Parametrized Limit Scenario

This scenario contains a limit with multiple aliases.

Building Blocks

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

One cover withhold category; deductible
A coverage regime that references the cover withhold category
A single limit; a insurable entity deductible

The following building blocks are in the received file:

  <content>
    <coverWithholdCategory
      uuid
      code DEDUCTIBLE
      description Deductible
    >

  <content>
      <coverageRegime
        uuid
        code DE
        description Deductible
        indActive Yes
          <coverageRegimeParameters
            <coverageRegimeParameter
              coverWithholdCategoryCode DEDUCTIBLE
            >
          >
      >

  <content>
    <limit
      uuid
      code INS_DED
      description Insurable Entity Deductible
      type Amount
      >

Accumulation Options

Using the imported building blocks, the following accumulation option is created:

Table 1. Accumulation Options
Count	Towards	When Reached
DEDUCTIBLE	INS_DED	Stop

This accumulation option has the following meaning.

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

Cover Withhold Categories

One cover withhold category was created. The user needs to indicate if it can be parametrized within Oracle Health Insurance Product Definition.

Table 2. Cover Withhold Categories
Code	Description	Type
DEDUCTIBLE	Deductible

The cover withhold category DEDUCTIBLE is used on rules that fully withhold - 100% - payment until the deductible limit is met. This is true for any product so there is no reason to make the percentage a settable parameter. The type field is left empty.

Notice that the type setting is not related to the actual deductible dollar amount. This is set elsewhere. The type setting specifies if the portion of the allowed amount counting towards the deductible should be parametrized; because it is always 100%, it should not.

Parameter Aliases

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

Table 3. Parameter Aliases
Code	Display Name	Cover Withhold Category	Limit
INS_DED_T1	Insurable entity deductible tier 1		INS_DED
INS_DED_T2	Insurable entity deductible tier 2		INS_DED

This setup says that there can be two different values (Insurable entity deductible tier 1 and tier 2) for the limit INS_DED. The user will have to pick which one applies when building the services within a product.

Service Options, Services, and Service Definitions

These three objects define the medical service, for example:

Service Option; Therapy
Service; Cesar Therapy
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. Two product service definitions are defined, one for tier 1 providers and one for tier 2 providers.

Earlier, setting up the parameter aliases, the system has detected that the user has a choice when it comes to the insurable entity deductible. Because of this a new column is displayed, named after the display name of the limit, in this case Insurable Entity Deductible.

Table 4. Initial Setup
Service	Service Definition	Provider Group	Type	Regime	Insurable Entity Deductible	Insurable Entity Limits
Cesar Therapy	Professional	TIER1	Cover
Cesar Therapy	Professional	TIER2	Cover

Selecting a Coverage Regime

Based on the selected coverage regime the user will be prompted to select a parameter alias if the cover withhold category is part of the coverage regime through a coverage regime parameter. In the shown example the following applies:

Both product service definitions use the DE coverage regime that does not contain any cover withhold categories that can be parametrized so no selection of a parameter alias needs to be done.

Table 5. Selecting a Coverage Regime
Service	Service Definition	Provider Group	Type	Regime	Insurable Entity Deductible	Insurable Entity Limits
Cesar Therapy	Professional	TIER1	Cover	DE
Cesar Therapy	Professional	TIER2	Cover	DE

Adding a Limit

The coverage regime for the physical therapy 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 be covered.

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. Because there are multiple parameter aliases defined for the deductible the user needs to select the applicable alias. This is visible in the user interface as follows:

The insurable entity limits column is updated and displays the INS_DED limit
The insurable entity deductible column will get a drop-down box to allow the user to select the applicable alias.

Table 6. Adding a Limit
Service	Service Definition	Provider Group	Type	Regime	Insurable Entity Deductible	Insurable Entity Limits
Cesar Therapy	Professional	TIER1	Cover	DE	Insurable entity deductible tier 1	INS_DED
Cesar Therapy	Professional	TIER2	Cover	DE	Insurable entity deductible tier 2	INS_DED

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:

Insurable entity deductible tier 1
Insurable entity deductible tier 2

Table 7. Parameter Values
Parameter Alias	Value	Type
Insurable entity deductible tier 1	500	Amount
Insurable entity deductible tier 2	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.