- Understanding the Insurance Claim Management Rules Ruleset
- Understanding the Insurance Claim Management Rules Ruleset
- You must have a solid working knowledge of Oracle SOA Suite, Oracle BPM Suite, and Oracle Business Rules before modifying any business rules. For information on these products, see:
- Oracle Fusion Middleware User's Guide for Oracle Business Rules
- Oracle Fusion Middleware Administrator's Guide for Oracle SOA and Oracle Business Process Management Suite
- Oracle Insurance Claim Management uses the ICM Action Activation Rules and the ICM State Transition Rules Decision Tables in the Insurance Claim Management Rules Ruleset to determine how to process a claim based on specific conditions.
- These decision tables include conditions and actions as the rows and rules as the columns. The rules test the values of the conditions and set corresponding values for the actions. The rules must account for all possible combinations of values of all conditions in the table. A dash means "this value doesn't matter." Bucketsets are used to set pre-defined values for certain rules.
- Upon submission of a claim, the rules engine tests each condition. If a combination of condition values matches a rule, the corresponding actions are taken.
- The ICM Action Activation Rules and the ICM State Transition Rules Decision Tables below provide the details for each condition, its rules, and the actions to execute. Following each table is an example scenario explaining how a claim is processed based on a given condition for that decision table.
- ICM Action Activation Rules Decision Table (1 of 3)
- ICM Action Activation Rules Decision Table (2 of 3)
- ICM Action Activation Rules Decision Table (3 of 3)
- For example, a customer service representative (CSR) creates a new claim. The status of this new claim is FNOL. The CSR then completes the Verify Coverage activity. The conditions for rule R1 are now met, as a
- result, the Assign Case Manager and Dispatch Service activities are activated. The CSR can now see the buttons for these activities on the Auto Insurance Claim for
- Name
- number
- ICM State Transition Rules Decision Table (1 of 2)
- ICM State Transition Rules Decision Table (1 of 2)
- For example, a CSR assigns a case manager to the claim. The status of the claim is now set to Evaluation. The conditions for rule R2 are now met, as a result, the Verify Coverage and Dispatch Service activities are withdrawn. A new set of activities may get activated
- based on evaluation of the R4, R5, R6 and R7 rules in the Action Activation Rule Decision
- Table.
- You can modify the existing ruleset, conditions, or actions. Take caution before modifying a condition or action; it can require source code changes. Claim processing fails if this ruleset is deleted.
- To modify the ruleset, conditions, or actions, see
- "Editing Rules in an Oracle Business Rules Dictionary at Run Time
- Oracle Fusion Middleware User's Guide for Oracle Business Rules.