Relations

This guide elaborates on the data model used to store demographic information in Oracle Health Insurance applications. This model is used to store demographic information for persons and organizations. Both of these roles are referred to as relations. Data of this type is referred to as reference data (as opposed to operational data and configuration data). In order to feed the relation data into Oracle Health Insurance applications there is an integration point. This integration point is also described in this Developer Guide.

Addresses

A person or organization can have one address at any give point in time, per address type. In other words, a person can have multiple site addresses over time, but can never have two site addresses on the same day. An address has the following fields:

Table 1. Addresses
Field Description

Relation

The person or organization that has the address

Type

The type of the address (Site or Mailing)

Street

The street of the address

House number

The house number of the address

Number addition

The house number addition, such as a floor or apt. number

City

The city where the address is situated

Postal code

The postal code of the address

Additional part 1

An address contains three generic fields that can be used to further specify the address

Additional part 2

Additional part 3

Country

The country in which the address is situated

Country region

The region of the country in which the address is situated (can be used for example, States and Departments)

County

Name of the county where the address is located

State and County Code

State and county code of the address

Start date

The start date of the address

End date

The end date of the address

Access restriction

The access restriction restricting access to the address (see the implementation guide on User Access for more details)

Constraints:

  • It is not allowed to have an overlap in time validity for addresses for the same type and relation

  • The country and the country region of an address should match

  • If the upper indicators (specified on country level) for street, city, number addition, and the additional parts are true, the values should be entered in uppercase

  • The address parts should comply with the dynamic logic for address parts that may be specified at country level

  • An address can only be linked to an access restriction of type Address Contact Detail

Assigned Providers

An assigned provider is a provider who is assigned to a person with a specific assignment. A person can have multiple assigned providers. Note that assigned providers are not available in the Oracle Health Insurance Authorizations application.

Example:

  • Provider Bob Smith is assigned to person John Doe as his Primary Care Provider from 01-Jan-2017 to 12-Dec-2017.

An assigned provider has the following fields:

Table 2. Assigned Providers
Field Description

Person

The person that has the assigned provider

Provider

The provider that is assigned to the person

Provider assignment type

The type of assignment of the provider assigned to the person

Start date

The start date of the assigned provider

End date

The end date of the assigned provider

Constraints:

  • It is not allowed to have an overlap in time validity for assigned providers for the same person and provider assignment type

Bank Account Numbers

A person or organization can have multiple bank account numbers. A bank account number has the following fields:

Table 3. Bank Account Numbers
Field Description

Relation

The person or organization that has the bank account number

Bank account number

The bank account number (can contain digits and characters)

Debit bank account number

The debit bank account number

Special name

The name of the person or organization, different from the relation name, that is to be used for the bank account number

Start date

The start date of the bank account number

End date

The end date of the bank account number

Preferred?

Is this the preferred bank account number for a relation?

Bank account validation

The validation that applies to the bank account number

Constraints:

  • It is not allowed to have an overlap in time validity for bank account numbers for the same relation, bank and bank account number

  • There may only be one preferred bank account number at any point in time for the same relation

  • If the bank account number references a bank account validation with indicator bank mandatory true then the bank should be specified

  • If the bank account number references a bank account validation with indicator debit number true then the debit bank account number should be specified else it should be unspecified

  • The bank account number should comply with the dynamic logic for bank account validation that it references

Contract Alignments

Contract alignments specify which persons are possibly relevant to which capitation contracts. A person can have multiple contract alignments. Note that contract alignments are not available in the Claims and [authComponent]applications.

