Loading...
| Rule Category | Rule | Code Location |
|---|---|---|
| Customer Eligibility | Age must be between 18-85 years | Lines 1273-1280 |
| Customer Validation | Customer name is mandatory (not blank) | Lines 1261-1266 |
| Customer Validation | SSN must be 9 numeric digits, not zero | Lines 1285-1290 |
| Contact Validation | Email must contain '@' symbol if provided | Lines 1318-1329 |
| Insurance Type | Must be HEALTH, LIFE, AUTO, PROPERTY, DENTAL, or VISION | Lines 1295-1302 |
| Coverage Limits | Coverage must be $1 to $999,999,999 | Lines 1307-1313 |
| Duplicate Prevention | Cannot create duplicate active policy (same customer + type) | Lines 1357-1382 |
| Claim Validation | Claim number is mandatory | Lines 2320-2325 |
| Claim Validation | Claim amount must be greater than zero | Lines 2340-2345 |
| Claim Type | Must be MEDICAL, HOSPITAL, EMERGENCY, DENTAL, VISION, AUTO, or PROPERTY | Lines 2350-2358 |
| Date Validation | Incident date cannot be in the future | Lines 2363-2369 |
| Date Logic | Claim date must be on or after incident date | Lines 2371-2377 |
| Renewal Validation | Renewal term must be 12, 24, or 36 months | Lines 1882-1888 |
| Renewal Type | Must be ST (Standard), UP (Upgrade), DN (Downgrade), or MY (Multi-Year) | Lines 1893-1899 |
| Rule Category | Rule | Code Location |
|---|---|---|
| Policy Status | Policy must be ACTIVE to accept claims | Lines 2416-2420 |
| Coverage Period | Incident must occur within policy start and end dates | Lines 2425-2430 |
| Duplicate Claims | Claim number must be unique (not already processed) | Lines 2436-2448 |
| Renewal Eligibility | Only ACTIVE policies can be renewed | Lines 1938-1942 |
| Factor | Points Added | Code Location |
|---|---|---|
| Age < 25 | +20 | Lines 1394-1401 |
| Age > 65 | +30 | Lines 1394-1401 |
| Age > 55 (but ≤65) | +15 | Lines 1394-1401 |
| Male gender | +5 | Lines 1406-1408 |
| Smoker status | +25 | Lines 1413-1415 |
| Pre-existing conditions | +20 | Lines 1420-1422 |
| High-risk occupation | +10 to +60 | Lines 1427-1433 |
Risk Profile: Score 0-29 = LOW, 30-69 = MEDIUM, 70-100 = HIGH
| Component | Formula | Code Location |
|---|---|---|
| Base Premium | Coverage Amount × Type Rate (HEALTH: 0.4%, LIFE: 0.2%, AUTO: 0.8%, PROPERTY: 0.3%, DENTAL: 0.15%, VISION: 0.1%) | Lines 1454-1473 |
| Deductible Adjustment | Premium reduced by (Deductible ÷ Coverage) × 30% | Lines 1478-1481 |
| Age Factor | Premium × Age Multiplier (18-25: 0.8x, 26-35: 1.0x, 36-45: 1.2x, 46-55: 1.5x, 56-65: 2.0x, 66-75: 3.0x, 76-85: 4.0x) | Lines 1486-1495 |
| Risk Adjustment | Base Premium × (Risk Score ÷ 100) | Lines 1500-1501 |
| State Tax | (Premium) × State Rate (NY: 8.875%, CA: 8.25%, TX: 6.25%, FL: 7%, Default: 8%) | Lines 1523-1534 |
| Processing Fee | Fixed $25 added to all policies | Line 1544 |
| Monthly Premium | Annual Premium ÷ 12 (if monthly payment selected) | Lines 1549-1551 |
| Component | Formula | Code Location |
|---|---|---|
| Deductible Applied | MIN(Claim Amount, Remaining Deductible) | Lines 2591-2603 |
