Product Entity Model

A product represents a set of healthcare benefits that apply to members enrolled on that product, either directly or through a group contract.

Products are created and maintained in Oracle Health Insurance Product Definition.

Product

Table 1. Product
Field	Description
Code	The code of the product
Description	The description of the product
Status	The status of the product (Edit, Queued, Review, Test, Approved)
Brand	A reference to the brand
Priority	A reference to the product priority. Determines in which order product benefits are applied in a scenario where a person or object is subscribed to two or more products
Aggregation Level	The aggregation level of the product
Product Line	A reference to the product line
Product Family	A reference to the product family
Funding Arrangement	A reference to the funding arrangement
Currency	The currency for amount fields in parameter values
Template?	Indicates if the product can be used to make product copies
Changed?	Indicates if the product has been changed since the last export of that product
Default Start Date	Any product service definition created in context of the product will have its start date set to this value
Validation Status	Indicates the result of the product validation process
Build Number	Integer that is incremented by 1 for each successful build

Product Limit Renewal Period

A product limit renewal period defines the renewal behavior of a limit in context of a product in a specific time period and applies to all the limits referenced by a product service definition contained in the product. A product limit renewal period is converted into a product limit during the product build process. If no product limit renewal period is specified for a limit, no product limit will be created. In this situation OHI Claims will use the renewal and other product’s carryover behavior specified on the limit whenever that limit is used in a product benefit specification.

Table 2. Product Limit Renewal Period
Field	Description
Product	A reference to the product
Limit	A reference to the limit
Renewal Period	Number of days, months or years after which the limit renews
Renewal Period Unit of Measure	The renewal period is counted in days, months or years
Reference	The date that the limit renews (on calendar year or on plan year)
Carry Over Period	Number of days, months or years for carryover
Carry Over Period Unit of Measure	The carryover period is counted in Days, Months or Years
Other Products Carry Over Period	Number of days, months or years for carryover of other products
Other Products Carry Over Period Unit of Measure	The other products carryover period is counted in Days, Months or Years
Start Date	The start date of the product limit renewal period
End Date	The end date of the product limit renewal period

The following business rules are enforced for product limit renewal periods:

The end date may not lie before the start date
Product limit renewal periods may not overlap in time for the same limit and product
The (other products) carryover period length and UoM should both be filled or both be left empty

Product Provider Group

Product provider groups represent the network of providers associated with a product. Product provider groups work in conjunction with the product service definition field "product provider group scope". Consider a scenario where a user configures two product service definitions, both having different benefits. The first applies only to claim lines for which the benefits provider is IN scope of at least one of the product provider groups, the second applies only when the benefits provider is OUT of scope for all of the product provider groups.

Table 3. Product Provider Group
Field	Description
Product	A reference to the product
Provider Group	A reference to the provider group
Assigned Provider Group Label	The qualifying label for the assignment of the provider group (if specified Claims will use the policy product provider group(s) with a matching assignment label when determining network status in the claims flow)
Start Date	The first day the provider group is part of the product
End Date	The last day the provider group is part of the product

The following business rules are enforced for product provider groups:

The end date may not lie before the start date
Product provider groups may not overlap in time for the same product, provider group and assigned provider group label
At least one of provider group and assigned provider group label must be specified

Parameter Value

A parameter alias allows the user to specify a parameter value in context of a product for a parameter alias, such as the height of a deductible limit that applies across all benefits specifications that use that deductible limit or the height of the copay that applies to all benefit specifications that use a coverage regime containing a copay that can be parametrized.

Table 4. Parameter Value
Field	Description
Parameter Alias	The parameter alias that the value applies to
Amount	The maximum amount of the limit / The amount per unit to be used in a cover withhold rule
Currency	The currency of the amount (it will automatically be set to the currency that is specified on the product)
Number	The maximum number of the limit
Service Days	The maximum service days of the limit
Percentage	The percentage to be used in a cover withhold rule
Product	Reference to the product from where the parameter value was set
Start Date	Start date of the parameter value for the combination of the product and the parameter alias
End Date	End date of the parameter value for the combination of the product and the parameter alias

The following business rules are enforced for parameter values:

The end date may not lie before the start date
Parameter values may not overlap in time for the same parameter alias and product

Product Line

Product lines, product families and funding arrangements are configurable dimensions on the product. Although these are commonly set on a product for informational purposes, they can serve as a trigger on the claims engine, for example, to exclude a certain benefit for a particular funding arrangement.

Table 5. Product Line
Field	Description
Code	The unique code of the product line
Description	The description of the product line

Product Family

Table 6. Product Family
Field	Description
Code	The unique code of the product family
Description	The description of the product family

Funding Arrangement

Table 7. Funding Arrangement
Field	Description
Code	The unique code of the funding arrangement
Description	The description of the funding arrangement

Product Service Option

Product service options are created and maintained in Oracle Health Insurance Product Definition. They represent the inclusion of a service option into a product. A service option can contain multiple services.

