Views:

Overview

This is part 3 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 the rules relating to previous claims. When a claim is made on a policy these checks are made after the coverage tests have been completed. 

Rules Checking Previous Claims

Rule # Description
PRE01

Not Covered so do not perform Previous Claims checks

If Covered equal FALSE then do not perform Previous Claims Checks
PRE02

Per Tooth Treatment with Interval Period and Previous Claims > Allowable Qty

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is specified, and
  3. the policy Coverage Interval Period is specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims for the specified tooth exceed the Coverage Quantity

Then:

  • Set Covered to FALSE
  • Set Amount Claimable to 0
  • Set External Message to You have already claimed for this tooth within the last [Coverage Period] months 
  • Set Internal Message to Already claimed for this tooth within the last [Coverage Period] months
PRE03

Per Tooth Treatment with Interval Period and no Previous Claims for specified tooth within specified period

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is specified, and
  3. the policy Coverage Interval Period is specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims for the specified tooth equal 0

Then:

  • Set Covered to TRUE
PRE04

Per Tooth Treatment without Interval Period and Previous Claims > Allowable Qty

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is specified, and
  3. the policy Coverage Interval Period is NOT specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims for the specified tooth exceed the Coverage Quantity

Then:

  • Set Covered to FALSE
  • Set Amount Claimable to 0
  • Set External Message to You have already claimed for this treatment and tooth 
  • Set Internal Message to Already claimed for this treatment and tooth
PRE05

Per Tooth Treatment without Interval Period and no Previous Claims for specified tooth

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is specified, and
  3. the policy Coverage Interval Period is NOT specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims for the specified tooth equal 0

Then:

  • Set Covered to TRUE
PRE06

Not Per Tooth Treatment with Interval Period and Previous Claims > Allowable Qty

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is NOT specified, and
  3. the policy Coverage Interval Period is specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims exceed the Coverage Quantity

Then:

  • Set Covered to FALSE
  • Set Amount Claimable to 0
  • Set External Message to You have already claimed for this treatment within the last [Coverage Period] months 
  • Set Internal Message to Already claimed for this treatment within the last [Coverage Period] months
PRE07

Not Per Tooth Treatment with Interval Period and no Previous Claims within specified period

If the claimant has:

  1. previously Approved Claims, and
  2. a Tooth Number is NOT specified, and
  3. the policy Coverage Interval Period is specified, and
  4. the policy Coverage Quantity is specified, and
  5. the Previously Approved Claims equal 0

Then:

  • Set Covered to TRUE

Decision Table

The rules above are translated into the following Decision Table:

Insurance Claims Adjudication Decision Table - Dynamics Business Rules Engine

Decision Sheet notes

  • When a match occurs on a row, the Actions and Inline Calculations are performed for that row only and no further rows are evaluated
  • When the Formula executes a dynamic FetchXML query returns all the previously approved claim records for the claimant 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 checks the Covered outcome from the previous Decision Sheet (Coverage Rules)  
    • If the value is FALSE, it means the claim item is not covered. This Decision Sheet would not process any further rules
  • Column C returns the previously approved claim item records
    • All rules in this sheet require that items are returned. If there are no items found then no further rules processing will be done
  • Column D determines whether there is a Tooth Number specified for the claim item
  • Column E determines whether the specified Treatment's coverage on the policy has an interval period value
  • Column F determines whether the specified Treatment's coverage on the policy has a quantity value (maximum number of claims allowable for the treatment)
  • Column G determines the number of previous claims falling within the allowable period for the specified tooth and treatment
    • If the number is greater than or equal to the number of claims allowed, then the claim will not be covered (cell G5)
  • Column H determines the number of previous claims for the specified tooth and treatment
    • If the number is greater than or equal to the number of claims allowed, then the claim will not be covered (cell H7)
  • Column I determines the number of previous claims for the specified treatment
    • If the number is greater than or equal to the number of claims allowed, then the claim will not be covered (cell I9)
  • Columns L and M log messages relating to the conditions met for the customer (external) and internal use