| Copay Amount | (Amount After Deductible) × Copay % (default 20%) | Lines 2608-2620 |
| OOP Maximum Protection | Patient payment capped at remaining OOP max | Lines 2625-2633 |
| Coverage Limit | Insurance payment capped at policy coverage amount | Lines 2641-2645 |
| Renewal Type | Coverage Change | Premium Change | Code Location |
|---|---|---|---|
| Standard (ST) | No change | +3% | Lines 1958-1960 |
| Upgrade (UP) | +25% or specified amount | +25% | Lines 1962-1970 |
| Downgrade (DN) | -25% or specified amount | -25% | Lines 1972-1980 |
| Multi-Year (MY) | No change | -5% for longer term | Lines 1982-1986 |
| Deductible Increase | No change | -5% premium reduction | Lines 2035-2045 |
| Deductible Decrease | No change | +5% premium increase | Lines 2035-2045 |
| Discount Type | Rate | Maximum | Code Location |
|---|---|---|---|
| Annual Payment | 5% | N/A | Lines 1509-1512 |
| Large Coverage (>$500K) | 10% | N/A | Lines 1515-1518 |
| Loyalty | 1% per year | 15% | Lines 1991-1998 |
| No-Claims | 2% per claim-free year | 20% | Lines 2003-2011 |
| Multi-Policy | 10% | N/A | Lines 2016-2030 |
Note: Multiple discounts can stack; maximum cumulative discount possible is ~45%
| Factor | Points Added | Code Location |
|---|---|---|
| Claim Frequency | ||
| >3 claims in 30 days | +25 | Lines 2460-2474 |
| 2-3 claims in 30 days | +10 | Lines 2460-2474 |
| Claim Amount | ||
| Claim amount > $50,000 | +15 | Lines 2479-2485 |
| Claim amount > $25,000 | +10 | Lines 2479-2485 |
| Provider Risk | ||
| Provider fraud score > 50 | +20 | Lines 2490-2508 |
| Provider marked inactive | +30 | Lines 2490-2508 |
| Pattern Detection | ||
| Identical claim (type + amount) in 90 days | +20 | Lines 2513-2526 |
| Timing Analysis | ||
| Incident on weekend (Sat/Sun) | +5 | Lines 2531-2535 |
| Score Range | Status | Approval Status | Payment Action | Code Location |
|---|---|---|---|---|
| ≥70 | UNDER REVIEW | FRAUD INVESTIGATION | $0 (blocked) | Lines 2542-2546 |
| 50-69 | PENDING | MANUAL REVIEW | Calculated but held | Lines 2547-2551 |
| < 50 and ≤$5,000 | PROCESSING | AUTO-APPROVED | Full payment | Lines 2556-2560 |
| < 50 and >$5,000 | PROCESSING | PENDING APPROVAL | Calculated but held | Lines 2556-2560 |
| Constraint | Value | Code Location |
|---|---|---|
| Maximum Coverage | $999,999,999 | Line 221 |
| Minimum Customer Age | 18 years | Line 222 |
| Maximum Customer Age | 85 years | Line 223 |
| Fraud Investigation Threshold | 70 points | Line 224 |
| Auto-Approve Limit | $5,000 | Line 225 |
| Database Commit Frequency | Every 500 records | Line 220 |
| Maximum Retry Attempts | 3 times | Line 219 |
Final Premium =
(Coverage Amount × Type Rate × Age Factor)
+ (Base Premium × Risk Score ÷ 100)
- Annual Payment Discount (5%)
- Large Coverage Discount (10%)
+ (Adjusted Premium × State Tax Rate)
+ Processing Fee ($25)
Insurance Payment =
Claim Amount
- Deductible Applied
- Copay Amount (20% default)
(capped at Coverage Limit)
Customer Payment =
Deductible Applied + Copay Amount
(capped at Out-of-Pocket Maximum)
Document Information: