Regimes

In OHI Claims Adjudication and Pricing, a coverage regime specifies the extent to which the allowed amount for a claimed health care service is paid for by the health care payer. An authorization regime specifies when an authorization is needed for the consumption of a health care service. A waiting period regime defines when a waiting period is needed and how long it will be. A reservation regime specifies the function that is used to match a claim line to a reservation line. A post benefits regime is unique combination that defines how much is covered or withheld through coordination of benefits. The system of record for regimes is OHI Claims Adjudication and Pricing. Regimes are imported into Oracle Health Insurance Product Definition as building blocks used when configuring product service definitions. Oracle Health Insurance Product Definition only imports the descriptive attributes of the regimes and the cover withhold categories used by the coverage regime. For each regime, regardless of its type, the following values are stored in each entity (coverage regime, authorization regime, reservation regime, waiting period regime, post benefits regime).

Field	Description
UUID	Unique identifier across OHI modules
Code	The code for this regime
Description	The description of the regime
Active Indicator	Indicator if new references can be created to the regime

The coverage regime parameters entity lists all the cover withhold categories that are used within the coverage regime, regardless if it can be parametrized or not.

Field	Description
Coverage Regime	A reference to the coverage regime
Cover Withhold Category	A reference to the cover withhold category