configuration for a counter. Each limit has its own behavior in terms of renewal, carry over, individual or family, and so on. Limits are described in Adjudication Limits.

The use of the count towards limit configuration is deprecated. The recommended way to connect limits to coverage calculations is by using either product benefit specification limits or claim line limits.

Count Towards Limit Fields

Table 4. Count Towards Limit Fields
Field	Description
Cover Withhold Rule	The Cover Withhold Rule of which the result will count towards the specified limit.
Reached action	Specifies what should happen once the specified limit has been reached: `<stop>` In the event of a cover limit, the limit excess should be withheld, in the event of a withhold limit, the limit excess should be covered `<continue>` The rule contributes towards the limit, but reaching the limit has no impact on the cover withhold rule.
Limit	The limit towards which is counted.
Maximum Amount	The maximum amount against which the limit adjudicates
Maximum Amount Currency	The currency of the maximum amount; it is automatically set to the currency that is specified on the coverage regime.
Maximum Number of Units	The maximum number of units against which this limit adjudicates.
Maximum Service Days	The maximum number of distinct service days against which this limit adjudicates.

Limits may be counted in either amounts, distinct service days or number of units. It is not possible to let a single Cover Withhold Rule count towards limits that have different types.

One Cover Withhold Rule may count towards multiple limits (of the same type), for example the result of a rule counts both towards the insurable entity deductible and the family deductible simultaneously both of which are specified by a maximum amount. When a rule counts towards multiple limits, all limits are counted towards simultaneously. Once the first limit with <stop> action is reached, the rule no longer counts towards any of the limits.

Consider the following scenario:

The product has a limit that represents a yearly maximum liability per person of $3000 across all benefits. This limit has the code <Out Of Pocket Max>.

Additionally, the payer has set up the following rule for specialist visits:

<Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
- Count the amount towards the <Out Of Pocket Max> and <stop> once the limit of <$3000> has been reached.

The payer receives a specialist visit claim line for $500 dollars. The current count for the out of pocket max is 2850 dollars. The resulting benefit specification states:

$500 Benefits input amount
$100 <Coinsurance withheld>
$400 <Amount after Coinsurance>
$400 to be paid
This claim line consumed $100 of the <Out Of Pocket Max> limit, making the current count $2950

Note that Claims keeps track how much was consumed on one or more particular limits per claim line, as reflected by the last bullet. Now suppose the payer receives a second claim for $500. Because this claim causes the <Out Of Pocket Max> to be reached and exceeded, the resulting benefit specification is different from the previous:

The rule specifies 20% of $500 to be withheld, which amounts up to a $100 Coinsurance. Before this result is applied, the $100 is counted towards the <out of pocket max>, but after only $50 the limit is reached. Because a <stop> action has been defined, only the first $50 is withheld, while the remaining $50 is not.

The results:

$500 Benefits input amount
$50 <Coinsurance withheld>
$450 <Amount after Coinsurance>
$450 to be paid
This service consumed $50 of the <Out Of Pocket Max> limit, making the current count $3000

The $450 <Amount after Coinsurance> is the sum of the $400 remaining after the Coinsurance, and the $50 that was not withheld as Coinsurance due to the fact that the <Out Of Pocket Max> limit was reached.

In general - given that the reached action is <stop> - any amount in excess of a cover limit is labeled with the withhold label as specified by the cover withhold category of the Cover Withhold Rule in question, and vice versa, any amount in excess of a withhold limit is labeled with the cover label as specified by the cover withhold category.

As stated before, it is possible for one Cover Withhold Rule to count towards more than one limit simultaneously.

Consider the following scenario:

The payer keeps track of two limits: a person level deductible and a family level deductible. Both limits are consumed at the same time but as soon as one of them is reached, both limits are considered to be met. The payer also requires a 20% Coinsurance that is applied before any deductibles.

