xRM Formula #277 - Insurance Claims Adjudication - 6. Policy Restrictions Checks - Overall Maximum Benefit

Overview

This is part 6 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 Tables which apply the rules relating to the restrictions for the overall maximum allowable benefit. When a claim is made on a policy, checks are made after the maximum allowable benefit for a treatment 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.

Rules for Overall Maximum Benefit Restrictions

Rule #	Description
RES11	Not Covered so do not perform Overall Maximum Benefit checks If Covered equal FALSE then do not perform Overall Maximum Benefit Checks
RES12	Maximum Lifetime benefit for policy, determine previous claims value If there are Policy Restrictions for policy and an Overall Maximum Benefit specified then: Calculate Overall Previous Claims Value for Treatment Calculate Overall Remaining Benefit Value for Treatment
RES13	Maximum Benefit Restriction not applicable so stop further checks If Overall Maximum Benefit rule RES12 is not applicable do not perform further Overall Maximum Benefit checks
RES14	Previous claims for policy exceed the overall maximum lifetime allowance If the Overall Remaining Benefit is less than or equal to 0 then: Set Covered to FALSE Set Amount Claimable to 0 Set External Message to You have already claimed the [overall max benefit value] overall maximum benefit for this policy Set Internal Message to Customer has already claimed the [overall max benefit value] overall maximum benefit for this policy
RES15	No previous claims for policy, but only allow Maximum Benefit If the Overall Remaining Benefit is greater than 0 and Overall Previous Claims Value is equal to 0: Set Covered to TRUE Set Amount Claimable to the minimum of the Amount Claimable or the Overall Maximum Benefit Set External Message to There is an overall maximum allowance of [overall max benefit value] for this policy Set Internal Message to There is an overall maximum allowance of [overall max benefit value] for this policy
RES16	Previous claims for policy, further allowance available If the Overall Remaining Benefit is greater than 0 and Overall Previous Claims Value is greater than 0: Set Covered to TRUE Set Amount Claimable to the minimum of the Amount Claimable or the Overall Remaining Benefit Set External Message to You have already claimed [Overall Previous Claims Value] out of a maximum allowance of [overall max benefit value] for this policy Set Internal Message to Customer has already claimed [Overall Previous Claims Value] out of a maximum allowance of [overall max benefit value] for this policy

These rules are translated into the following Decision Tables:

Step 1 - Determine Overall Previous Claims Value and Overall Remaining Benefit

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 (Maximum Benefit for a Treatment 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 associated with a Treatment
• Column D returns records where there is an Overall Maximum Benefit restriction
  • If there are one or more restriction records returned then the Overall Previous Claims Value (E5) and the Overall Remaining Benefit (F5) are calculated. These values are also stored in variables for use in the next Decision Sheet

Step 2 - Determine Coverage and Amount Claimable

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 (Step 1 above)  
  • 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 Overall Remaining Benefit amount calculated in the previous sheet
  • If the amount is less than or equal to zero then the claim item is deemed not covered
• Column D returns the Overall Previous Claims Value amount calculated in the previous sheet
  • If the amount is zero, then the Amount Claimable value is set to the minimum of either the Amount Claimable or the Overall Maximum Benefit amount
  • If the amount is greater than zero, then the Amount Claimable value is set to the minimum of either the Amount Claimable or the Overall Remaining Benefit amount
• 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