Data Model

This page describes the data model of the enrollment product and add-on.

Enrollment Product Category and Type

Category

An enrollment product category is used to categorize enrollment products (for example Medical and Dental). The category can for example be used to assign specific premium schedules and adjustments to enrollment products of a specific category in the context of a group client or a group account.

Field	Description
Code	The unique code of the enrollment product category
Description	The description of the enrollment product category

Type

An enrollment product type specifies a combination of properties that typically applies to (large) subset of enrollment products.

Field	Description
Code	The unique code of the enrollment product type
Description	The description of the enrollment product type
Enrollment Product Category	The enrollment product category that belongs to this enrollment product type

Constraints:

• The product category of the enrollment product and the product category of the enrollment product’s type must match if they are both specified

Reinsurance Setting

An enrollment product type can have one or more reinsurance settings. A reinsurance setting specifies the percentage that should be paid out to a reinsurer.

Field	Description
Enrollment Product Type	The enrollment product type for which the reinsurance setting is applied
Organization	The organization that acts as a reinsurer
Percentage	The percentage of the premium that has to be payed to the reinsurer
Alias Code	The alias code for reinsurance (this is transferred to OHI Claims in the enrollment response if reinsurance is applied)
Start Date	The start date of the reinsurance setting
End Date	The end date of the reinsurance setting

Constraints:

• It is not allowed to have an overlap in time validity for reinsurance settings with the same enrollment product type, organization and alias code

Reinsurance Exclusion

A reinsurance setting can have one or more reinsurance exclusions. A reinsurance exclusion specifies the premium types, adjustments and surcharges that are excluded from the base amount used for the reinsurance payment calculation.

Field	Description
Reinsurance Setting	The reinsurance setting for which the exclusions apply
Premium Schedule Type	The excluded premium schedule type
Schedule Definition	The excluded schedule definition

Note that not all schedule definitions are relevant to reinsurance, for example, schedule definitions that belong to the "Fee" schedule definition type have no relevance within the context of a reinsurance exclusion.

Enrollment Product

An enrollment product is the level for all the premium and adjustments calculations. It consists of one or more products that are packaged together. It has the following fields:

Field	Description
Code	The unique code of the enrollment product
Display Name	The display name of the enrollment product
Description	The description of the enrollment product
Line of Business	The line of business of the enrollment product
Enrollment Product Type	The type to which this enrollment product belongs
Enrollment Product Category	The category of the enrollment product
Amount Distribution	The way an amount is divided over calculation periods: on a daily basis or evenly
Partial Period Resolution	Charge for a partial period (per day, no charge, full period or enrolled days threshold)
Enrolled Days Threshold	The enrolled days threshold for the partial period resolution
Premium Currency	The currency for the adjustment and add-on amounts specified on the enrollment product (all adjustment and add-ons will have the same currency)
Parameter Currency	The currency for the parameter amounts specified on the enrollment product (all parameters of type amount will have the same currency)

Constraints:

• The product category of the enrollment product and the product category of the enrollment product’s type must match if they are both specified

• The enrolled days threshold must and may only be specified if the partial period resolution is set to enrolled days threshold

Product

A product uniquely identifies a set of benefits. OHI Enterprise Policy Administration uses these configured products as reference data in the setup of the enrollment product.

Products are added as reference data and the following fields are available:

Field	Description
Code	The unique code of the product
Description	The description of the product

Product Covered Service

A product covered service is a template for the waiting period and the score value of a service within a product.

Field	Description
Product	The reference to the product
Service Code	The code of the service
Description	The description of the service within the product
Covered Service Type	The type of the covered service (Limit or Parameter)
Covered Service Tier	The reference to the covered service tier
Wait Period Length	The length of the waiting period
Wait Period Unit of Measure	The unit of measure of the wait period
Default Score	The numerical value of how good this product service is
Start Date	The start date of the product covered service
End Date	The end date of the product covered service

Enrollment Product Detail

The enrollment product details specify which products are packaged together with the enrollment product.

Field	Description
Enrollment Product	The enrollment product
Product	The product (unique in combination with the enrollment product)

Enrollment Product Premium Schedule

Enrollment product premium schedules specify which premium schedules are assigned to an enrollment product.

Field	Description
Enrollment Product	The enrollment product
Premium Schedule	The premium schedule (unique in combination with the enrollment product)
Start Date	The start date of the assignment of the premium schedule
End Date	The end date of the assignment of the premium schedule

Constraints:

• The amount interpretations of the premium schedules of an enrollment product must be the same (all Calculation Period or all Calendar Year)

• The schedule definition types of the premium schedules of an enrollment product must be Premium or Policy Based Premium or a combination of these types

• It is not allowed to have an overlap in time validity for enrollment product premium schedules with the same enrollment product and premium schedule

Enrollment Product Time Period

This is a time period that is used in the context of the enrollment product. The enrollment product time period has the following fields

Field	Description
Enrollment Product	The enrollment product that has the enrollment product time period
Display Name	The display name of the enrollment product time period (unique in combination with the enrollment product)
Start Date	The start date for the enrollment product time period
End Date	The end date for the enrollment product time period

Enrollment product adjustment values and add-on premium schedules are within the enrollment product time period.

Constraints:

• It is not allowed to have overlapping time periods

Enrollment Product Adjustment

Enrollment product adjustments specify which adjustments are assigned to an enrollment product. The adjustments are calculated in the ascending order of the sequence. This is especially relevant for the adjustments that are based on a percentage. The adjustment types having the same sequence, say N, take the same base amount for the percentage based adjustment calculations and it is premium +/- all the adjustments up to and including (N-1) sequence. More information on how adjustment amounts are evaluated can be found in the implementation guide for premium calculation.