Limit <Person Deductible>
Limit <Family Deductible>

The payer has set up a new cover withhold category for deductibles:

Category <Deductible>
- Withhold label is <person and/or family deductible>
- Cover label is <Amount after deductible>

The payer has set up the following rule for specialist visits:

<Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
<Withhold> <100%> of the <amount after Coinsurance> applied to the <remaining covered> amount as category <Deductible>.
- Count towards the <Person Deductible> and <stop> withholding once the limit of <$1500> is reached.
- Count towards the <Family Deductible> and <stop> withholding once the limit of <$3000> is reached.

The current count for the person deductible is $1450. The current count for the family deductible is $2910. A specialist visit claim line comes in for a benefits input amount of $200.

After processing of the first rule, the benefits input amount is split up into $40 Coinsurance and a remaining amount of $160. Before the $160 is paid one of the deductibles must be fully consumed. Both limits are consumed at the same time but the <Person Deductible> is the first one to reach the limit, after $50. The result is the following specification:

$200 benefits input amount
$40 <Coinsurance withheld>
$50 <Person and/or family deductible>
$110 <Amount after deductible>
$110 to be paid
This service consumed $50 of the <Person Deductible> limit, making the current count $1500
This service consumed $50 of the <Family Deductible> limit, making the current count $2960

Finally, consider the following scenario in which the limits are consumed sequentially rather than simultaneously.

The payer keeps track of two limits: a serviced person or object level deductible that is person level deductible and family level deductible. First the serviced entity deductible should be consumed. Once the serviced entity deductible has been reached, the family deductible is consumed. Once the family deductible is reached, the payer starts to pay. The payer has set up the following limits.

Limit <Person Deductible>
Limit <Family Deductible>

The payer has set up the following rule for specialist visits:

<Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
<Withhold> <100%> of the <amount after Coinsurance> applied to the <remaining covered> amount as category <Deductible>.
- Count the amount towards <Person Deductible> and <stop> withholding once the limit of <$2000> is reached.
<Withhold> <100%> of the <amount after deductible> applied to the <remaining covered> amount as <Deductible>.
- Count the amount towards <Family Deductible> and <stop> withholding once the limit of <$4000> is reached.

The current count for the person deductible is $1850. The current count for the family deductible is $3890.

A specialist visit claim line comes in for a benefits input amount of $500.

After processing of the first rule, the benefits input amount is split up into $100 Coinsurance and $400 that is to be paid. However, before the $400 is paid the person deductible must be fully consumed. The limit is consumed after $150, which leaves $250 to be paid. However, before the payer starts to pay, the family deductible must be consumed as well. The second limit is consumed after $110, which leaves an amount of $140 to be paid.

The result is the following specification:

$500 benefits input amount
$100 <Coinsurance person liability>
$260 <Person and/or family deductible>
$140 <Amount after deductible>
$140 to be paid
This service consumed $150 of the <Person Deductible> limit making the current count $2000.
This service consumed $110 of the <Family Deductible> limit, making the current count $4000.

Note that because the $150 withheld due to the first limit and the $110 withheld due to the second limit both received the same coverage label <Person and/or family deductible>. Because of this the two amounts are added up in the benefit specification. This is a set up choice: to have different labels for both deductibles, set up two separate cover withhold categories that would make use of two separate labels for withheld deductibles.

Tranches and Periods

The use of the Tranches and Periods is deprecated. The recommended way to create tiered calculations is by using limits in combination with Cover Withhold Rules that apply to specic coverage labels.

So far Cover Withhold Rules has been explained without specifying under what circumstances they apply. Claims allows the payer to set up a number of circumstances that are dependent on the serviced person or object and prior consumption. The first concept is the tranche. A tranche represents a 'slice' of consumption expressed in either a monetary amount or number of units. To clarify this concept, consider the following scenarios:

Payer A wants to set up his benefits in such a way that, for doctor visits, the first 12 visits have a copay of $5, while the next 12 visits have a copay of $20. After the 24th visit the payer requires a copay of $35. Regardless of the number of prior visits, a $500 deductible is withheld.

Payer B wants to set up his benefits in such a way that, for specialist visits, the first $500 of benefits input amount has a 10% Coinsurance, while the next $500 has a 20% Coinsurance. After a $1000 of benefits input amount has been claimed, the payer requires a 50% Coinsurance.

