Oracle Health Insurance Implementation Ed 1

OHI Introduction

• Objectives
• Background and Business Benefits
• Health Care Payer Challenges
• Oracle Health Insurance
• Summary
• The Application Landscape
• Oracle Health Insurance Ecosystem
• A Componentized Health Care Payer Application Landscape Which functions does a
• payer require? The Oracle Health Insurance perspective
• A Componentized Health Care Payer Application Landscape Which functions does a
• payer require? The Oracle Health Insurance (OHI) Vision
• OHI Components Ecosystem Claim Processing
• OHI Components Ecosystem Eligibility and premium calculation
• OHI Analytics Dashboards
• Functional Overview
• Highly Configurable Rule-Based Components
• Functionality out of the box
• Flexibility
• Multilinguality
• Coverage in Different Countries
• Code System Independence
• Straight Through and Continuous Processing
• Summary

Extensibility

• Objectives
• Introduction
• Fixed Fields Versus Extensibility
• Main Concepts
• Example 1
• Example 2
• Dynamic Fields and Usages
• Dynamic Field Example
• Flex Codes
• Flex Code Example
• Dynamic Records
• Reference Sheet
• Reference Sheet Example
• Summary

Dynamic Logic

• Objectives
• Fixed Versus Dynamic Logic
• Types of Dynamic Logic
• Dynamic Logic Page
• Signatures
• Subtypes
• Subtype: Validation
• Subtype: Condition
• Subtype: Function
• Oracle Health Insurance Object Model
• Object Model
• Object Model: Methods
• Reference Sheets
• Summary

OHI Enterprise Policy Administration Introduction

• Objectives
• Architecture
• Policies Ecosystem Premium Calculation
• Functional Overview
• What else? (1/8) Premium Calculation Methods and Scenarios
• What else? (2/8) Keeping track of changes
• What else? (3/8) Generating source files for member collateral
• What else? (4/8) Integration. RESTful.
• What else? (5/8) Cafeteria-style benefit plans
• What else? (6/8) Savings Accounts
• What else? (7/8) User-defined Processing Rules
• What else? (8/8) Group Clients and Group Accounts
• Summary

Policy Administration

• Objectives
• Creating a Policy
• Action Oriented Policy Page
• Policy Wizard
• Group Accounts
• View Member Page
• Policy Maintenance
• Validate and Submit
• Policy Maintenance
• Policy Activities
• Activity Processing
• Financial Flow
• Calculate Premium
• Financial Processing
• Financial Message
• Summary

Product Configuration

• Objectives
• Introduction
• Enrollment Products
• Enrollment Products & Products
• Enrollment Products and Premium Schedules
• Enrollment Products and Surcharge and Adjustment Rules
• Enrollment Products and Add-ons
• Schedule Definitions
• Schedule Definitions and Dimension Types
• Dynamic Field Dimension
• Parameter Dimension
• Generic Dimension
• Group Clients and Group Accounts
• Group Clients
• Group Accounts
• Summary

Policy Rules

• Objectives
• Policy Process Steps
• Activity Processing
• Bulk Updates
• Generate Output
• Generate Fee (a.k.a. Incidental Charge)
• Generate Policy Mutations
• Summary

OHI Claims Introduction

• Objectives
• Introduction
• What Is Pricing?
• What Is Adjudication?
• OHI Claims Pricing and Adjudication
• Standard Integration Points
• Claim Model
• Pricing the Claim
• Finding the Benefit
• Process rules
• Accumulators
• OHI Claims Pricing
• Extensible Provider Data Model
• Pricing Worksheets: Configure executed contracts
• Reimbursement Methods
• Out-of-the-box Pricing Rules
• OHI Claims Pricing
• OHI Claims Adjudication
• Extensible Claim Data Model
• Benefit Selection
• Benefit Calculation
• Financial Preprocessing
• Authorization Matching
• OHI Claims Adjudication
• Summary

Processing Claims and Flow Overview

• Objectives
• Claims Flow Overview
• The Step-by-Step Claims Flow
• Summary

Pricing Configuration

• Objectives
• Pricing Components
• Pricing the Claim
• How Do We Support Pricing in OHI?
• Provider Pricing Clauses
• OHI Claims Pricing Configuration Model
• Provider Pricing Clauses
• Pricing’s Main Instrument: The PPC
• Selecting Provider Pricing Clauses
• Pricing Methods and Rules
• Methods and Rules
• Reimbursement Methods
• Out-of-the-box Pricing Rules
• Claim Classification
• Claims Classification
• Classification components
• How Classification Fits in With the Other Parts of Pricing
• Pricing Templates
• The Need for Configuration Efficiency
• Overview of Features
• Pricing Options
• Pricing Templates
• Pricing Worksheets
• Pricing Worksheets: Advanced Editing
• Pricing Worksheets: Validation and Build
• Summary

Benefits Configuration

• Objectives
• Benefits Components
• Products
• What Is a Product?
• Schedule of Benefits Example
• What Are the Main Components of a Product?
• Benefit Specifications
• What Is a Benefit Specification?
• High-Level Product
• Coverage Regimes
• Coverage Regime
• Adjudication Limits
• Linking the Limits
• Authorization and Waiting Period Regimes
• Authorization Regimes
• Authorization Matching
• Waiting Period Regimes
• What Happens After the Benefits Are Calculated?
• Claim Finalization
• Summary

Configuration Migration

• Objectives
• Introduction
• Configuration Migration in a Nutshell
• Building a Migration Set
• Selecting Items for Migration
• Selecting items for migration
• Selecting Items for Migration
• Exporting a Migration Set
• Importing a Migration Set
• Summary