System and method having a hierarchical model with override capability for generating a flexible insurance plan

摘要

A system and method for implementing an insurance plan to coordinate an adjudication of a submitted claim corresponding to the plan. The plan includes a people model and a benefit model, such as hierarchical trees combined by a plurality of policies. The system and method comprise assigning a first predefined inheritance of global attributes to coupled elements of the people tree and assigning a second predefined inheritance of global attributes to coupled elements of the benefits tree. The system and method also assigning a local administration rule for at least one local attribute of the trees, the assignment between a selected people element of the people tree and a selected benefit element of the benefits tree. The local administration rule overrides the corresponding global attributes of the selected elements, such that resolution of the global attributes with the local attributes for the selected elements provides a rule set for adjudication of the submitted claim.

主权项

1. A method for implementing an insurance plan for a group of people with rules to coordinate adjudication of a submitted claim corresponding to the plan, the plan including a people model and a benefit model combined by a plurality of policies, the method comprising the steps of:
assigning inheritance of global attributes pertaining to people between at least two coupled people elements representing people of the group of people within the people model; assigning a policy model containing the plurality of policies, the model for assigning respective global priority to each of the policies in the policy model; setting a local priority for a selected policy of the policy model; and resolving conflicts in administering the insurance plan, by a computer processor through overrides, by making the local priority override the global priority of the selected policy as defined by the policy model; wherein overriding of the global priority with the local priority for the selected policy provides a rule set and associated benefits from the benefit model for adjudication of the submitted claim.