Payer C wants to set up his benefits in such a way that, for doctor visits, a 25% Coinsurance is applied. After 6 person visits or 12 family visits - whichever comes first - a 50% Coinsurance is applied.

Let us consider the scenario of Payer A. Depending on the number of prior visits, the payer wants to apply a $5, $20 or $35 copay. This means that Claims has to be aware of two things:

The number or prior visits
The levels, that is, the number of visits it takes for the next copay to apply.

A regime counter keeps track of the number of prior visits. See the Regime Counters on the regime counters model for specifics. Regime tranches store the levels, that is, the number of required visits before the next copay applies. Consider the figure below. The three tranches reflect the three levels, that is, the first 12 visits, the next 12 visits, and all visits starting with the 25th. Depending on what tranche is the current given the prior number of visits, a separate set of Cover Withhold Rules should be applied, that is, the $5, $20 or $35 copay.

Note that there is a hierarchical relationship between tranches and Cover Withhold Rules: a tranche can have multiple Cover Withhold Rules and a Cover Withhold Rule always belongs to a tranche. Also note that the last tranche can never specify a maximum. This prevents a situation where the benefits calculation hits a 'void' when the maximum of the last tranche is exceeded.

Coverage Regime Period Tranche

Table 5. Coverage Regime Period Tranche
Field	Description
Sequence	In the event of multiple tranches, the sequence specifies the order in which the tranches should be applied.
Maximum Amount Insurable Entity	The maximum benefits input amount for a person or object (insurable entity) that can be consumed in this tranche. Once this amount is exceeded, subsequent a tranche will apply. Only the amount consumed within this tranche counts towards the maximum.
Maximum Amount Insurable Entity Currency	The currency of the maximum amount insurable entity field; it is automatically set to the currency that is specified on the coverage regime.
Maximum Number Insurable Entity	The maximum number of allowed units for a person or object (insurable entity) that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of units consumed within this tranche counts towards the maximum.
Maximum Service Days Insurable Entity	The maximum number of (distinct) service days for a person or object (insurable entity) that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of service days consumed within this tranche counts towards the maximum
Maximum Amount Family	The maximum benefits input amount for a family that can be consumed in this tranche. Once this amount is exceeded, subsequent a tranche will apply. Only the amount consumed within this tranche counts towards the maximum.
Maximum Amount Family Currency	The currency of the maximum amount family field; it is automatically set to the currency that is specified on the coverage regime.
Maximum Number Family	The maximum number of allowed units for a family that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of units consumed within this tranche counts towards the maximum.
Maximum Service Days Family	The maximum number of (distinct) service days for a family that can be consumed in this tranche. Once this number is exceeded, a subsequent tranche will apply. Only the number of service days consumed within this tranche counts towards the maximum.

Reconsider the scenario of payer A, to clarify how tranches are configured. Disregard the deductible Cover Withhold Rules to prevent the scenario from being needlessly complex.

Payer A sets up three tranches for doctor visits, each with its own (set of )Cover Withhold Rules:

Tranche with a maximum of <12> allowed units:
- <Withhold> <$5> applied to the <original> amount as category <Copay>.
Tranche with a maximum of <12> allowed units:
- <Withhold> <$20> applied to the <original> amount as category <Copay>.
Tranche without a maximum.
- <Withhold> <$35> applied to the <original> amount as category <Copay>.

A doctor visit claim line comes in for $100. The person had 16 prior doctor visits. This means that the second tranche is the current: 12 visits fell into the first tranche, and the 16th doctor visit represents the 4th visit in the 12 visits in the second tranche. Hence, a copay of $20 is applied.

Payer B sets up three tranches for specialist visits, each with its own (set of) Cover Withhold Rules:

Tranche with a maximum of <500> benefits input amount
- <Withhold> <10%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
Tranche with a maximum of <500> benefits input amount
- <Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
Tranche without a maximum.
- <Withhold> <50%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

A specialist visit claim line comes in for $1300. The person has had no prior specialist visits. The first tranche is applied to the first $500 of the benefits input amount, resulting in a (10% of $500 ) $50 Coinsurance insurable entity liability. The remaining $800 will be divided over the subsequent tranches. The second tranche is applied to the next $500, resulting in a (20% of $500 ) $100 Coinsurance insurable entity liability. The last $300 goes to the last tranche, resulting in a (50% of $300) $150 Coinsurance insurable entity liability. Once all tranches have been applied, the result is a ($50+$100+$150) $300 Coinsurance insurable entity liability and $1000 is to be paid.