Example:

  • Member John Smith is possibly relevant to capitation contract CONTR123 from 01-Jan-2017 to 12-Dec-2017

A contract alignment has the following fields:

Table 4. Contract Alignments
Field Description

Person

The person that has the contract alignment

Capitation Contract

The capitation contract that is aligned to the person

  • Capitation contracts in Oracle Health Insurance Value-Based Payments are described in the Capitation Contracts section of the Oracle Health Insurance Value-Based Payments implementation guide

  • Capitation contracts in Policies only contain a code and a description

Start date

The start date of the contract alignment

End date

The end date of the contract alignment

Constraints:

  • It is not allowed to have an overlap in time validity for contract alignments for the same person and capitation contract

Marital Statuses

A person can have one and only one marital status at any given point in time. Note that marital statuses are not available in the Oracle Health Insurance Authorizations and Oracle Health Insurance Value-Based Payments applications. A marital status has the following fields:

Table 5. Marital Statuses
Field Description

Person

The person that has the marital status

Type

The reference to a marital status type

Start date

The start date of the marital status

End date

The end date of the marital status

Constraints:

  • It is not allowed to have an overlap in time validity for marital statuses for the same person

  • The time validity of the marital status must be within the time validity of the person

Organizations

In the Oracle Health Insurance applications, all organizations are stored as an organization. An organization has the following fields:

Table 6. Organizations
Field Description

Code

The unique key that is used to identify the organization

Name

The name of the organization

Business phone number

The phone number that is used for business purposes

Private phone number

The private phone number

Mobile phone number

The mobile phone number

Fax number

The fax number

Email address 1

The email address

Email address 2

The second email address

Preferred language

Preferred language for correspondence with this organization

Language

Language for correspondence with this organization

End date

The end date of the organization

An organization can have the following details: addresses, tags and bank account numbers.

Constraints:

  • A specified e-mail address must comply with standards for specifying e-mail addresses

  • The language of a relation needs to be an installed language.

Person Covered Services

The person covered service holds information to determine whether wait periods have been served and whether current coverage is better / worse than previous ones.

Person covered services also support storing 'Transfer Certificates', that is enrollment information from other payers that can be used for serving a waiting period.
Specify a (no-enrollment, no-cover) product for that purpose and create the person covered services under that product. Set the Locked? indicator to true if these person covered services should be protected from removal when regenerating person covered services.
Table 7. Person Covered Services
Field Description

Person

The reference to the person

Product

The reference to the product

Service Option Service Code

The service option service code of the covered service

Covered Service Tier

The reference to the covered service tier

Covered Service Type

The type of the covered service (Limit or Parameter)

Wait Start Date

Earliest date as of when member has held this combination of service and type with the same or better level

Score

The numerical value of how good this covered service is

Ind Waived

Is the waiting period for this service waived?

Ind Blocked

Should this person covered serviced be protected from removal when regenerating person covered services?

Waiver Reason

The reference to the waiver reason

Start Date

The start date of the person covered service

End Date

The end date of the person covered service

Person Titles

A person can have multiple titles. A person title has the following fields:

Table 8. Person Titles
Field Description

Person

The person that has the title

Title

The title that the person has

Persons

A person record stores the demographic information for a person. It has the following fields:

Table 9. Persons
Field Description

Code

The unique key that is used to identify the person

Initials

The abbreviation of the first names of the person

First name

The first name of the person

Middle name

The middle name of the person

Prefix

The prefix to the last name of that person

Name

The name of the person

Prefix partner

The last name prefix of the partner of the person

Name partner

The last name of the partner of the person

Suffix

The suffix of the person

Gender

The gender of the person

Date of birth

The date of birth of the person

Date of birth interpretation

The way the date of birth should be interpreted. There are three possible values:

  • The date is exact

  • Only the month and year are accurate (all date of birth related checks will treat this date as though it specifies the first day of the month)

  • Only the year is accurate (all date of birth related checks will treat this date as though it specifies the first day of the year)

Business phone number

The phone number that is used for business purposes

Private phone number

The private phone number

Mobile phone number

The mobile phone number

Fax number

The fax number

Email address 1

The email address
The email address has to meet the IETF RFC2882 standards

Email address 2

A second email address
The email address has to meet the IETF RFC2882 standards

Preferred language

Preferred language for correspondence with this person

Language

Language for correspondence with this person

End date

The end date of the person

Contact details access restriction

The access restriction restricting access to the contact details of the person (see the "User Access Restrictions Model" chapter of the Security Guide for more details)

Access restriction

The access restriction restricting access to the person (see the "User Access Restrictions Model" chapter of the Security Guide for more details)

A person can have the following details: addresses, tags, bank account numbers, marital statuses, titles, assigned providers and contract alignments.

