Certificate Cost Sharing

This file defines the copayment and coinsurance applicable to each insured policyholder in a plan. It also specifies the minimum amount required for direct billing to be applicable.

Product group codes come from a predefined list provided by Osigu during the integration process. Examples include:

#	Product Group Name	Description
1	generic-drug	Group containing all medications classified as generics.
2	non-generic-drug	Group containing various branded medications.
3	x-ray	Group of diagnostic tests under the X-ray category.
4	medical-evaluation	Group of services related to medical evaluations, such as general outpatient consultations or pediatric consultations.

Version 2

File Name: v2_certificate_costs_sharings.csv

The fields in this file apply to every policyholder/insured individual matching the policy number and certificate number provided in each line.

Structure

The required fields are marked in bold.

#	Field Name	Type	Description
1	insurer_slug	String[64]	Slug of the Payer provided by Osigu.
2	policy_number	String[32]	Policy/plan number, must match a record in the `v2_policies.csv` file.
3	policyholder_certificate	String[64]	Policyholder certificate. If unavailable, the payer can use a constant value, e.g., "CERT01".
4	currency_code	String[3] using the ISO 4217	Currency code for the amounts.
5	product_group	String[128]	Name of the product/service group affected by this configuration.
6	provider_category	String[64]	Provider category this configuration applies to. Use `DEFAULT` if no specific category applies.
7	minimum_total_amount	Decimal(15,5)	Minimum amount required for direct billing to apply.
8	copayment_amount	Decimal(15,5)	Fixed amount in the currency for the policyholder’s copayment.
9	coinsurance_percent	Decimal(15,5)	Percentage of the policyholder’s participation as coinsurance.

Version 3

File Name: v3_certificate_costs_sharings.csv

This version includes the maximum_total_amount field, which sets a limit for direct billing. When this limit is reached during a transaction, a pre-authorization will be required.

Structure

The required fields are marked in bold.

#	Field Name	Type	Description
1	insurer_slug	String[64]	Slug of the Payer provided by Osigu.
2	policy_number	String[32]	Policy/plan number, must match a record in the `v2_policies.csv` file.
3	policyholder_certificate	String[64]	Policyholder certificate. If unavailable, the payer can use a constant value, e.g., "CERT01".
4	currency_code	String[3] using the ISO 4217	Currency code for the amounts.
5	product_group	String[128]	Name of the product/service group affected by this configuration.
6	provider_category	String[64]	Provider category this configuration applies to. Use `DEFAULT` if no specific category applies.
7	minimum_total_amount	Decimal(15,5)	Minimum amount required for direct billing to apply.
8	maximum_total_amount	Decimal(15,5)	Maximum amount allowed for direct billing before requiring pre-authorization.
9	copayment_amount	Decimal(15,5)	Fixed amount in the currency for the policyholder’s copayment.
10	coinsurance_percent	Decimal(15,5)	Percentage of the policyholder’s participation as coinsurance.