Payer C sets up two tranches for doctor visits, each with its own (set of )Cover Withhold Rules:

Tranche with a maximum of <6> allowed units on Insurable Entity level and <12> allowed units on family level:
- <Withhold> <25%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
Tranche without a maximum.
- <Withhold> <50%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

Some notes on tranches:

The amount maximum is always counted on the basis of the benefits input amount. So if the first tranche specifies a maximum of $500, but a $600 deductible is applied, the second tranche is reached before the payer starts to pay.
The number maximum is always counted on the basis of the allowed number of units^[1]. So if the first tranche specifies a maximum of 10 units, but the first 6 units are not paid due to a withheld limit, those 6 units still count towards the first tranche.
The last tranche in a set of one or more subsequent tranches must be specified without a maximum.
A set of subsequent tranches all specify either a maximum amount or a maximum number, except the last tranche in which the maximum must be left unspecified.
If both a maximum on Insurable Entity level and on family level is specified, it means that the tranche ends when one of the maximums is reached.

Tranches without regard for an associated period is explained so far. However, it may very well be that a time period - given a certain as-of date - determines which set of Cover Withhold Rules should be applied. Consider the following scenarios:

Payer A needs a 50% Coinsurance for orthodontic services in the first year of subscription. The second year the Coinsurance is lowered to 20%. After the second year the Coinsurance is lowered to 10%.

Payer B provides full coverage for all physical therapist visits in the 60 days directly following (and related to) the initial visit due to a broken leg. After those 60 days, further visits related to the same broken bone are no longer covered.

Let us consider the scenario of payer A. To determine whether the 50% or the 20% Coinsurance applies, Claims needs to 'know' the following things:

The level, that is the length of the time it takes before another benefit applies.
The as-of date

The length of the period is specified by a Coverage Regime Period. The as-of date defines when to start counting the specified period. Amongst others, this date may reflect the start of a new year, the date that the person/object first enrolled or the first day of a specific health condition. It is possible to define multiple subsequent periods with different pertaining Cover Withhold Rules. All of these periods use the same as-of date. For this reason, the as-of date is not a field of a coverage regime period, but is stored at a higher level encompassing all periods: the coverage regime level.

Consider the figure below which conceptually depicts the scenario for Payer A for orthodontic services:

As there is no use for tranches in this scenario, they are not depicted. As with tranches, there exists a hierarchical relationship between periods and Cover Withhold Rules. As with tranches, periods are sequenced and allow for an unspecified length. A period without a specified length is interpreted as 'forever', for example, the period box labeled 'After that' in the figure above.

Coverage Regime Period

Table 6. Coverage Regime Period
Field	Description
Sequence	In the event of multiple periods the sequence specifies the order in which the periods should be applied.
Length	An integer representing the length of the time period.
Unit of Measurement	Specifies whether the length should be interpreted as number of days, months or years.

Let us consider the set-up required for the scenario for payer A

Payer A sets up three coverage regime periods for orthodontic procedures, each with its own (set of )Cover Withhold Rules. The contract start date is specified as the as-of date:

Period of <1> <year>:
- <Withhold> <50%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
Period of <1> <year>:
- <Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
Period of <unspecified length>:
- <Withhold> <10%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

An orthodontic procedure claim line comes in for $140 with a service date on 11-MAY-2009. The person is subscribed to the product that provides the benefit since 03-MAY-2008. It is determined that the patient has been a subscribed person for 1 year and 8 days, qualifying the claim line for the second specified period. The cover withhold pertaining to this period specifies a 20% Coinsurance, hence a copay of $28 is applied.

Now let us consider a scenario that make use of both periods and tranches. This scenario also introduces the concept of a repeating period.

