Shared Parameter Alias Scenario

This scenario shows us a tiered copay structure. In addition the co-payments are controlled by a limit to ensure the copay is never taken twice on the same day for the same provider.

Building Blocks

The following items being sent in through the Building Blocks Integration Point.

A cover withhold category; COPAY
A coverage regime that references the cover withhold category COPAY
A benefit limit; CP_PPPD

The following building blocks are in the received file:

  <content>
    <coverWithholdCategory
      uuid
      code COPAY
      description Copay
    >

  <content>
      <coverageRegime
        uuid
        code CP
        description Copay Regime
        indActive Yes
          <coverageRegimeParameters
            <coverageRegimeParameter
              coverWithholdCategoryCode COPAY
          >

  <content>
    <limit
      uuid
      code CP_PPPD
      description Copay per provider per day
      type Amount
      >

Accumulation Options

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

Table 1. Accumulation Options
Count	Towards	When Reached
COPAY	CP_PPPD	Stop

This accumulation option has the following meaning.

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

Cover Withhold Categories

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

Table 2. Cover Withhold Categories
Code	Description	Type
COPAY	Copay	Amount

This setup implies the following:

The amount of copay that needs to be paid by the insurable entity can vary between benefits.

Parameter Aliases

The next step is to define aliases for the limit and the cover withhold category.

Table 3. Parameter Aliases
Code	Display Name	Cover Withhold Category	Limit
CP_OV1	Office visit copay tier 1	COPAY	CP_PPPD
CP_OV2	Office visit copay tier 2	COPAY	CP_PPPD

Two parameter aliases are set up, both referring to the same category and limit.

By linking both the category and the limit to the parameter alias the system will ask the user to set only a single dollar amount. The system then uses this dollar amount both for the COPAY rule as well as the CP_PPPD limit.

So suppose the user sets the value to $20, the system knows to take $20 dollars per allowed unit (COPAY), and to never take more than $20 per day for the same provider (CP_PPPD).

Service Options, Services, and Service Definitions

These three objects define the medical service, for example:

Service Option; Physician Services
Service; Routine Physical 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.

For each cover withhold category that has its type set to amount or percentage a column will appear in this table. Copay will therefore have a column. The copay per provider per day limit has its indicator display in UI set to no (as determined during the setup of the parameter aliases), this will not result in an extra column in the table.

Table 4. Initial Setup
Service	Service Definition	Type	Regime	Provider Group	Copay	Insurable Entity Limits
Routine Physical Exam	Professional	Cover		TIER1
Routine Physical Exam	Professional	Cover		TIER2

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:

Table 5. Selecting a Coverage Regime
Service	Service Definition	Type	Regime	Provider Group	Copay	Insurable Entity Limits
Routine Physical Exam	Professional	Cover	CP	TIER1	Office visit copay tier 1
Routine Physical Exam	Professional	Cover	CP	TIER2	Office visit copay tier 2

Now the copay amount defined for the selected aliases must be applied to this product service definition; how this amount is set is explained later on in the example.

Adding a Limit

The next step is to indicate that the copay in the coverage regime must count towards the copay per provider per day 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. There is no dynamic column allowing the user to select one of the parameter aliases that are defined for the limit. The determination of the correct alias is done by the application.

This is visible in the user interface as follows:

The insurable entity limits column is updated and displays the CP_PPPD limit.

During the product validation process the system will encounter a product service definition that counts towards a limit but does not have a parameter alias selected that is used to determine the height of the limit. The application will look up the parameter alias that was selected for the cover withhold category for the same product service definition and will make the limit refer to the same parameter alias.

Table 6. Adding a Limit
Service	Service Definition	Type	Regime	Provider Group	Copay	Insurable Entity Limits
Routine Physical Exam	Professional	Cover	CP	TIER1	Office visit copay tier 1	CP_PPPD
Routine Physical Exam	Professional	Cover	CP	TIER2	Office visit copay tier 2	CP_PPPD

Parameter Values

After configuring product service definitions it is possible to define parameter values for all the parameter aliases used in the product service definitions contained in the product. For this scenario the following parameters have a usage for a product service definition.

Table 7. Parameter Values
Parameter Alias	Value	Type
Office visit copay tier 1	20	Amount
Office visit copay tier 2	40	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.