Data Model

Policy

A policy is an agreement between the insurance carrier and the policyholder that defines a certain coverage or set of benefits in exchange for a premium. Group accounts (referenced by policies) are described in the Operations Guide. Data access groups (referenced by policies) are described in the "User Access" chapter of the Security Guide.

Table 1. Policy
Field Description

Code

The code of the policy

Version

The version of the policy

Gid

The global unique identifier of the policy (this identifier is automatically issued when entering a new policy. It remains the same for all versions of the policy)

Status

The status of the policy: Edit, In Process, Pended, Pending File Review, Approved or Canceled

Line of Business

The line of business that the policy belongs to

Brand

The brand that the policy belongs to

Type

The type of the policy (optional): Medicare Advantage or Medicaid

Data Access Group

The data access group used to differentiate over user access rights

Calculate on Cancellation?

Indicates if the policy is re-calculated when it is canceled; calculating the policy as part of the cancellation process is required for scenarios that include cancellation fees (an example is provided in the Cancel Policy section of the Developer Guide)

Process Flow

The group of process steps and process rules that apply to a policy

Pre-Approved?

  • Yes - Suppress the generation of any pre-approval notifications

  • Null - Do not suppress the generation of any pre-approval notifications

Constraints:

  • Multiple policies with the same code and version are not allowed; the same applies for multiple policies with the same gid and version.

Policy Identifiers

A policy can have multiple identifiers, for example the subscriber’s Social Security Number, an external identifier, a concatenation of a group account code and the subscriber’s identification etc.

A policy identifier has the following fields:

Table 2. Policy Identifiers
Field Description

Policy GID

The policy’s global unique identifier.

Policy identifier type

The type of identifier.

Identifier

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

Ind enabled?

Is the policy identifier enabled?

Policy Identifiers Type

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

A policy identifier type has the following fields:

Table 3. Policy Identifiers Type
Field Description

Code

Unique code of a policy identifier type

Display Name

The display name of the identifier type

Access restriction

The access restriction restricting access to the identifiers of the policy identifier type.

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 specified.

  • A concealment expression must be a valid regular expression.

Policyholder

A policyholder is the person who is legally accountable for the duties that stem from a policy. In case of health insurance often an employee is the policyholder, with the employee, spouse and children as insured persons on the policy. In case of a P&C insurance often the owner of the object is the policyholder. A policy has a single policyholder at any point in time, but the role of the policyholder can be transferred to another person.

Table 4. Policyholder
Field Description

Policy

The policy that the policyholder holds

Person

The person that holds the policy

Start Date

The start date of the policyholder

End Date

The end date of the policyholder

Constraints:

  • It is not allowed to have an overlap in time validity for policyholders with the same policy.

Policy Broker Agent

Brokers and agents are described in the Brokers and Agents section of this document. A policy has a single policy broker and/or agent at any point in time, but the policy can be transferred from one broker and/or agent to another.

Table 5. Policy Broker Agent
Field Description

Policy

The policy that the policy broker agent is intermediary for

Broker

The broker that serves as intermediary

Agent

The agent that serves as intermediary

Start Date

The start date of the policy broker agent

End Date

The end date of the policy broker agent

Constraints:

  • Either the broker or the agent must be specified

  • An overlap in time validity for policy brokers agents with the same policy is not allowed

Policy Calculation Period

A policy calculation period defines the premium calculation period for a specific policy. A policy can have one or more policy calculation periods.

Table 6. Policy Calculation Period
Field Description

Policy GID

The global unique identifier of the policy

Reference Date

The date that is used to evaluate time active variables in the calculation, such as the rate or the member’s age

Calculation Date

The date that is compared to the parameter date in the calculate premium activity to determine if the period is taken up for calculation. Periods having the same calculation date are considered to be part of a single collection cycle are calculated together.

Days

Number of days used to calculate premium for this period. Can be set to a fraction, for example, to achieve an even distribution of premium over periods that represent months.

Ind Generated?

Indicates if the policy calculation period is generated by the Generate Policy Calculation Periods activity

Ind Monthly

Indicates if the policy calculation period is generated by the collection setting having calculation period UoM as month or is unspecified (as the default behavior is month)

Pay Date

The payment due date

Start Date

The start date of the policy calculation period

End Date

The end date of the policy calculation period

PCP Span Start Date

The start date of the policy calculation period span

PCP Span End Date

The end date of the policy calculation period span

Constraints:

  • An overlap in time validity for group client collection settings with the same group client is not allowed

Policy Contract Period

A policy contract period specifies the length and the reference date of the policy’s contract. A policy can have one or more policy contract periods.