Payer C requires a 10% Coinsurance on the first dental check-up each three months. All subsequent dental check-ups in the same three months have a Coinsurance of 20%. Payer C specifies a single period of three months. The first day of the calendar year is specified as the as-of date. Within that period, payer C specifies two tranches, the first tranche specifies a maximum of 1 unit. This maximum reflects the first dental check-up in those three months. The second tranche is specified without a maximum, which reflects all subsequent dental check-ups within those three months.

Period of <3> <months>
- Tranche with a maximum of <1> allowed unit:
  - <Withhold> <10%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.
- Tranche without a maximum.
  - <Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

This set up takes care of the first three months in a calendar year. However, the intention of payer C is to repeat this coverage regime period during the year. Because it would be extremely cumbersome to define enough identical subsequent periods - in this example, four identical three month periods - it is possible to specify a set of periods - in the example the set has only one period - as repeating. As before with the as-of date, whether a set of subsequent periods should repeat applies to that set as a whole.

Whether periods are repeating is specified at the Coverage Regime level, that will be introduced in the next section. Note that even though there is no maximum on the second tranche, once the cover regime period starts anew, all the tranches are evaluated anew as well. In the example that means that, every three months, the very first dental check-up after the first day of the calendar year is always considered to be in the first tranche.

As reflected in the figure, tranches and periods have a hierarchical relationship: one period can have one or more tranches. A tranche always belongs to a period. Note that - although tranches are a required level in the hierarchy - setting up a single tranche without a maximum per period is functionally identical to not having a tranche at all. Consider the scenarios for payer A and payer B at the start of this section, these scenarios do not require specific tranches to be set up. The same is true for the coverage regime period: although it is a mandatory entity, not specifying a period length is is identical to stating that no period applies.

Coverage Regime

The 'asOf' date and repeating field which apply to the encompassed set of coverage regime periods is explained already. These fields are specified in the coverage regime.

Coverage Regime Fields

Table 7. Coverage Regime Fields
Field	Description
Code	Identifier for this regime.
Description	Descriptor of this regime.
Indication Active	If unchecked, no more references to this regime may be made.
Reference	Specifies the reference date that the system uses to plot the coverage regime periods. The following as-of dates can be specified: After Start of Calendar Year - in short: Calendar Year. The first period starts at January 1st of the year of the service^[2]. After Start of Insurance - in short: Insurance. The first period starts at the contract start date. After Start of Plan Year - in short: Plan Year. The first period starts on the most recent occurrence of the subscription day/month, either on or going back from the service date ^[3]. After Date of Insurable Entity - in short: Insurable Entity . Person: The first period starts at the date of birth of the person. Object: The first period starts at the object date of the object After Start of Case - in short: Case. The first period starts on the case start date 2. If the sum total of the period lengths specified under the coverage regime is more than a year, the first period starts in on January 1st in the year that the person or object subscribed. 3. For example, if a person subscribed on December 3rd 2006, then the first period set out, given a service date March 5th 2009, would be December 3rd 2008.
Indication Repetitive	If checked, the system cycles through the specified regime periods, until the the next reference date. If the reference date is not inherently repetitive - such as the reference: Date of Birth - the system cycles through the regime periods indefinitely. For example, a repetitive regime with a single 3-month regime period and a calendar year reference will cycle through the period 4 times per calendar year.
Currency	The currency for amount fields in tranches, Cover Withhold Rules and count towards limits.

A coverage regime represents the construct of its underlying periods, tranches and rules. In other words, a coverage regime represents a reusable building block that can be attached to one or more benefit specifications.

Coordination of Benefits

Coordination of Benefits (CoB) is a process where a claim is adjudicated sequentially by more than one health insurance payer. For a subsequent payer to calculate the benefits, it is necessary to receive the adjudication results of the preceding payer. CoB can be handled within Claims in two ways:

Before applying benefits: Adjust the benefits input amount based on the information from the preceding payer and calculate the benefits. Often this is done by deducting the preceding payer paid amount from the allowed amount and use that as input for benefits.
After applying benefits: Apply - in addition - post benefits logic to the outcome of the benefits calculation.

