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.

1. Cost Sharing Estimator
Zainab Almugbel
Special thanks to Prof. Harold Boley for his
contribution in this use case
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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
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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).
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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
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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
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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)
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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)
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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).
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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
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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)

24. Example: paymentCalculator rule
24

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

27. Example: paymentCalculator rule
27

28. Transforming POSL to RuleML (manually)
POSL RuleML
paymentCalculator
(?Price,?Compensation,
?Payment) :-
lessThan(?Compensation,
?Price),
Equal(?Payment,subtract(?Price,
?Compensation)).
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29. Visualizing RuleML as Grailog(svg)
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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
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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
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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”
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33. 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
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