Overview
This is part 7 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 the update of the Claim detail and Claim header records. When a claim is made on a policy, checks are made after the overall maximum allowable benefit tests have been completed.
Rules for Updating Claim Records
| Rule # | Description |
|---|---|
| CED01 |
Update Claim Detail Record when Treatment is Covered If Covered equal TRUE then update the Claim Detail record fields:
|
| CDE02 |
Update Claim Detail Record when Treatment is Not Covered If Covered equal FALSE then update the Claim Detail record fields:
|
| CDE03 |
Update Claim Header Record with Messages Update Claim Header Record with Messages setting the following values:
|
These rules are translated into the following Decision Tables:
Step 1 - Update Claim Detail Record
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
- Column B checks the Covered outcome from the previous Decision Sheet (Overall Maximum Benefit Rules)
- If Covered equals TRUE
- Set Status Reason to Approved
- Set Claimable Amount to the calculated value
- Set Internal Message to the specified internal messages
- Set External Message to the specified external messages
- If Covered equals FALSE
- Set Status Reason to Rejected
- Set Claimable Amount to 0
- Set Internal Message to the specified internal messages
- Set External Message to the specified external messages
- If Covered equals TRUE
Decision Sheet notes
- This sheet updates Claim Header field values:
- Set Messages - Internal (Most Recent) to the specified internal messages
- Set Messages - Internal to the specified internal messages concatenated with existing messages
- Set Messages - External (Most Recent) to the specified external messages
- Set Messages - External to the specified external messages concatenated with existing messages