A full blown coordination of benefits could make use of the following key points of the application:

Claims In. Native fields: preceding payer code (at claim level) and preceding payer paid amount (at claim line level). Dynamic fields for more granular information, if needed, like preceding payer deductible or preceding payer Copayment
Enrollment. Product specific information can be sent back with respect to the primary plan, like Medicare or Commercial. This information can be stored in a dynamic field.
Pre Benefits Derivation Rule. Based on the information so far, a dynamic field CoB indicator can be set to specify if CoB is applicable. The logic could also depend on for example claim form, bill type and procedure of the claim line.
Pre Benefits Process Field Derivation Rule. The process field derivation rule for the benefits input amount can be molded so that a different outcome is possible depending on for example the primary plan. Popular choices are the allowed amount, the preceding payer allowed amount or logic like the greater of or the lesser of these two.
Calculate Benefits per Product. Normal execution of this step.
Calculate Post Benefits per Product
- Select the applicable post benefits specification.
- Apply the post benefits regime with the result of the normal calculation as input.

A post benefits regime is similar to a coverage regime without periods and tranches; it only includes (post) Cover Withhold Rules.

Post Benefits Regime

Table 8. Post Benefits Regime
Field	Description
Code	Identifier for this regime.
Description	Descriptor of this regime.
Indication Active	If unchecked, no more references to this regime may be made.

A post Cover Withhold Rule is the most elementary configuration rule in context of coordination of benefits. A post Cover Withhold Rule has the following fields:

Post Cover Withhold Rule

Table 9. Post Cover Withhold Rule
Field	Description
Sequence	In the event of multiple post Cover Withhold Rules, the sequence specifies the order in which these rules should be applied.
Action	Specifies whether the outcome of the dynamic logic function should be interpreted as an amount that is paid by the payer (coverage rule) or a insurable entity liability (withhold rule).
Result applied to	This field specifies the part of the benefits input amount to which the calculation results should apply. The possible values are (1) the remaining covered amount, (2) the remaining withheld amount or (3) a specific coverage label
Coverage Label	The coverage label to which the result applies when option 3 is selected.
Category	Specifies the category of the post cover withhold rule, which in turn drives the labels that are associated with the results of this rule.
Function dynamic logic	Specifies the function dynamic logic to calculate the amount that is to be covered or withheld.
Message	Specifies a message that is attached to the claim line whenever this post Cover Withhold Rule is applied to that claim line and the covered (or withheld) amount is greater than 0. Substitution parameters for the message Description of the post coverage regime The type of rule (action) The amount that is the outcome of the rule postfixed by a space and the currency display code of the amount Description of the product Description of the post benefits specification Post benefits specification Procedure group 1 usage concatenated with the Procedure group 1 description or the Procedure condition usage concatenated with the Procedure condition description (procedure group takes precedence if both are specified) Post benefit specification Diagnosis group usage concatenated with the Diagnosis group description or the Diagnosis group condition description Post benefits specification Age from '-' Age to Post benefits specification Gender description

Typical examples of post benefits regime logic are:

Scenario: "Cover up to Allowed" The rule is not to cover more than the difference between the benefits input amount and the preceding payer paid amount AND not to cover beyond CoB. In a formula this would look like:

 (claimLine benefitsInputAmount - claimLine precedingPayerPaidAmount)

The condtion "not to cover more than you covered without CoB" is fulfilled by the behavior of the rule when the rule is applied to the remaining covered: if the outcome of the formula exceeds the remaining covered, it is automatically lowered to the remaining covered. Note that this behavior is different from Cover Withhold Rules for coverage regimes, where is it possible to specify a percentage greater than 100% thereby increasing the remaining covered.

Scenario: "Benefits less Benefits" The rule is not to cover more in total than the calculated amount without CoB. In a formula this would look like:
```
(claimLine.coveredAmount - claimLine precedingPayerPaidAmount)
```

Up to Allowed

Suppose the payer has set up two cover withhold categories:

Category <Coinsurance> with:
- withhold label <Coinsurance>.
- cover label <Covered>
Category <UpToAllowed> with:
- withhold label <COB savings>
- cover label <Covered>

Now suppose the payer sets up the following cover withhold rule, including a reference to the cover withhold category <Coinsurance>:

<Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

In addition, the payer sets up the following post cover withhold rule, including a reference to the cover withhold category <UpToAllowed>:

<Cover> (benefits input amount - preceding payer paid amount) applied to the <remaining covered> amount.

