This is part 2 of a series of articles on how to implement Insurance Claims Adjudication rules using the North52 business rules engines for Microsoft Dynamics 365. Please see the overview article for a table of contents of related articles.
This article details the rules and Decision Table which apply Coverage Rules for a claim. When a claim is made on a policy these coverage rules are assessed first.
Coverage on a Policy
Coverage is defined on a policy via several records, each specifying the details of the coverage, for example, the treatment type and percentage cover.
Check Coverage for Treatment: % Cover
If coverage for specified Treatment, and % Cover is specified:
Check Coverage for Treatment: Maximum Coverage
If coverage for specified Treatment, and Maximum Coverage is specified:
Check Coverage for Treatment: No Coverage
If no coverage for specified Treatment:
The rules above are translated into the following Decision Table:
Decision Sheet notes
- The North52 Formula has been set up against a Custom Action (n52demo_CoverageCheck) which means that these rules could be called via an API call
- When the Formula executes a dynamic FetchXML query returns the policy coverage records and loads them into memory using North52's xCache functionality. xCache can significantly increase the performance of complex rules by using in-memory processing and reducing API calls
- Column B returns the policy coverage record that matches the treatment being claimed
- If a record is NOT found the variable Covered will be set to FALSE
- Column C returns the policy coverage record that matches the treatment being claimed and has a Percentage Coverage value defined
- If found the percentage defined on the policy coverage record is used to calculate the Amount Claimable (column F)
- Column D returns the policy coverage record that matches the treatment being claimed and has a Maximum Amount value defined
- If found the Amount Claimable is set to the minimum of the claim item Fee (full amount being claimed) or the maximum amount specified on the policy coverage record
- Columns G and H log messages relating to the conditions met for the customer (external) and internal use