Table 7. Policy Contract Period
Field Description

Policy

The policy that has the contract period

Reference Date

The date that is used as a look-up date in premium calculation

Start Date

The start date of the contract period

End Date

The end date of the contract period

Constraints:

  • An overlap in time validity for policy contract periods with the same policy is not allowed

Policy Group Account

A policy group account specifies the group account a policy belongs to at a certain moment in time. Group Accounts are described in the Operations Guide.

Table 8. Policy Group Account
Field Description

Policy

The policy that belongs to the group account

Group Account

The group account the policy belongs to

Start Date

The start date of the time period the policy belongs to the group account

End Date

The end date of the time period the policy belongs to the group account

Constraints:

  • An overlap in time validity for policy group accounts with the same policy is not allowed

Policy Message

A policy message is the message that is stored during the processing of the policy. A policy can have one or more policy messages.

Table 9. Policy Message
Field Description

Policy

The policy that has the message

Message

The message that specifies severity and the static part of the message text

Value 0 through Value 9

The parts of the message text that are determined at run time

Process Step

The process step in which the message was attached to the policy

Policy Pend Reason

A policy may pend for external intervention, usually because a human operator needs to work on the policy before it can continue to be processed. Whenever a policy pends, one or more reasons are attached to that policy, explaining why the policy pended. Policy pend reasons store only the current pend reasons, that is, they are discarded once the policy is submitted after resolving pends. The full history of pend reasons is stored in a separate entity named 'Policy Pend History' (specified below).

Table 10. Policy Pend Reason
Field Description

Policy

The policy that is pended

Pend Reason

The pend reason that explains why the policy is pended

Process Step

The process step in which the pend reason was attached to the policy

Constraints:

  • It is not allowed to have multiple policy pend reasons for the same policy with the same pend reason and process step

Policy Status History

The policy status history keeps track of all status transitions, so that it is possible to trace back how a policy flowed through the processes and how long it took to complete certain steps within the process.

Table 11. Policy Status History
Field Description

Policy

The policy that has the status history

Gid

The global unique identifier of the policies that the history belongs to

Status

The status of the policy at date time

Date Time

Date and time when the policy entered the status

Policy Pend History

The reasons why a policy pended are stored as a detail of a policy status history that logs a Pended status.

Table 12. Policy Pend History
Field Description

Policy Status History

The policy status history under which the pend reason was active

Pend Reason Code

The code of the pend reason

Pend Reason Description

The description of the pend reason

Process Step Display Name

The display name of the process step in which the pend rule was executed

Process Step Sequence

The sequence of the process step

Pend Date Time

The date and time when the pend reason was attached

Resolved By

The user who resolved the pend reason

Resolved Date Time

The date and time when the pend reason was resolved

Policy Output History

The policy output history keeps track of all output that were generated for the policy or a person or object on the policy.

Table 13. Policy Output History
Field Description

Gid

The global unique identifier of the policies that the history belongs to

Version

The version of the policy

Status

The status of the policy

Insurable Entity

The person or object for which output was generated

Output Definition

The output definition for which output was generated

Cause

The cause of the generation (set to 'Periodic Output Generation', 'Manual Output Generation' or if applicable transferred from the cause of the mutation)

Generation Date Time

The date and time when the output was generated

Policy Bulk Update History

The policy bulk update history keeps track of all the bulk updates that are applied to a policy, so that it is possible to trace back who applied the update to the policy.

Table 14. Policy Bulk Update History
Field Description

Gid

The global unique identifier of the policies that the history belongs to

Version

The version of the policy

Bulk Update Definition

The bulk update definition in which policy was included

User

The user who applied the bulk update on the policy

Bulk Update Date Time

The date and time when the bulk update was applied

Policy Fee History

The policy fee history keeps track of all fees that were generated for the policy or a person or object on the policy.

Table 15. Policy Fee History
Field Description

Gid

The global unique identifier of the policies that the history belongs to

Version

The version of the policy

Status

The status of the policy

Insurable Entity

The person or object for which a fee was generated

Fee Definition

The fee definition for which a fee was generated

Cause

The cause of the generation (transferred from the cause of the mutation)

Generation Date Time

The date and time when the fee was generated

Policy Activities and Calculation Results

The premium calculation is started by executing an activity. A policy can have one or more policy activities. When executed, these activities create calculation results. The calculation result is a snapshot of the premium calculation process. It holds the outcome of a premium calculation at the policy level for a contract period. A calculation result can have one or more calculation result lines that are related to policy enrollment products. These entities are described in more detail in the Premium Calculation chapter of the Operations Guide.

