Overview

In Oracle Health Insurance Enterprise Policy Administration (Policies), a policy is an agreement between a healthcare payer and a policyholder. The policy lists the persons that are covered under the policy, the members. For each member, the policy lists the services for which the payer (partially) covers the incurred costs. The policyholder can be one of the members, but this is not required. The payer agrees to pay (a part of) the member’s healthcare costs. In return the policyholder pays a premium.

In Policies a group represents the situation where a healthcare payer contracts with a group of policyholders. Such a group can, for example, represent a company, and the policyholders its employees. In Policies the group client represents the company, and the group account holds the terms that apply to all the policies within the context of that group account. For more details on groups see Groups.

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. For more information on how Oracle Health Insurance calculates premium for a policy see Calculate Premium.

Policies supplies a change history for each policy. Changes to an approved policy will automatically lead to a new version of that policy. The policy needs to pass a list of user-configurable business rules before the system considers it a valid ('approved') policy. As long as the newer version of a policy has not passed the approval process, the system considers the previous version the actual one.

This chapter describes the policy object and its details.

Policy

Creating and Editing a Policy

Policies supplies multiple option to create and edit policies.

  • The seeded JET user interface page

  • The Policy In integration point

  • The Policy File Enrollment

  • The generic Policy API

Unique identifier

A Policy is typically identified by the policy code. The policy code can either be entered or generated by the system using a customer-configurable logic.

The system supports the definition of additional policy identifiers like Social Security Number, an external identifier, a concatenation of a group account code and the subscriber’s identification etc.

Brand

Insurance Type

Line of Business