Grailog Use Case
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This document describes a cost sharing estimator that uses rules to calculate a client's cost sharing for medical expenses based on their insurance coverage. It includes: 1) Data facts about medical expenses, insurance offers, clients, and partner hospitals. 2) Decision rules for the cost sharing estimator that calculate payment based on whether the client has insurance, the hospital is in-network, and compensation covers expenses. 3) An example of transforming the rules from POSL format to RuleML and visualizing them as a Grailog diagram.
![Steps of Creating CostSharingEstimator
22
First
Second
Third
• Data and rules were
written in POSL
• OO JDREW[1] is used
to transform POSL
into RuleML
• Saxon[2] gets inputs:
the .ruleml of second
step and .xslt [3] to
output Grailog (.svg)](https://image.slidesharecdn.com/insuranceusecase-160601121555/85/Grailog-Use-Case-22-320.jpg)
![Note
• <Naf> [4] is not yet identified by Grailog.
Therefore, whenever it’s needed in a predicate,
the predicate is preceded by “not”
• For example:
23
POSL
naf(partner(tawuniya,
?Hospital))
RuleML (not)RuleML (naf)](https://image.slidesharecdn.com/insuranceusecase-160601121555/85/Grailog-Use-Case-23-320.jpg)
![Saxon
• Saxon [2] is used to transform the RuleML
version of this usecase into Grailog. It takes the
.ruleml and the .xslt files as inputs to produce
the .svg as output of the transformation process
• Saxon does not have an interface; it uses DOS
command for this purpose
30](https://image.slidesharecdn.com/insuranceusecase-160601121555/85/Grailog-Use-Case-30-320.jpg)
![Grailog
• More information about Grailog is available
on[5]
• [3] is the .xslt file that is used to transform
RuleML in to Grailog visualization
31](https://image.slidesharecdn.com/insuranceusecase-160601121555/85/Grailog-Use-Case-31-320.jpg)
![References
[1]http://www.jdrew.org/oojdrew/demo.html
[2]http://www.saxonica.com/documentation/#!ab
out/gettingstarted/gettingstartedjava
[3]http://www2.unb.ca/~lbidlak1/GrailogKSViz2_
0StandAlone.xslt
[4]http://wiki.ruleml.org/index.php/Glossary_of_
Deliberation_RuleML_1.02#.3CNaf.3E
[5]http://wiki.ruleml.org/index.php/Grailog
33](https://image.slidesharecdn.com/insuranceusecase-160601121555/85/Grailog-Use-Case-33-320.jpg)
Grailog Use Case
- 1. Cost Sharing Estimator Zainab Almugbel Special thanks to Prof. Harold Boley for his contribution in this use case 1
- 2. Cost sharing estimator • Cost sharing is the share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges, but it doesn't include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. 2 https://www.healthcare.gov/glossary/cost-sharing/
- 3. 3
- 4. 4 start Client has insurance ? Compensation > treatment cost cost sharing inquiry yes Payment = treatment cost cost sharing result end no Payment = 0 yes Payment = treatment cost - compensation no Partner hospital? yes no
- 5. Data Fact / Decision Rule Architecture 5 insuranceOffer client partnermedicalExpenses Data Facts costSharingEstimator paymentCalculator Decision Rules
- 6. This includes medicalExpenses, insuranceOffer, client and partner 6
- 7. Data facts: medicalExpenses • This predicate stores the expenses/price of having a service in a specific hospital : 1. medicalExpenses(saudiGermanHospital, teeth, xray, 300^^Integer). %...(hospital, site, required treatment, price) 2. medicalExpenses(britishSaudiHospital, teeth, xray, 350^^Integer). 3. medicalExpenses(dallahHospital, teeth, xray, 350^^Integer). 4. medicalExpenses(dallahHospital, teeth, surgery, 2000^^Integer). 5. medicalExpenses(britishSaudiHospital, teeth, surgery, 1350^^Integer). 6. medicalExpenses(binsinaMedicalCenter, teeth, surgery, 1500^^Integer). 7. medicalExpenses(medCareHospital, teeth, surgery, 1350^^Integer). 7
- 8. Data facts: insurance offers • This predicate stores the information about the available medical insurance offers in a specific insurance company. The compensation for treating a specific site is categorized based on the insurance type: 1. insuranceOffer(tawuniya, silver, teeth, 1000^^Integer). %...(insurance company, insurance type, site, compensation) 2. insuranceOffer(tawuniya, gold, teeth, 1500^^Integer). 3. insuranceOffer(tawuniya, platinum, teeth, 2000^^Integer). 4. insuranceOffer(tawuniya, diamond, teeth, 2500^^Integer). 8
- 9. Data facts: client • This predicate stores the registered clients, their insurance company, and their insurance type: 1. client(11122, tawuniya, silver). %...(clientSSN,insurance company, insurance type) 1. client(66700, tawuniya, gold). 9
- 10. Data facts: partner • This predicate stores the partners : 1. partner(tawuniya, saudiGermanHospital). %...(insurance company, partner hosipital) 1. partner(tawuniya, britishSaudiHospital). 2. partner(tawuniya, dallahHospital). 10
- 11. This includes costSharingEstimator and paymentCalculator 11
- 12. Decision Rule: costSharingEstimator • The predicate costSharingEstimator estimates the cost sharing ?Payment for a client ?ClientSSN who may have a medical insurance in ?InsCompany and needs a treatment ?RequiredTreatment for a ?Site in a ?Hospital • ?InsCompany is bound to Tawuniya company in this usecase but it could be bound to any other value 12 costSharingEstimator(?ClientSSN, ?InsCompany, ?Hospital, ?Site, ?RequiredTreatment, ?Payment) :-