Policy Events and Mutations

A policy event stores the information that a policy related change should lead to recalculation and/or regeneration of output which is then transferred into policy mutations. A policy can have one or more policy events and policy mutations. This is described in more detail in the Premium Calculation chapter in the Operations Guide.

Policy Enrollment

A policy enrollment specifies a person or object participating in a policy. A policy can have one or more policy enrollments.

Table 16. Policy Enrollment
Field Description

Policy

The policy that the person or object is enrolled to

Insurable Entity

The person or object that participates in the policy

Enrollment Type

The enrollment type that applies to the policy enrollment

Medicare Details

Related information about US Medicare Advantage that is optional for policy enrollment. See policy enrollment Medicare details for additional information.

Enrollment Type

An enrollment type specifies the enrollment of a person or object in a policy. Examples of enrollment types are Adult or Child.

Table 17. Enrollment Type
Field Description

Code

The code of the enrollment type

Display Name

Te display name of the enrollment type

Dynamic Fields

The non time valid dynamic fields defined to capture additional information about the enrollment type

Policy Enrollment Product

A policy enrollment product specifies a person or object being enrolled for a specific enrollment product on a policy. A policy enrollment can have one or more policy enrollment products. Enrollment products and group account products are described in the Operations Guide.

Table 18. Policy Enrollment Product
Field Description

Policy Enrollment

The policy enrollment that has the policy enrollment product

Enrollment Product

The enrollment product that the person or object is enrolled to

Group Account Product

The group account product that the person or object is enrolled to

Premium Amount

The amount of the premium that acts as override

Premium Amount Currency

The currency of the override premium amount (will be the same as the premium currency specified on the related enrollment product)

Commission Percentage

The percentage of the enrollment product premium that is paid out as commission to either the broker or agent

Commission Amount Interpretation

The way amounts are interpreted (per Calendar Year, per (system) Calculation Period or Specific (number of days))

Comm. No of Days

Number of days for which the commission is specified when Amount Interpretation Specific is chosen (must and may only be specified if the amount interpretation is Specific)

Commission Amount

The commission amount

Commission Amount Currency

The currency of the commission amount (is the same as the premium currency specified on the related enrollment product)

Medicare Details

Related information about US Medicare Advantage that is optional for policy enrollment product. See policy enrollment product Medicare details for additional information.

Start Date

The start date of the policy enrollment on a product

End Date

The end date of the policy enrollment on a product

Coverage Never In Force

Shows whether a policy enrollment product was never in force. If this indicator is checked, the policy enrollment product is excluded from calculations.

Coverage Never In Force Reason

The reason for a policy enrollment product to be never in force.

Constraints:

  • If the policy belongs to a Group Account, specify a Group Account Product for the specific Group Account. Else, specify an Enrollment Product.

  • When choosing a Group Account or a Policy Enrollment Product, the product must fall within the coverage period of the Policy Group Account.

  • Time validity cannot overlap for Policy Enrollment Products with the same Policy Enrollment, Enrollment Product, and Group Account Product.

  • Cannot specify both commission Amount and Percentage.

  • A Coverage Never In Force Reason is required when a policy enrollment product is checked as being never in force.

Coverage Never In Force Reason

A coverage never in force reason explains why a coverage was never in force.

Field Description

Code

The code of the coverage never in force reason

Description

The description of the coverage never in force reason

Policy Add-on

A policy add-on specifies a person or object being enrolled for a specific add-on to an enrollment product on a policy. A policy enrollment product can have one or more policy add-ons. Add-ons are described in the Configuration Guide.

Table 19. Policy Add-on
Field Description

Policy Enrollment Product

The policy enrollment product that has the add-on

Add-on

The add-on that the person or object has

Start Date

The start date of the add-on

End Date

The end date of the add-on

Constraints:

  • An overlap in time validity for policy add-ons with the same policy enrollment product and add-on is not allowed

  • Specify an add-on that is not configured on the enrollment product or group account product is not allowed

Policy Enrollment Insurable Class

A policy enrollment insurable class specifies a person or object being enrolled on a policy in a specific role, for example spouse or dependent Insurable Class and Enrollment products are described in the Operations Guide.