Field	Description
Enrollment Product	The enrollment product that has the enrollment product adjustment
Adjustment Type	The schedule definition of the type adjustment
Sequence	The sequence specifies the order in which adjustments get applied
Start Date	The start date of the assignment of the adjustment
End Date	The end date of the assignment of the adjustment

Constraints:

• The schedule definition must be of type adjustment

• It is not allowed to have an overlap in time validity for enrollment product adjustments with the same enrollment product and adjustment type (schedule definition)

Enrollment Product Adjustment Value

The enrollment product adjustment value is a value for the adjustment rule used in the context of the enrollment product i.e it overrides the adjustment value of the adjustment rule that was specified during the default setup.

Field	Description
Amount	The adjustment amount (negative means that the premium is lowered)
Currency	The currency of the adjustment amount (it will automatically be set to the premium currency that is specified on the enrollment product)
Percentage	The adjustment percentage (negative means that the premium is lowered)
Amount Function	Reference to a function dynamic logic function with signature 'Adjustment' that determines the adjustment amount
Adjustment Rule	The reference to an adjustment rule (unique in combination with the enrollment product time period)
Enrollment Product Time Period	The enrollment product time period to which this record belongs to

Enrollment Product Provider Group

Enrollment product provider groups specify which provider groups are assigned to an enrollment product.

Field	Description
Enrollment Product	The enrollment product that has the enrollment product provider group
Provider Group	The provider group that is assigned to the enrollment product
Assigned Provider Group Label	The qualifying label for the assignment of a provider group to an enrollment product (assigned provider group labels are configured separately; they have a code and a display name)
Start Date	The start date of the assignment of the provider group
End Date	The end date of the assignment of the provider group

Constraints:

• It is not allowed to have an overlap in time validity for enrollment product provider groups with the same enrollment product, assigned provider group label and provider group

Add-on

An add-on provides an extension of the benefits offered by the enrollment product.

Field	Description
Code	The unique code of the add-on
Display Name	The display name of the add-on
Description	The description of the add-on

Add-on Detail

The add-on details specify which products are packaged together with the add-on.

Field	Description
Add-on	The reference to the add-on
Product	The product (unique in combination with the add-on)

Add-on Premium Schedule

An add-on premium schedule defines which add-on an enrollment product offers in a specific time period and based on which schedule definition the add-on premium is calculated.

Field	Description
Add-on	The reference to the add-on
Enrollment Product Time Period	The enrollment product time period to which this record belongs to
Schedule Definition	The schedule definition on which the add-on premium schedule is based on

Add-on Premium Schedule Line

An add-on premium schedule can have one or more add-on premium schedule lines. Add-on premium schedule lines store all the premium values for an add-on premium schedule in the context of an enrollment product. An add-on premium schedule line can have group account product add-on overrides; these are overriding values on the group account product level (described below). An add-on premium schedule line can also have schedule dimension values (described in the Data Model section of the Premium Configuration implementation guide).

Field	Description
Add-on Premium Schedule	The reference to the add-on premium schedule
Amount	The amount by which the base premium is increased
Currency	The currency of the add-on amount (it will automatically be set to the premium currency that is specified on the enrollment product)
Percentage	The percentage by which the premium is increased
Function	The dynamic logic function used to calculate the add-on amount

Parameter Domain and Domain Value

A parameter domain defines per enrollment product/group account product and parameter alias combination if a non discrete value is applicable or that the parameter domain holds a list of predefined values.

Parameter Domain

A parameter domain has the following attributes:

Field	Description
Parameter Alias	The parameter alias
Enrollment Product	The enrollment product to which the parameter domain applies
Group Account Product	The group account product to which the parameter domain applies
Discrete	Indicates whether the parameter domain is a list of predefined discrete values or a single non-discrete value.
Amount	The default value (amount) of a non discrete parameter domain (only for parameter aliases of type Amount)
Currency	The currency of the amount (only for parameter aliases of type Amount; it will automatically be set to the parameter currency that is specified on the enrollment product)
Percentage	The default value (percentage) of a non discrete parameter domain (only for parameter aliases of type Percentage)
Number of Units	The default value (number of units) of a non discrete parameter domain (only for parameter aliases of type Number of Units)
Service Days	The default value (service days) of a non discrete parameter domain (only for parameter aliases of type Service Days)

Constraints:

• Either the enrollment product or the group account product must be specified

Parameter Domain Value

Parameter domain values are allowed values for a parameter alias in a policy enrollment product. Parameter domain values can only be defined for discrete parameter domains.

A parameter domain value has the following attributes:

Field	Description
Parameter Domain	The parameter domain
Amount	The value (amount) of the parameter (only for parameter aliases of type Amount)
Currency	The currency of the amount (only for parameter aliases of type Amount; it will automatically be set to the parameter currency that is specified on the enrollment product)
Percentage	The value (percentage) of the parameter (only for parameter aliases of type Percentage)
Number of Units	The value (number of units) of the parameter (only for parameter aliases of type Number)
Service Days	The value (service days) of the parameter (only for parameter aliases of type Service Days)
Default	Indicates whether the value is the default value for the parameter domain
Condition	Reference to a condition dynamic logic function with signature 'Parameter Value' that determines if the domain value is applicable for a person or object for an enrollment product in a policy Note : This condition is applicable only for the ADF UI
Start Date	The start date of the parameter domain value.
End Date	The end date of the parameter domain value.

Constraints:

• The value (amount, number of units, percentage or service days) that matches the type (amount, number, percentage or service days) of the parameter alias is required and the other values are not allowed

• Only 1 domain value can be the default value within a parameter domain

• A condition can only be set for a domain value that is not the default value

• The start date of the parameter domain value is mandatory.