- 13. Decision Rule: costSharingEstimator Cont’d. costSharingEstimator has three versions: • Client has medical insurance: ▫ Hospital is a partner with his insurance company(1) Compensation covers treatment cost Compensation does not cover treatment cost ▫ Hospital is not a partner with his insurance company (2) • Client does not have an insurance (3) 13
- 14. Decision Rule: costSharingEstimator(1) costSharingEstimator(?ClientSSN, ?InsCompany, ?Hospital, ?Site, ?RequiredTreatment, ?Payment) :- client(?ClientSSN, tawuniya, ?InsType), % check if the client has insurance partner(tawuniya, ?Hospital), % check the partnered hospitals medicalExpenses(?Hospital, ?Site, ?RequiredTreatment, ?Price), % check the price (cost of the service) insuranceOffer(tawuniya, ?InsType, ?Site, ?Compensation), % check the compensation(money given by the insurance company) paymentCalculator(?Price, ?Compensation, ?Payment). % calculate the cost sharing (?Payment) 14 This rule executes when the hospital that provides services to clients is partner of its insurance company % costSharingEstimator(in, in, out, in, in, out)
- 15. Decision Rule: paymentCalculator paymentCalculator (?Price, ?Compensation, ?Payment). Since compensation is based on the insurance type. The compensation may not cover the total treatment price. As a result, there are two versions of this rule: 1. If compensation >= price then payment=0 paymentCalculator (?Price, ?Compensation, ?Payment) :- greaterThanOrEqual(?Compensation, ?Price), subtract(?Payment, ?Price, ?Price). 2. If compensation < price then payment= price - compensation paymentCalculator (?Price, ?Compensation, ?Payment) :- lessThan(?Compensation, ?Price), subtract(?Payment, ?Price, ?Compensation). 15
- 16. Decision Rule: costSharingEstimator(2) costSharingEstimator(?ClientSSN, ?InsCompany, ?Hospital, ?Site, ?RequiredTreatment, ?Payment) :- client(?ClientSSN, tawuniya, ?InsType), naf(partner(tawuniya, ?Hospital)), % return true if the hospital is in not a partner with the insurance company medicalExpenses (?Hospital, ?Site, ?RequiredTreatment, ?Payment). • This rule executes when the hospital that provides services to clients is not partner (naf) of its insurance company. The client has to pay the full cost of the service 16
- 17. Decision Rule: costSharingEstimator(3) costSharingEstimator(?ClientSSN, ?InsCompany, ?Hospital, ?Site, ?RequiredTreatment, ?Payment) :- naf(client(?ClientSSN, ?InsCompany, ?InsType)), % return true if the client in not registered in the insurance company medicalExpenses (?Hospital, ?Site, ?RequiredTreatment, ?Payment). • This rule executes when the client is not registered (naf) in any insurance company. The client has to pay the full cost of the service 17
- 18. 1. costSharingEstimator is the main query 2. Both knowledgebase and query could be run using OO JDREW on http://www.jdrew.org/oojdrew/download.html 18
- 19. Query Sample 1 This query is for (Exist client); it gives 2 results: 19 • costSharingEstimator(11122, tawuniya, ?Hospital, teeth, surgery, ?Payment). Only partner hospitals that provide the required treatment are shown in the results
- 20. Query Sample 2 This query is for (exist client) with (non partner hospital); it gives one result: 20 • costSharingEstimator(11122, tawuniya, medCareHospital, teeth, surgery, ?Payment). •Only the selected hospital is shown in the result •The client has to pay the full cost of the service
- 21. Query Sample 3 This query is for (non exist client); it gives 4 results: 21 • costSharingEstimator(11622, tawuniya, ?Hospital, teeth, surgery, ?Payment). •All available hospitals that provide the required treatment are shown in the results •The client has to pay the full price of the service
- 22. Steps of Creating CostSharingEstimator 22 First Second Third • Data and rules were written in POSL • OO JDREW[1] is used to transform POSL into RuleML • Saxon[2] gets inputs: the .ruleml of second step and .xslt [3] to output Grailog (.svg)
- 23. Note • <Naf> [4] is not yet identified by Grailog. Therefore, whenever it’s needed in a predicate, the predicate is preceded by “not” • For example: 23 POSL naf(partner(tawuniya, ?Hospital)) RuleML (not)RuleML (naf)
- 25. Transforming POSL to RuleML (OO JDREW) POSL RuleML paymentCalculator (?Price,?Compensation, ?Payment) :- lessThan(?Compensation, ?Price), subtract(?Payment, ?Price, ?Compensation). 25
- 26. Visualizing RuleML as Grailog(svg) 26
- 28. Transforming POSL to RuleML (manually) POSL RuleML paymentCalculator (?Price,?Compensation, ?Payment) :- lessThan(?Compensation, ?Price), Equal(?Payment,subtract(?Price, ?Compensation)). 28
- 29. Visualizing RuleML as Grailog(svg) 29
- 30. Saxon • Saxon [2] is used to transform the RuleML version of this usecase into Grailog. It takes the .ruleml and the .xslt files as inputs to produce the .svg as output of the transformation process • Saxon does not have an interface; it uses DOS command for this purpose 30
- 31. Grailog • More information about Grailog is available on[5] • [3] is the .xslt file that is used to transform RuleML in to Grailog visualization 31
- 32. Future work • Data in this use case can be extended to: ▫ contain comparable information about different medical insurance companies in a specific region to help the user to select the most suitable insurance for himself ▫ include additional insurance types(ex, car insurance) • Grailog can be extended to visualize “naf” 32