Table 8. Product Service Option
Field	Description
Product	A reference to the product
Service Option	A reference to the service option

The following business rule is enforced for Product Service Options:

When a Product Service Option is removed, associated Product Services are also deleted i.e. which share the same Service Option

Product Service

Product services are created and maintained in Oracle Health Insurance Product Definition. They represent the inclusion of a service into a product. A service can contain multiple service definitions.

Table 9. Product Service
Field	Description
Product	A reference to the product
Service	A reference to the service

Product Service Definition

Product service definitions are created and maintained in Oracle Health Insurance Product Definition. They represent the time valid inclusion of a service definition into a product. Attributes affecting the cost share of the benefit specification are defined on the product service definition.

Table 10. Product Service Definition
Field	Description
Product	A reference to the product
Service Definition	A reference to the service definition
Start Date	Start date of the inclusion of the service definition in the product
End Date	End date of the inclusion of the service definition in the product
Gender	The gender a person must have for this product service definition to be applicable
Age From	The minimum age a person can have for this product service definition to be applicable
Age To	The maximum age a person can have for this product service definition to be applicable
Product Provider Group Usage	The scope of the provider groups of the product, in, out or either
Provider County Region Usage	Determines whether the listed region or group is required for or excluded from the product service definition
Provider Country Region	The benefit only applies if the provider is based in the referenced region
Provider Country Region Group	The benefit only applies if the provider is based in the referenced group of regions
Person Country Region Usage	Determines whether the listed region or group is required for or excluded from the product service definition
Person County Region	The benefit only applies if the person is based in the referenced region
Person County Region Group	The benefit only applies if the person is based in the referenced group of regions
Employer County Region Usage	Determines whether the listed region or group is required for or excluded from the product service definition
Employer County Region	The benefit only applies if the employer is based in the referenced region
Employer County Region Group	The benefit only applies if the employer is based in the referenced group of regions
Specific Provider Group Usage	The scope of the specific provider groups, in or out
Product Service Definition Provider Group	A reference to the code of a specific provider group
Product Service Definition Priority	A reference to the priority of the product service definition
Authorization Regime	A reference to the applied authorization regime
Coverage Regime	A reference to the applied coverage regime
Waiting Period Regime	A reference to the applied waiting period regime
Reservation Regime	A reference to the applied reservation regime
Post Benefits Regime	A reference to the applied post benefits regime
Indicator Authorization Missing	Indication if this is a (coverage) product service definition that applies if no authorization was found
Condition	A reference to a dynamic logic condition
Indicator Marked for Selection	Is this product service definition marked by the user in the All Product Service Definitions page?
Indicator New	Is this product service definition marked as new the in the All Product Service Definitions page?

The following business rules are enforced for product service definitions:

Either a country region or a country region group can be specified for an employer, person or provider, but not both.
The country region usage for an employer, person or provider must be specified when a country region or a country region group is used and may not be specified when these are not used.
The specific provider group usage must be specified when a product service definition provider group is used and may not be specified when these are not used.
The indicator authorization missing can only have a value if the service definition is of type "Coverage".
Age from should not be larger than age to.
The end date may not lie before the start date.
If the service definition that is referenced by the product service definition has a gender specified, then the gender field on the product service definition must be empty.
If the service definition that is referenced by the product service definition has an age from or age to specified, then the both the age from and the age to fields on the product service definition must be empty.

Selected Accumulation Option

Selected accumulation options indicate to which limits a product service definition counts. An accumulation option is a combination of a cover withhold category, a limit and a reached action. For example: the cover withhold category "Deductible" counts towards the limit "In-Network Insurable Entity Deductible" and stops counting when the limit is reached.

Table 11. Selected Accumulation Option
Field	Description
Product Service Definition	A reference to the product service definition
Accumulation Option	A reference to the accumulation option

The following business rules are enforced for Selected Accumulation Options:

Parameter Alias Usages for the limit linked to the Accumulation Option is also added when a new Accumulation Option is added for a Product Service Definition
when a Selected Accumulation Option is removed, the parameter Alias Usage for the limit associated with the accumulation option is also removed (if the limit is not applicable for any other selected accumulation option)

Parameter Alias Usage

The Parameter alias usage defines an alias for a parameter in the context of a product service definition. Whenever a parameter alias is selected (by the user or by the application depending on the number of defined aliases) this then indicates that the product service definition will use that parameter alias (and its associated parameter value) for a limit or a cover withhold category.

Table 12. Parameter Alias Usage
Field	Description
Product Service Definition	A reference to the product service definition
Parameter Alias	A reference to the parameter alias
Limit	A reference to the limit
Cover Withhold Category	A reference to the cover withhold category

Product Service Definition Provider Group

Product service definition provider groups represent the network of providers associated with a product service definition. Product service definition provider groups are provider groups codes (and not foreign keys). When building a product, the provided codes are matched against the existing provider groups.

Product service definition provider groups work in conjunction with the product service definition field "specific provider group scope". Consider a scenario where a user configures two product service definitions, both having different benefits. The first applies only to claim lines for which the benefits provider is IN scope of at least one of the product service definition provider groups, the second applies only when the benefits provider is OUT of scope for all of the product service definition provider groups.