As an example, a claim had a preceding payer allowed amount of $75 of which $50 was paid and now the claim is sent in.

Let’s assume the benefits input amount would come to $75 - in alignment with the original allowed amount.

After applying the coverage regime for Coinsurance, the outcome would be:

$75 benefits input amount
$15 <Coinsurance>
$60 <Covered>

Now the post benefits regime for coordination of benefits is applied. The post Cover Withhold Rule would start with the remaining covered which is $60 and then apply the formula (benefits input amount - preceding payer paid amount) which is = $25.

So the outcome would be:

$75 benefits input amount
$15 <Coinsurance>
$25 <Covered>
$35 `<COB savings

Benefits less Benefits

Suppose the payer has set up two cover withhold categories:

Category <Coinsurance> with:
- withhold label <Coinsurance>
- cover label <Covered>
Category <BenefitsLessBenefits> with:
- Withhold label <COB savings>
- Cover label <Covered>

Now suppose the payer sets up the following cover withhold rule, including a reference to the cover withhold category <Coinsurance>:

<Withhold> <20%> of the <original> amount, applied to the <original> amount as category <Coinsurance>.

In addition, the payer sets up the following post cover withhold rule, including a reference to the cover withhold category <BenefitsLessBenefits>:

<Withhold> preceding payer paid amount applied to the <remaining covered> amount

As an example, a claim had a preceding payer allowed amount of $75 of which $50 was paid and now the claim is sent in.

Let’s assume the benefits input amount would come to $75 - in alignment with the original allowed amount.

After applying the coverage regime for Coinsurance, the outcome would be:

$75 benefits input amount
$15 <Coinsurance>
$60 <Covered>

Now the post benefits regime for coordination of benefits is applied. The post Cover Withhold Rule would start with the remaining covered which is $60 and then apply the formula to withhold the preceding payer paid amount, being $50.

So the outcome would be:

$75 benefits input amount
$15 <Coinsurance>
$10 <Covered>
$50 `<COB savings

Claim Line Coverages

The preceding sections have introduced coverage labels in a number of different examples, as the resulting 'specifications'. In this section, how those amounts and labels in such a benefit specification are actually stored is explained.

A cover withhold category is a set of two coverage labels: one for the part of the amount that is withheld, one for the part of the amount that is covered. Consider a simple scenario where the user has set up the following category:

Category <Copay>
- Withhold label <Insurable Entity Liability>
- Cover label <Covered by payer>

A claim line comes in for a procedure with a $100 benefits input amount. The following Cover Withhold Rule applies:

<Withhold> <$20> applied to the <original> amount as category <Copay>.

The following figure below depicts what happens next:

In all the images the term 'allowed amount' is used. Actually, the starting point is the 'benefits input amount', so assume that the allowed amount is put into the benefits input amount through the process field derivation rule (which is the normal situation).

To withhold rule splits the benefits input amount up into two parts: the withheld amount, represented by the box with the white text and dark back ground, and the covered amount, represented by the box with the light background. Note that this division does not depend on the action of the cover withhold rule, that is, a cover rule would also have split up the benefits input amount into two boxes. Each of the boxes represents a Claim Line Rule Coverage.

A Claim Line Rule Coverage specifies the combination of the following fields:

Claim Line Rule Coverage

Table 10. Claim Line Rule Coverage
Field	Description
Action	Indicates whether the amount is a covered amount or a withheld amount.
Amount	The amount covered or withheld.
Number	The number of units covered or withheld.
Claim Line	The claim line in which the procedure is specified that is covered or withheld.
Coverage Label	The coverage label.
Product	The product to which the applied benefit belongs.
Cover Withhold Rule	The Cover Withhold Rule that resulted in this 'rule coverage'.
Post Cover Withhold Rule	The post Cover Withhold Rule that resulted in this 'rule coverage'.
Display Name	The display name of the claim line rule coverage.