Table 20. Policy Enrollment Insurable Class
Field Description

Policy Enrollment

The policy enrollment in which the person or object is enrolled

Insurable Class

The insurable class in which the person or object is enrolled on the policy

Start Date

The start date of the enrollment in a specific role

End Date

The end date of the enrollment in a specific role

Constraints:

  • Only one policy enrollment insurable class can be valid at a certain moment in time.

Parameter Value

A policy enrollment product can have one or more parameter values for parameter aliases. The parameter alias serves as a reference for providing a name for a parameter. The parameter aliases are described in the Schedule Definition page in the Premium and Fees Configuration of the Configuration Guide. The parameter value is the value of a parameter alias in the context of a policy enrollment product.

When a schedule dimension is of the type parameter, the parameter alias provides the name to the dimension and its dimension values are evaluated against the parameter values.

A parameter value has the following attributes:

Table 21. Parameter Value
Field Description

Parameter Alias

The parameter alias

Start Date

The start date of the validity of the parameter value for the policy enrollment product

End Date

The end date of the validity of the parameter value for the policy enrollment product

Policy Enrollment Product

The policy enrollment product to which the parameter value applies

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 currency that is specified on the parameter alias)

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)

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

Policy Collection Settings

A policy collection setting specifies how often the premium is collected. A policy can have one or more policy collection settings.

Table 22. Policy Collection Settings
Field Description

Policy

The policy that has the collection setting

Span Reference Date

The date to determine the start of a span of calculation periods

Advance Length

Length of a span of calculation periods

Advance UoM

Unit of measure for a span of calculation periods (Days / Months / Years)

Policy Calculation Periods

Indicator that defines whether policy specific calculation periods are used in this policy

Policy Calculation Period Length [1]

Length of the generated calculation periods

Policy Calculation Period UoM ![1]]

Unit of measure for the generated calculation periods (Days / Months / Years)

Collection Method

The reference to the method of collection, for example, direct debit, invoice based

Start Date [2]

The start date of the collection setting

End Date

The end date of the collection setting

Constraints:

  • An overlap in time validity for policy collection settings with the same policy is not allowed

  • Both Advance Length and Advance UoM (unit of measure) have to be set or both have to be unspecified

  • Both Policy Calculation Period Length and Policy Calculation Period UoM (unit of measure) have to be set or both have to be unspecified

Policy Billing Accounts

A policy can have one or more policy billing accounts. A policy billing account is an account that is used for billing purposes on a policy. The allocation of a bill to a policy billing account is configured within the policy premium bill allocations and bill receivers setup (described in the Policy Premium Bill Allocations section).

Table 23. Policy Billing Accounts
Field Description

Policy Gid

The global unique identifier of the policy that the billing account belongs to (a policy billing account does not belong to a specific version of a policy; it applies across policy versions)

Code

The code of the policy billing account (unique across billing accounts)

Description

The description of the policy billing account

Billing Contact

The billing contact (relation) for the billing account

Default?

Is this the default billing account for the policy? (if set to Yes, this billing account will be the default bill receiver if not specified otherwise on the Policy Premium Bill Allocations and Policy Bill Receivers)

Constraints:

  • There can be only one default billing account for a policy

  • A policy billing account must refer to an existing policy gid

Policy Premium Bill Allocations

A policy can have one or more policy premium bill allocations. A policy premium bill allocation stores the specification on how to allocate the premium bill on an individual policy.

Table 24. Policy Premium Bill Allocations
Field Description

Policy

The policy that has the policy premium bill allocation

Insurable Class

The insurable class for which the policy premium bill allocation is defined

Schedule Definition

The schedule definition for which the policy premium bill allocation is defined

Premium Schedule Type

The type of premium schedules for which the policy premium bill allocation is defined

Enrollment Product

The enrollment product for which the policy premium bill allocation is defined

Enrollment Product Category

The enrollment product category for which the policy premium bill allocation is defined

Add-on

The add-on for which the policy premium bill allocation is defined

Start Date

The start date of the policy premium bill allocation

End Date

The end date of the policy premium bill allocation

Active

Is the premium bill allocation currently active?