Table 13. Product Service Definition Provider Group
Field	Description
Product Service Definition	A reference to the product service definition
Provider Group Code	Contains the provider group code, either picked from the existing codes from the provider group entity or a new code
Assigned Provider Group Label	The qualifying label for the assignment of the provider group (if specified Claims will use the policy product provider group(s) with a matching assignment label when determining network status in the claims flow)

The following business rules are enforced for product service definition provider groups:

At least one of provider group code and assigned provider group label must be specified

Product Message

Product messages represent the result of product validation. For each validation error that is encountered a product message is logged. Next to references identifying the product and the message the entity contains all the placeholder values for the parts of the message that are variable.

Table 14. Product Message
Field	Description
Product	A reference to the product
Message	A reference to the message
Message placeholders	Up to ten message placeholders

Product Benefit Specification

Product benefit specifications are created and maintained in Oracle Health Insurance Product Definition. The product benefit specification defines the time valid inclusion of a benefit specification in the product. Product benefit specification are created by the build product function.

Table 15. Product Benefit Specification
Field	Description
Product	A reference to the product
Benefit Specification	A reference to the benefit specification
Start Date	Start date of the inclusion of the benefit specification in the product
End Date	End date of the inclusion of the benefit specification in the product

Product Benefit Specification Value

A product benefit specification value defines which value (that is an actual amount or percentage) is defined for a cover withhold category within a specific product benefit specification; this value is used in the cover withhold rules that refer to the cover withhold category. They are derived from the parameter values and parameter alias usages during the build of a product.

Table 16. Product Benefit Specification Value
Field	Description
Product Benefit Specification	A reference to the product benefit specification
Cover Withhold Category	A reference to the cover withhold category
Amount Per Unit	The amount per unit to be used in a cover withhold rule
Currency	The currency of the amount
Percentage	The percentage to be used in a cover withhold rule

Product Benefit Specification Limit

A product benefit specification limit defines which limit height (that is actual amount or number) is defined for a limit within a specific product benefit specification. In this way, reuse of limits is easy where limits only vary in amount or number, even within the same product. They are derived from the parameter values, selected accumulation options and parameter alias usages during the build of a product.

Table 17. Product Benefit Specification Limit
Field	Description
Product Benefit Specification	A reference to the product benefit specification
Cover Withhold Category	A reference to the cover withhold category that counts towards the limit
Limit	A reference to the limit
Reached Action	Once the limit is reached (stop/continue) to apply the rule
Exclude From Carry Over?	An indicator with a `yes` or `no` values to determine whether a consumption with this product benefit specification limit is part of the carryover.
Maximum Amount	The maximum amount of the limit
Currency	The currency of the amount
Maximum Number	The maximum number of the limit
Maximum Service Days	The maximum service days of the limit

Product Limit

Product limits are creating during the build of a product by converting the product limit renewal periods into product limits. They contain the period and (other products) carryover period attributes of the limits. The height of the limit is stored as a value on the product benefit specification limit.

Table 18. Product Limit
Field	Description
Product	A reference to the product
Limit	A reference to the limit
Renewal Period	Number of days, months or years after which the limit renews
Renewal Period Unit of Measure	The renewal period is counted in days, months or years
Reference	The date that the limit renews (on calendar year or on plan year)
Carry Over Period	Number of days, months or years for carryover
Carry Over Period Unit of Measure	The carryover period is counted in Days, Months or Years
Other Products Carry Over Period	Number of days, months or years for carryover of other products
Other Products Carry Over Period Unit of Measure	The other products carryover period is counted in Days, Months or Years
Start Date	The start date of the period for which the limit will be applied
End Date	The end date of the period for which the limit will be applied

Product Filter

Product filters are predefined combinations of search criteria used to search for configured products.

Table 19. Product Filter
Field	Description
Code	The code of the product filter
Description	The description of the product filter
Display Sequence	The display sequence of the filter, determines the order when displaying a list of product filters
Product Line	A reference to the product line
Product Family	A reference to the product family
Funding Arrangement	A reference to the funding arrangement
Source Product	A reference to a product functioning as a source product
Source Template	A reference to a product functioning as a source template
Condition	A reference to a dynamic logic condition

Validation Check

Validation checks are user defined dynamic logic conditions used to extend the product validation process with customer specific checks.

Table 20. Validation Check
Field	Description
Code	The code of the validation check
Description	The description of the validation check
Level	The level on which the check is executed (Product, Parameter Value, Product Service Definition (Single), Product Service Definition (Combination))
Condition	A reference to a dynamic logic condition
Message	A reference to a message
Indicator Enabled	Indicates if the validation is executed during the validation process

Product Status History

The product status history keeps track of all status transitions, so that it is possible to trace back who changed the status of the product and when.

Table 21. roduct Status History
Field	Description
Product	A reference to the product
Status	The status of the product at datetime
Build Number	The build number of the product at datetime
User	The user that changed the status of the product
Datetime	Date and time when the product entered the status