Segment Level Service Benefits Prototype
This feature provides the ability in OIPA to store various Services for which coverages/benefit values can be defined. It provides a provision for hierarchical grouping of the services described above called Service Group.Benefits and are defined for the services for each segment.
Prerequisites
N/A
New Items
- Master level Service Groups and Service tables are created in Palette with Various Services and Groups applicable to Vision benefits and Dental Benefits.
- AsCode Values are added as defined in feature document for Service Level, Service Category and Service Status . These codevalues are also listed below. Additionally, two new segment types in AsCodeSegmentType with Code value 79 and 78 for Vision and Dental Supplemental are also added.
ServiceGroupCategoryCode
| 01 | Medical |
| 02 | Dental |
| 03 | Vision |
| 04 | Pharmacy |
| 05 | Accidents |
| 06 | Supplemental |
ServiceStatusCode
| 01 | New |
| 02 | Pending |
| 03 | Pending Approval |
| 04 | Expired |
ServiceLevel
| 01 | All |
| 02 | Facility |
| 03 | Professional |
- The data added in the tables relevant to Vision Care and Dental are also listed below: The Columns ServiceGroupCategory, ServiceStatus Code stores corresponding AsCodevalues
- Guid columns and other system generated data columns are not included in the document.
- Security is provided for Benefit Screen Rule for the user group under the company.
ServiceGroup Table
| ServiceGroupDescription | ServiceGroupCode | ServiceGroupCategoryCode |
| Diagnostic and Preventive Services | GPA | 2 |
| Vision Exam | VEA | 3 |
| Lenses | VLA | 3 |
| Contact Lenses | PLKM | 3 |
| General (Adjunctive) Services | POLK | 2 |
Service Table
| ServiceCode | ServiceDescription | ServiceGroupCategoryCode |
| OVA | Oral Evaluation | 3 |
| XRY | XRAY | 3 |
| UYT | Cleaning | 3 |
| OPI | Space Maintainers | 3 |
| VEAB | Vision Exam | 3 |
| KPLM | Single Vision | 3 |
| HJUK | Bifoccal | 3 |
| PUYT | Progressive | 3 |
| TRER | TriFocal | 3 |
| NMBV | Elective | 3 |
| XCVF | Non elective | 3 |
| GMP | General anesthesia | 3 |
| EMT | Emergency palliative treatment | 3 |
| JKL | Consultations | 3 |
Existing Items
None
Configuration Details
- BenefitScreen Business rule is added under screen rules at Global Level. Benefit Screen rule includes configuration for Dental and Vision care segments and their Service Benefit Fields for Palette and OIPA.
- The two segments VisionCare and Dental are added in Group Prototype Product under Prototype Group Child Company. Any plan created under this product in OIPA group can add VisionCare and Dental to the respective plan.
- Service Benefits are created for the two segments Vision Care and Dental through Palette Administration ServiceBenefit Node.
- Refer benefit data set up below for VisionCare for each of the Services created in the AsServiceTable. The Benefit Data is stored in AsSegmentNameBnft and AsSegmentNameBnftField table for corresponding segment.
- Refer benefit data set up below for Dental Care for each of the Dental Services added in AsService Table. The Benefit Data is stored in AsSegmentNameBnft and AsSegmentNameBnftField table for corresponding segment.