Constraints:

  • An overlap in time validity for policy premium bill allocations with the same policy, insurable class, schedule definition, premium schedule type, enrollment product, enrollment product category and add-on is not allowed

  • Only one of enrollment product or enrollment product category can be specified

  • Only one of schedule definition, premium schedule type or add-on can be specified

Policy Bill Receiver

A policy premium bill allocation can have one or more policy bill receivers. The policy bill receiver defines who pays what percentage of the policy premium.

Table 25. Policy Bill Receiver
Field Description

Policy Premium Bill Allocation

The policy premium bill allocation that applies

Relation

The relation (person or organization) that is the bill receiver

Billing Account

The billing account that is the bill receiver (this can be a billing account of the policy or a billing account of the group client in context)

Percentage

The percentage of the premium that this bill receiver has to pay

Constraints:

  • A relation or a billing account (only one) must be specified

Brokers and Agents

A broker is a company that serves as an intermediary between the payer and the policyholder. An agent is an employee of a broker company.

Broker

Table 26. Broker

Field

Description

Code

The unique key that is used to identify the broker

Name

The name of the broker

Broker Address

A broker can have one or more addresses.

Table 27. Broker Address
Field Description

Broker

The broker that has the address

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

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 , for example, States and Departments)

Additional Part 1

Used for additional (country specific) address information

Additional Part 2

Used for additional (country specific) address information

Additional Part 3

Used for additional (country specific) address information

Start Date

The start date of the address

End Date

The end date of the address

Constraints:

  • An overlap in time validity for addresses for the same broker is not allowed

  • 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 must be entered in uppercase

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

Agent

Table 28. Agent

Field

Description

Code

The unique key that is used to identify the agent

Initials

The abbreviation of the first names of the agent

First Name

The first name of the agent

Middle Name

The middle name of the agent

Prefix

The prefix to the last name of the agent

Name

The last name of the agent

Suffix

The suffix of the agent

Gender

The gender of the agent

Agent Address

Agents can have one or more addresses. The same model (including the constraints) applies as for brokers.

Attached Policy Data

Attached policy data provides the ability to write additional information to a policy without affecting its status, so no re-processing is needed. Examples are fields that reflect the policyholder’s payment status.

The information that is written to an attached policy data is the process information related to enrollment that may play a role in the finalization of a policy, but the information lifecycle of the attached data has no (retro)active consequences of premium calculations and or output. This information does not introduce the need for reprocessing the policy. Without the existence of attached policy data, adding information to an approved policy would lead to the creation of a new policy version and the need for reprocessing.

The attached policy data entity serves as an umbrella for dynamic records and dynamic fields that can be configured at the user’s discretion. The entity itself does not have any attributes that are exposed to the user.

Table 29. Attached Policy Data
Fields Description

Policy Gid

The global unique identifier of the policies that the attached policy data belongs to

Manual?

Did the policy enter the system through manual entry? (note that this indicator is automatically set, and is not visible in the user interface)

Ignore Bulk Update?

If checked, this policy is automatically excluded from bulk updates, unless the bulk update definition is configured to ignore this indicator.

Date Paid To

The date up to which the coverage is purchased

Disable Update From Queue?

Checking the box ensures that the long-running process avoids applying any policy update requests to the policy.

Transaction Reply Report

The optional policy transaction reply report (TRR) keeps track of the incoming transaction replies from the Centers for Medicare and Medicaid Services (CMS). See TRR for additional information.

Dynamic Fields and Records

The dynamic fields and records defined to capture additional information about the policy

The attached policy data record is created automatically along with the policy. The attached policy data can be manipulated through the Attached Data IP or through the View and Edit Policy page. Attached policy data is also accessible from the dynamic logic (through the policy object).

Notes

Notes are used to maintain a record of history of policies. Furthermore, the document discussions, conversations, actions carried out and advice given to policyholders can be recorded in the form of notes. A policy can have one or more notes.

Table 30. Notes
Field Description

Policy Gid

The global unique identifier of the policy that the note belongs to

Version

The version of the note (when an existing note is updated a new version of that note containing the updates is created; existing records of notes are never updated)

Note Text

The text of the note

Policy Enrollment Event

Policy Enrollment event holds the history of changes that were applied to a policy.

Table 31. Policy Enrollment Event
Fields Description

Policy Gid

The global unique identifier of the policy that the enrollment event belongs to.

Policy Code

The policy for which the event is raised

Policy ID

Reference to the policy (version) for which the event is created

Relation ID

Reference to the relation for which the event is raised

Descr

The description of the enrollment event.

Change Details

JSON object that explains the changes that lead to this event.