Constraints:

  • The end date of a person may not lie in the future

  • A person can only be linked to an access restriction of type Non-Address Contact Detail for the non-address contact details and type Person Details for all details

  • The prefix for the partner may only be specified if the name partner is also specified

  • A specified e-mail address must comply with standards for specifying e-mail addresses

  • The language of a relation needs to be an installed language

Relation Identifiers

A person or an organization can have multiple identifiers for example the Social Security Number, Driver License number etc.

A relation Identifier has the following fields:

Table 10. Relation Identifiers
Field Description

Relation

The person or organization that has the identifier.

Identifier type

The unique key that is used to identify the identifier type.

Identifier

The identifier with ID (can contain digits and characters).

Ind enabled?

Is the relation identifier enabled?

Relation Links

Persons and organization can have links to other persons and organizations. Relation links store these relationships.

A relation link has the following fields:

Table 11. Relation Links
Field Description

Relation

The person or organization that is linked to another relation

Relation link type

The type of relation link, like PARENT_CHILD

Linked relation

The relation that is the subject of the link

Link direction

The direction of the link

Possible Values:

  • F, for a forward link. E.g. Parent of

  • B, for a backward link. E.g. Child of

Enabled?

Is the relation link enabled?

Relation links are always created in pairs. So whenever a relation link is created from relation A to relation B, the system creates the corresponding relation link from relation B to relation A automatically. Also, when a relation link is deleted or disabled, the corresponding relation link is deleted or disabled as well.

When the relation link has a link type where auto disable is checked, the system disables existing relation links for the same relation and relation link type. For example when a relation link type of 'Legal representative' is configured as auto disable and a new 'Legal representative' link is created for a relation, the existing 'Legal representative' relation links for that relation are disabled.

Relation Tags

Relation tags serve to categorize persons and organizations. A person or organization can have multiple tags. Note that relation tags are not available in the Policies, Oracle Health Insurance Authorizations and Oracle Health Insurance Value-Based Payments applications. A relation tag has the following fields:

Table 12. Relation Tags
Field Description

Relation

The person or organization that has the tag

Tag type

The type of tag

Start date

The start date of the tag

End date

The end date of the tag

Constraints:

  • It is not allowed to have an overlap in time validity for tags for the same relation and tag type

Relation Configuration

The following section describes the setup that supports the relation data model. These are typically the value domains that are used by the reference data, such as the list of available countries, tags etc.

Address Type

An address type specifies the purpose of an address.

Table 13. Address Type
Field Description

Code

Unique identifier for an address type

Ind default

Is this the default address type?

Display name

Description of the address type

Bank Account Validations

A bank account number must specify a bank account validation. Such a validation is a check to which the account number needs to comply. For example, consider a validation where the bank account has nine or ten digits and must be dividable by eleven. Another example is the international IBAN-format.

Table 14. Bank Account Validations
Field Description

Code

The unique code of the bank account validation

Description

The description of the bank account validation

Ind default

Is this bank account validation the default?

Ind debit number

Will there be a debit number?

Default debit number

The default debit number

Ind bank mandatory

Is it mandatory to specify a bank?

Ind direct debit

Is direct debit allowed?

Active?

If unchecked, this type is not available when creating or updating bank account numbers

Constraints:

  • There should be one and only one default bank account validation and this should be an active one

  • The default debit number is mandatory if the debit number indicator is true; it may not be specified if the debit number indicator is false

Banks

A bank can be specified on a bank account number.

Table 15. Banks
Field Description

Code

The unique code of the bank

Name

The name of the bank

Bank identifier code

The BIC (Bank identifier Code) of the bank.

