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Overview

This is part 4 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 waiting period restrictions. When a claim is made on a policy, checks are made after the previous claims tests have been completed. 

Restrictions on a Policy

Restrictions are defined on a policy via several records, each specifying the details of the restriction, for example, the treatment or treatment type and whether it is a waiting period or maximum cover restriction.

Insurance Claims Adjudication Policy Restrictions - Dynamics Business Rules Engine

Rules for Waiting Period Policy Restrictions

Rule # Description
RES01

Not Covered so do not perform Waiting Period checks

If Covered equal FALSE then do not perform Waiting Period Checks
RES02

Waiting Period Restriction in effect

If there are Policy Restrictions for specified Treatment and the Waiting Period is in effect, then:

  • Set Covered to FALSE
  • Set Amount Claimable to 0
  • Set External Message to There is a waiting period for this treatment which expires on [dd MMMM yyyy]
  • Set Internal Message to There is a waiting period for this treatment which expires on [dd MMMM yyyy]
RES03

Waiting Period Restriction has passed

If there are Policy Restrictions for specified Treatment and the Waiting Period is has passed, then:

  • Set Covered to TRUE

These rules 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 Policy Restriction records for the policy 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 (Previous Claims 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 Policy Restriction 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 returns records where there is a waiting period in effect
    • If there are one or more restriction records returned then the claim item is deemed not covered
  • Column E sets the Coverage variable
  • Column F set the Amount Claimable variable
  • Columns G and H log messages relating to the conditions met for the customer (external) and internal use