To clarify how claim line rule coverages are created, consider the following scenario. A payer has set up the following category:

Category <Copay>
- Withhold label <Not Covered>
- Cover label < Amount after copay>
Category <Coinsurance>
- Withhold label <Not Covered>
- Cover label < Amount after Coinsurance>
Category <Deductible>
- Withhold label <Not Covered>
- Cover label <Amount after deductible>

Copay is applied first, then Coinsurance, then the deductible. The payer has set up a limit called <Deduc>. The following Cover Withhold Rules are set up:

<Withhold> <$20> applied to the <original> amount as category <Copay>.
<Withhold> <20%> of the <Amount after copay> applied to the <remaining covered> amount as category <Coinsurance>.
<Withhold> <100%> of the <Amount after Coinsurance> applied to the <remaining covered> amount as category <Deductible>.
- Count towards the <Deduc> limit and <Stop> withholding when reached.

Suppose a claim line comes in for a benefits input amount of $100. At that time only $15 of the deductible remains before it is reached. The following figure depicts the break-down of the benefits input amount.

The first rule splits the original benefits input amount up into two amounts: $20 labeled <Not covered> and $80 labeled <Amount after copay>.

The second rule is calculated on the amount that is labeled <Amount after copay> which is $80. The second rule calculates a withheld of $16. The result is applied to the <remaining covered amount>, which, after rule 1, consists of the (same) $80 <Amount after copay>, which is subsequently split up into $16 <Not covered> and $64 <Amount after Coinsurance>.

Finally, the third rule is calculated. The percentage is based on the amount labeled <Amount after Coinsurance>, which is $64. 100% of $64 which is still $64. However, before the result is applied, the $64 is counted towards the <Deduc> Limit. The limit is reached after counting only the first $15, resulting in a $15 <Not covered> rather than the full $64. The remaining $49 is labeled <Amount after deductible>.

The example results in four claim line rule coverages, that is, three specifying withhold labels, one specifying a cover label. Depending on the number of triggered Cover Withhold Rules, a claim line can accumulate multiple claim line rule coverages. Some of these claim line rule coverages may have the same coverage label, product and action. Consider the example above, in which the amount withheld due to Coinsurance, copay and deductible all used the same label <Not covered>, all are withhold labels and all are (assumed) to be calculated under the same product. Using the same label for different Cover Withhold Rules is a setup choice, and Claims interprets this choice as a request to aggregate the amounts that use the same coverage label. The benefit specification resulting from the scenario above would be:

$100 benefits input amount
$51 <Not covered>
$49 <Amount after deductible>
$49 to be paid.

Note that only one amount is listed for the <Not covered> and the listed amount is the sum of the $16 Coinsurance, the $15 deductible and the $20 copay. If the payer had wanted to list those liabilities separately, separate labels should have been used. The second and third bullet all represent an aggregation - an aggregation of a label for which only a single amount or number exists is also considered an aggregation.

The aggregation of claim line rule coverages is persisted by an entity named Claim Line Coverage:

Claim Line Coverage

Table 11. Claim Line Coverage
Field	Description
Action	Indicates whether the aggregated amount is a covered amount or a withheld amount.
Amount	The aggregated amount covered or withheld.
Number	The aggregated number of units covered or withheld.
Claim Line	The claim line in which the procedure is specified that is covered or withheld.
Coverage Label	The coverage label that specifies the aggregated number or amount.
Product	The product to which the applied benefit belongs.
Display Name	The display name of the claim line coverage.

Note that the claim line coverage does not hold a reference to a specific cover withhold rule, as it represents the aggregate amount or number over all the Cover Withhold Rules that were processed for the pertaining claim line.

Scenarios

This section contains a number of use cases with the purpose of providing the reader with a comprehensive understanding of coverage regimes, periods, tranches, Cover Withhold Rules and limits.

Scenarios are divided into four categories:

A: Scenarios that focus only on Cover Withhold Rules.
B: Scenarios that include limits.
C: Scenarios that include limits, tranches, periods and regimes.
D: Scenarios focus on reinsurance.