Bank routing number

The ABA Number or Bank Routing Number

IBAN bank code

The IBAN Bank Code

Active?

If unchecked, no new references can be made to this bank

Business phone number

The phone number

Private phone number

The private phone number

Mobile phone number

The mobile phone number

Fax number

The fax number

Email address 1

The email address

Email address 2

A second email address

Preferred language

Preferred language for correspondence with this bank

Language

Language for correspondence with this bank

Constraints:

  • For bank identifier number, IBAN bank code and bank routing number:

    • bank identifier code and IBAN bank code are specified with bank routing number unspecified OR

    • bank routing number is specified with bank identifier code and IBAN bank code unspecified OR

    • bank identifier number, IBAN bank code and bank routing number are unspecified

  • A specified e-mail address must comply with standards for specifying e-mail addresses

  • The language of a relation needs to be an installed language

Countries, Country Regions, Country Region Groups, and Country Region Group

Countries are used by relation addresses. A country region represents a part of a country, such as a state or a province.

Table 16. Country
Field Description

Code

The unique code of the country

Name

The standard name of the country

Indication upper street

Should a street in this country display in uppercase?

Indication upper city

Should a city in this country display in uppercase?

Indication upper country region

Should a region in this country display in uppercase?

Ind default

Is this country the default?

Active?

If unchecked, this type is not available when creating or updating addresses

Date

The date with MM (month) in uppercase since mm represents minutes. For example, MM/dd/yyyy

Constraints:

  • There should be one and only one default country and this should be an active one

A country can have zero, one or more country regions. Country regions are also used on relation addresses.

Table 17. Country Regions
Field Description

Country

The country that has the country region

Code

The code of the country region, unique within the country

Display code

The display code of the country region

Constraints:

  • If the upper indicator for country region (specified on country level) is true, the code of the region should be in uppercase

Country regions can be part of country region groups. This grouping then can be used to make a benefit specification or a product benefit specification only applicable for persons, providers or employers in a specific country region group.

Table 18. Country Region Group
Field Description

Code

The unique code of the country region group

Description

The description of the country region group
Table 19. Country Region Group Detail
Field Description

Country region group

The reference to the country region group

Country region

The reference to the country region

Covered Service Tiers

The product service tier differentiates between multiple wait times within the same service.

A product service tier has the following fields:

Table 20. Covered Service Tiers
Field Description

Code

The code of the covered service tier

Description

The description of the covered service tier

Ind Active

Is this covered service tier still in use?.

Gender Identities

Gender identity represents the gender of an individual.

Table 21. Gender Identities
Field Description

Display Name

Display name for a gender identity

CODE

Unique identifier for a gender identity

Geographic Regions

Geographic regions represent demographic regions rather than topographic regions, such as a low income area. Geographic regions are not directly connected to an address, but are accessible in dynamic logic through the 'inGeographicRegion' method. See the implementation guide for dynamic logic for details. Note that geographic regions and conditions are not available in Policies, Oracle Health Insurance Authorizations and Oracle Health Insurance Value-Based Payments applications.

Table 22. Geographic Regions
Field Description

Code

The unique code of the geographic region

Description

The description of the geographic region

Geographic Condition

A geographic region can have one more conditions attached to it. These conditions are tested against an address when calling the 'inGeographicRegion' method.

Table 23. Geographic Condition
Field Description

Geographic region

The geographic region that has the geographic condition

Dynamic logic condition

The condition (on a person’s address)

Start date

The first date that an address must qualify for this condition

End date

The last date that an address must qualify for this condition

Constraints:

  • It is not allowed to have an overlap in time validity for geographic conditions for the same geographic region

Identifier Types

The identifier type defines the list of possible identifier types that a relation can have.

An identifier type has the following fields:

Table 24. Identifier Types
Field Description

Code

The type of identifier

Display Name

The display name of the identifier

Unique?