Event Datetime

The date and time of the enrollment event.

Activity ID

The id of the activity that was a part of the enrollment event.

Enrollment Event Type

The type of the event (Message, Change, Time Valid Change or Business).

Business Event Definition

Reference to a business event definition (only for policy enrollment events of type Business)

Value0 .. Value9

Substitution parameters for the display text in business event definition

Recalculate?

Was a policy event of type Recalculation created along with the policy enrollment event of type Business?

Effective Date

The effective date for the policy event (only applicable when indicator Recalculate is set to true).

Policy Accounts

Policy accounts provide the ability to store savings based on a policy.

Policy Account

Table 32. Policy Account
Fields Description

Account Number

The account number of the policy account

Policy GID

The GID to which the policy account belongs to
Note that the policy account does NOT refer to the policy version.

Policy Account Definition

The policy account definition for this account

Person

The person for whom the account is set up

Dynamic Fields

The time valid dynamic fields defined to capture additional information about the policy account

Policy Account Definition

Table 33. Policy Account Definition
Fields Description

Code

The code of the policy account definition

Descr

The description of the policy account definition

Display Name

The display name of the policy account definition

Period

The period of the policy account definition

Account Level

The level of the policy account definition

Currency

The currency to be used for policy accounts of this definition

Function Dynamic Logic

The dynamic logic function that defines how to generate an account number for the policy account

Function Dynamic Logic

The dynamic logic function that defines how to generate a transaction number

Function Dynamic Logic

The dynamic logic function that defines how to generate a general ledger event

Dynamic Fields

The time valid dynamic fields defined to capture additional information about the policy account definition

Enrollment Product Account Definition

Table 34. Enrollment Product Account Definition
Fields Description

Enrollment Product

The enrollment product

Account Definition

The account definition

Autocreate Account?

Is a policy account of this definition automatically created for this enrollment product?

Policy Account Transaction

Table 35. Policy Account Transaction
Fields Description

Code

The code of the policy account transaction

Descr

The description of the policy account transaction

Transaction Datetime

The date of the transaction

Amount

The amount of the transaction

Reversed?

Is the transaction reversed?

Reversal Datetime

The date the transaction was reversed

Currency

The currency of the transaction

Policy Account Transaction Type

The policy account transaction type of the transaction

Person

The person for whom the transaction is.
This field is, for example, to be used if the account definition is on Policy level but the person for whom an amount is used must be stored for documentation purposes

Dynamic Fields

The non time valid dynamic fields defined to capture additional information about the policy account transaction

Policy Account Transaction Type

Table 36. Policy Account Transaction Type
Fields Description

Code

The code of the policy account transaction type

Descr

The description of the policy account transaction type

Manual?

Are transactions for this transaction type entered manually?

Create GL Event?

Should a transaction of this type lead to a GL event?

Dynamic Fields

The time valid dynamic fields defined to capture additional information about the policy account transaction type

Enrollment File

Enrollment File

The Enrollment File represents a list of all policies that are associated with an enrollment file. This entity holds information like filename, status of the file, several counts, and the dates the status changed. The purpose of this entity is to provide an umbrella entity that facilitates the visibility of which policy versions are associated with a particular file.

Table 37. Enrollment File
Fields Description

File Name

The name of the file

Descr

The description of the file

Status

The status of the file

Group Client

Optional reference to the group client

Total Policy Count

The total number of policies in the file

Total Enrollment Count

The total number of policy enrollments in the file

Received Policy Count

The number of policies received, associated with this file

Received Enrollment Count

The number of policy enrollments received, associated with this file

Expected Date

The date the file is expected to be loaded in the system

Loaded Date

The date the file is loaded in the system

Pended Date

The date the file is pended

Approved Date

The date the file is approved

Canceled Date

The date the file is canceled

Dynamic Fields

The dynamic fields defined to capture additional information about the policy account transaction type

The difference between the Total Count and the Received Count reflects the number of policies that never make it into the application. This accounts for the fact that files are typically filtered in EDI pre-processing.

For example, a file with 1000 policies is filtered down to only 200 policies with actual updates. The data file set received would then only contain 200 policies. In this scenario the total count is 1000 and the received count is 200.

