Overview

This guide describes how the OHI Enterprise Policy Administration system stores person-, group- and policy records, and their related business operations and services.

In OHI Enterprise Policy Administration, a policy is a contract between the payer and a policyholder, typically one of the insured persons on that policy. The policy lists the persons that are covered under the policy, the enrollments or 'members'. For each enrolled person, the policy lists the services for which the payer (partially) covers the incurred costs, the enrollment products.

The policyholder can be one of the members, but this is not required.

In OHI Enterprise Policy Administration group accounts represent the situation where healthcare payers contract with a group of policyholders. Such a group typically represents a company, and the policyholders are its employees. In OHI Enterprise Policy Administration the group client typically represents the company, and the group account holds the terms that apply to all the policies within the context of that group account. Enrollment products are typically customized to meet the need of the group.

The premium is the agreed amount to be paid by the policyholder to the payer. Although the policyholder is ultimately liable for the premium, it is possible that the group or another third party pays the premium.

The following chapters describe the various policy- and person or object user interfaces, the data model, the processing of policies, the generation for policy related output, and the integration points.