Are identifier of this type unique across relations?

Access restriction

The access restriction restricting access to the identifiers.

Concealment expression

This field specifies a regular expression, that controls the concealment of restricted identifiers.

Constraints:

  • A concealment expression can only be specified if an access restriction is defined on the identifier type.

  • An identifier type cannot be set to unique when identifiers exist.

  • A concealment expression must be a valid regular expression.

Table 25. Business Rule
Type Entities Description Message

Validation

Identifier Type

An identifier type cannot be set to unique when identifiers exist for the identifier type

An identifier type cannot be set to unique when identifiers exist
Note that the following Covered Service Type, Waiver Reason and Person Covered Service are only available in Policies and Claims applications.

Marital Status Types

Marital Status Types define the list of possible marital statuses that a relation can have. Marital status types, like marital statuses are not available in the Oracle Health Insurance Authorizations and Oracle Health Insurance Value-Based Payments applications. A marital status type has the following fields:

Table 26. Marital Status Types
Field Description

Code

The code of the marital status type

Descr

The description of the marital status type

Active?

Is this marital status type still in use?

Prefixes

A person can have a single prefix.

Table 27. Prefixes
Field Description

Code

The unique code for this prefix

Display code

The displayed text for this prefix

Active?

Indicates whether this prefix can be selected when creating or updating a person

The actual display code is ultimately determined by the dynamic logic function specified in a persons name format. In other words, the 'display code' has no inherent logic behind it, but serves as input for the name format function.

Provider Assignment Types

Provider assignment types define the list of possible assignment types that an assigned provider of a person can have.

Table 28. Provider Assignment Types
Field Description

Code

The unique code of the provider assignment type

Description

The description of the provider assignment type

Relation Link Types

Relation Link Types define the list of possible link types that a relation can have.

A relation link type has the following fields:

Table 29. Relation Link Types
Field Description

Code

The code of the relation link type

Descr

The description of the relation link type

Forward link name

The name of a forward link. E.g. Parent of

Backward link name

The name of a backward link. E.g. Child of

Auto Disable?

Is the relation link disabled automatically when a new relation link is created for the relation of the same relation link type?

Duplicate?

Is the relation link type configured to register duplicate relations?

Active?

Is the relation link type active for use in new relation links?

Tag Types and Messages

Tag types define the list of possible tags that can be used for tagging a relation. Note that tag types and tag type messages are not available in Policies, Oracle Health Insurance Authorizations and Oracle Health Insurance Value-Based Payments applications.

Table 30. Tag Types and Messages
Field Description

Code

The unique code of this tag type

Description

The description of this tag type

Active?

If unchecked, this type is not available when creating or updating relation tags

A tag type can specify one or more tag type messages.

Table 31. Tag Type Messages
Field Description

Tag type

The tag type that has the tag type message

Message

The message associated with this tag type

Start date

The start date of the tag type message

End date

The end date of the tag type message

Constraints:

  • It is not allowed to have an overlap in time validity for tag type messages for the same tag type

  • It is not allowed to have a gap in time validity for tag type messages

Titles

A person can have one or more titles.

Table 32. Titles
Field Description

Code

The unique code for this title

Display code

The displayed text for this title

Before?

Indicates whether this title should go before or after a person’s name

Display order

Specifies the displayed order in case a person has multiple titles

Active?

Indicates whether this title can be selected when creating or updating a person

The actual display code, order or whether a title goes before or after a person’s name is ultimately determined by the dynamic logic function specified in a persons name format. In other words, the 'display code, 'display order' and 'before?' fields have no inherent logic behind them, but serve as input for the name format function.

Waiver Reasons

When waiving a waiting period a waiver reason indicates the reason for the waiver.

A waiver reason has the following fields:

Table 33. Waiver Reasons
Field Description

Code

The code of the waiver reason

Description

The description of the waiver reason

Ind Active

Is this waiver reason still in use?

Message

Reference to the message that is attached to the person covered service when it is waived for this reason