Benefit Specifications
A benefit specification specifies a number of dimensions like procedures, diagnoses, providers, regions and other conditions to indicate when a care service is covered and a reference to a coverage regime to indicate how much is actually covered.
Benefit Specifications are created and maintained in Oracle Health Insurance Product Definition by the application itself. Users will be able to view the generated benefit specifications but they can not be edited directly.
Benefit Specification
| Field | Description |
|---|---|
Service Definition |
A reference to a service definition on which the benefit specification is based |
Code |
The code of the benefit specification |
Description |
The description of the benefit specification |
Procedure Group Usage |
How should the procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line. |
Procedure Group |
A reference to the group of procedures to which the benefit specification applies |
Procedure Group 2 Usage |
How should the second procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line. |
Procedure Group 2 |
A reference to the second group of procedures to which this benefit specification applies |
Procedure Group 2 Usage |
How should the third procedure group be evaluated? In: When one or more of the procedures in the group are present on the claim line. Not In: When none of the procedures in the group are present on the claim line. |
Procedure Group 3 |
A reference to the third group of procedures to which this benefit specification applies |
Procedure Condition Usage |
How should the procedure condition be evaluated? In: When one or more of the procedures on the claim line meet the condition. Not In: When none of the procedures on the claim line meet the condition. |
Procedure Condition |
A reference to a dynamic logic condition specifying the applicable procedures |
Diagnosis Group Usage |
To indicate In or Not in for a diagnosis group or condition |
Diagnosis Group |
A reference to the group of diagnoses to which the benefit specification applies |
Diagnosis Condition |
A reference to a dynamic logic condition specifying the applicable diagnoses |
Diagnosis Type |
The type of diagnoses to which this benefit specification applies |
Product Provider Group Scope |
The scope of the provider groups of the product, in, out or either |
Specific Provider Group Scope |
The scope of the specific provider groups, in or out |
Case Definition |
A reference to the case definition that applies to the benefit specification |
Coverage Regime |
A reference to the applied coverage regime |
Authorization Regime |
A reference to the applied authorization regime |
Waiting Period Regime |
A reference to the applied waiting period regime |
Post Benefits Regime |
A reference to the applied post benefits regime |
Age From |
The minimum age a person can have for this benefit to be applicable |
Age To |
The maximum age a person can have for this benefit to be applicable |
Gender |
The gender a person must have for this benefit to be applicable |
Employer Country Region Usage |
Determines whether the listed region or group is required for or excluded from the benefit specification |
Employer Country Region |
The benefit only applies if the employer of the insured is based in the referenced region |
Employer Country Region Group |
The benefit only applies if the employer of the insured 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 benefit specification |
Person Country Region |
The benefit only applies if the person is based in the referenced region |
Person Country Region Group |
The benefit only applies if the person is based in the referenced group of regions |
Provider Country Region Usage |
Determines whether the listed region or group is required for or excluded from the benefit specification |
Provider Country Region |
The benefit only applies if the servicing provider is based in the referenced region |
Provider Country Region Group |
The benefit only applies if the servicing provider is based in the referenced group of regions |
Location Type Usage |
Determines whether the listed location types are required for or excluded from the benefit |
Authorization Missing |
Does the coverage specification apply only if an authorization is missing? |
Consume Authorization |
Will the claim line on which the authorization specification is applied write consumption on returned authorizations? |
Benefit Priority |
A reference to the priority of the benefit specification. |
Indicator Active |
Indication if new references can be created to the benefit specification |
Modifier Usage |
Determines whether the listed modifiers are required for or excluded from the benefit |
Specialty Usage |
Determines whether the listed specialties are required for or excluded from the benefit |
Claim Form Type |
A reference to the claim form type |
One or more benefit specification conditions, other than diagnosis and procedure conditions may be added to a benefit specification. These are user defined conditions to evaluate if a benefit applies in a specific situation.
Benefit Specification Condition
| Field | Description |
|---|---|
Benefit Specification |
A reference to the benefit specification. |
Dynamic Logic |
A reference to the condition dynamic logic. |
Indication Service Definition? |
Is the benefit specification condition based on a service definition condition or product service definition condition? |
One or more benefit specification provider groups may be added to a benefit specification. These are the specific provider groups that are to be used as criteria in the evaluation of the benefit specification.
Benefit Specification Provider Group
| Field | Description |
|---|---|
Benefit Specification |
A reference to the benefit specification. |
Provider Group |
A reference to the provider group. |
Assignment Label |
The qualifying label for the assignment of the provider group. |
One or more benefit specification location types may be added to the benefit specification. These are the specific location types for which the benefit specification applies (or does not apply).
Benefit Specification Location Type
| Field | Description |
|---|---|
Benefit Specification |
A reference to the benefit specification. |
Location Type |
A reference to the location type |
One or more benefit specification specialties may be added to the benefit specification. These are the specialties that apply to the benefit specification (or do not apply).
Benefit Specification Specialty
| Field | Description |
|---|---|
Benefit Specification |
A reference to the benefit specification. |
Location Type |
A reference to the location type |
One or more benefit specification modifiers may be added to the benefit specification. These are the modifiers that apply to the benefit specification (or do not apply).