The possible statuses are:

Table 38. Possible Statuses
Status Meaning

Accepted

The file has been either auto-accepted or has been accepted by a user

Rejected

The file has been rejected by a user

Pending Review

The file has not yet been accepted or rejected

Enrollment File Policy

Table 39. Enrollment File Policy
Fields Description

Enrollment File

Reference to enrollment file

Person Count

Number of policy enrollments

Policy Code

The code of the policy

Version

The version of the policy

Policy ID

The identifier of the policy

Policy Update Requests

The Policy Update Request represents a list of policy updates received from the Policy Update Request Integration Point.

Policy Update Request

Table 40. Policy Update Request
Fields Description

Policy Gid

The globally unique identifier of the matched policy

Policy Version

The policy version for the update

Enrollment File

A reference to enrollment file

Data File Sequence

An incremental integer representing the sequence of the request within the data file

Line Of Business

A reference to the Line of Business

Brand

Reference to the Brand

Group Client

A reference to the Group Client

Group Account

A reference to the Group Account

Data Access Group

A reference to the Data Access Group

Mime Type

The media type of the update request payload

Payload

The payload in the update request

Data File Set

A reference to the dataFileSet

Submit Policy?

Submit policy after applying the update?

Process Status

The current processing status for the update request

Last Processed Date Time

The timestamp when the payload was used to update the policy

Processed Manually?

Was the update applied by a user or system?

Last Update Failed?

Shows if the process failed when applying the update request

Policy Identifier Type

A reference to the Policy Identifier Type

Matched Policy Code

The code of the matched policy based on the policy identifier from the payload

Policy Update Request Status History

A reference to the policy update request history

The possible process statuses are:

Table 41. Policy Update Request: Possible Status
Status Meaning

Initial

Update request received and is ready to be queued

Queued

The update request is queued and ready to be applied

Rejected

The update request is rejected and is ignored when applying the updates from the queue

Loaded

The update request has successfully been applied to a policy, pending processing

Failed

The update request failed when applying to the matched policy

Processed

The update request was processed successfully

Processed No Update

The update request was processed successfully, but the update request included no changes for the policy

Processed Notification Sent

When the external system is notified and the policy is reverted because of an enrollment event notification

Policy Update Request Status History

Table 42. Policy Update Request Status History
Fields Description

Policy Update Request

Reference to policy update request

Process Status

The current processing status for the update request

Processed Date Time

The timestamp when the payload was used to update the policy

Processed Manually?

Was the update applied by a user or system?

Policy Update Request Error Details

A reference to the error message, if any.

Policy Update Request Error Details

Table 43. Policy Update Request Error Details
Fields Description

Message

Reference to the message

Value0 .. Value9

Substitution parameters for the display text for the message

Policy Update Request History

Reference to the policy update request history

Enrollment Event Notification

The Enrollment event notification represents the list of notifications created and sent on the generation of business events against the policy enrollment events.

Table 44. Enrollment Event Notification
Fields Description

Correlation ID

Unique identifier of a notification

Policy Gid

The globally unique identifier of the matched policy

Notification Status

The current processing status for the notification

Obsolete?

Indicates if the notification is obsolete or not.

  • Yes

  • No

Request Headers

To store the headers of the outbound in the form of a JSON payload

Notification Payload

To store the payload generated in related Policy Enrollment Event

Notification Definition

Reference to notification definition

The possible enrollment event notification statuses are:

Table 45. Enrollment Event Notification Statuses
Status Meaning

Ready

Notification is generated and ready to be sent

Sent

Notification sent to external system

Failed

Failed to send notification due to technical errors

Waiting for policy approval

Notification created but not sent out as it is waiting for policy to get to approved status

Cancelled

Notification manually cancelled by the user when it is in the status failed or Waiting for policy approval

Response Received

Sent notifications which got a response.

Rejected

Sent notifications which got rejected.

Refer Enrollment Event Notifications for more information on processing of notifications.

Policy Update Request Notification

The Policy update request notification links enrollment event notifications to the respective policy update requests.

Table 46. Policy Update Request Notification
Fields Description

Enrollment Event Notification

Reference to the enrollment event notification

Policy update request

Reference to the policy update request(s) from which the enrollment event notification is generated
1. When unspecified for a collection setting with the indicator policy calculation period set to 'Yes', the system considers policy calculation period length and UoM as 1 Month.Note - Modifying the collection setting after policy calculation period generation may result in inconsistency, it is recommended that periods are re-generated if the collection setting is modified.
2. With negative calculation date offset - The collection setting must start on or before the span reference date + calculation date offset. This is to ensure that system finds a valid collection setting to generate periods when the calculation date is set to be before the period start date.