Parametrized Cover Withhold Category Scenario

This scenario shows us a service definition that is covered in full and a second one containing a copay counting towards a deductible.

Building Blocks

In addition to many other (types of) configuration items consider the following items being sent in through the Building Blocks Integration Point.

• Three cover withhold categories: copay, covered and deductible

• A coverage regime that references two of the three cover withhold categories: a deductible and a copay

• Another coverage regime that references the remaining cover withhold category: covered

• A single limit: an insurable entity deductible

The following building blocks are in the received file:

  <content>
    <coverWithholdCategory
      uuid
      code COPAY
      description Copay
    >
    <coverWithholdCategory
      uuid
      code COVERED
      description Covered
    >
    <coverWithholdCategory
      uuid
      code DEDUCTIBLE
      description Deductible
    >

  <content>
      <coverageRegime
        uuid
        code CP_DEDUC
        description Copay and Deductible Regime
        indActive Yes
          <coverageRegimeParameters
            <coverageRegimeParameter
              coverWithholdCategoryCode COPAY
          >
            <coverageRegimeParameter
              coverWithholdCategoryCode DEDUCTIBLE
          >
      >
      <coverageRegime
        uuid
        code CIF
        description Covered in Full
        indActive Yes
          <coverageRegimeParameters
            <coverageRegimeParameter
              coverWithholdCategoryCode COVERED
          >

  <content>
    <limit
      uuid
      code INS_DED_OUT
      description Insurable Entity Deductible out of network
      type Amount
      >

Accumulation Options

Using the imported building blocks, the following accumulation option can be created:

Count	Towards	When Reached
DEDUCTIBLE	INS_DED_OUT	Stop

This accumulation option has the following meaning.

• Withhold any amounts labelled as DEDUCTIBLE and count them towards the limit INS_DED_OUT. When the limit is reached, stop withholding DEDUCTIBLE amounts.

Cover Withhold Categories

Three cover withhold categories were created by the integration point. For each one the user needs to indicate if it can be parametrized within OHI Product Definition.

Code	Description	Type
COPAY	Copay	Amount
COVERED	Covered
DEDUCTIBLE	Deductible

Choosing a type for a cover withhold category tells the application that the category is a settable parameter. This setup means: * The amount of COPAY that needs to be paid by the insured can vary between services. The exact dollar amount will need to be specified by the user when building a product. * The cover withhold category COVERED is used on rules that cover 100% of the allowed amount. Since it’s always going to be 100% on every product, there is no reason to make it a settable parameter. So the type field is left empty. * The cover withhold category DEDUCTIBLE is used on rules that fully withhold - 100% - payment until the deductible limit is met. Again, this is true for any product so there is no reason to make the percentage a settable parameter. The type field is left empty.

Parameter Aliases

The next step is to define aliases for the limit and the cover withhold category that can be parametrized.

Code	Display Name	Cover Withhold Category	Limit
OV_COPAY	Office visit copay	COPAY
ER_COPAY	Emergency room copay	COPAY
INS_DED_OUT	Insurable Entity Deductible out of network		INS_DED_OUT

Notice that two aliases have been set up for the cover withhold category COPAY. This allows the user to pick and choose which copay applies for a particular service. This matters because the two copays have different dollar amounts associated with them.

Service Options, Services and Service Definitions

These three objects define the medical service, for example:

• Service Option: Physician Services

• Service: Routine Eye Exam

• Service Definition: Professional

The service definition contains the procedures, diagnoses, location types and cases that define the actual medical service.

Product Service Definitions

Initial setup

In this step of the configuration process the user determines how each service definition will be covered within the context of the product. Consider the following table, containing a selection of the fields that can be configured for a product service definition.

A column appears for each cover withhold category that has a type. In this example that means the application shows an additional column called "Copay".

Service	Service Definition	Type	Network	Regime	Copay	Insurable Entity Limits
Routine Eye Exam	Professional	Cover
Routine Eye Exam	Professional	Cover

Selecting a Coverage Regime

Whenever the user fills out a coverage regime, the system checks what kind of rules the regime contains. If the regime contains a rule that matches one of the categories that require an amount or percentage, a drop down menu appears. In the example the following applies:

• Routine eye exams received though an in network provider are covered in full. This coverage regime does not include a COPAY rule so no drop down menu will appear in the "Copay" column

• Routine eye exams received though an out of network provider apply a copay and a deductible. They are covered through a coverage regime that contains a COPAY and a DEDUCTIBLE rule. The system detects the COPAY rule and reveals a menu that allows the user to choose which copay applies (the Office visit copay or the Emergency room copay). The user selects the Office visit copay

Service	Service Definition	Type	Network	Regime	Copay	Insurable Entity Limits
Routine Eye Exam	Professional	Cover	In	CIF
Routine Eye Exam	Professional	Cover	Out	CP_DE	Office visit copay

Adding a Limit

The coverage regime for the routine eye exam received through an out of network provider also contains the cover withhold category deductible, indicating that first all payments are withheld until a deductible limit is met and any payments after that will have a co-payment. The next step is to indicate that the deductible in the coverage regime must count towards the insurable entity deductible limit. This is already configured as an accumulation option. By adding this accumulation option to the product service definition, the limit will now apply in the context of the product service definition. This is visible in the user interface as follows:

• The insurable entity limits column is updated and displays the INS_DED_OUT limit

Service	Service Definition	Type
Network	Regime	Copay
Insurable Entity Limits	Routine Eye Exam	Professional
Cover	In	CIF
		Routine Eye Exam
Professional	Cover	Out
CP_DE	Office visit copay	INS_DED_OUT

Parameter Values

After configuring product service definitions, the next step is to set parameter values. For this scenario the application requires a value for the following two parameters:

• Office visit copay

• Insurable Entity Deductible out of network

Notice that it does not require a value for the 'Emergency room copay'. This is because in our scenario we haven’t configured any service definition that requires this particular copay. So two parameter values can be set for this product.

Parameter Alias	Value	Type
Office visit copay	20	Amount
Insurable Entity Deductible out of network	1000	Amount

In the example scenario only a single product service definition uses these values. But any parameter values defined apply to all product service definitions that have a usage for the alias.