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Claim Management System

Tim Bridwell

Information Systems Analysis & Design

L & I SCI 788 SEC 001

Dr. Jin Zhang

Spring 2010

Table of Contents

Context DFD ……………………………………………………………………………………………………………………….. 1

Diagram 0 …………………………………………………………………………………………………………………………… 2

Process 1 ……………………………………………………………………………………………………………………………. 3

Process 2…………………………………………………………………………………………………………………………….. 4

Process 3…………………………………………………………………………………………………………………………….. 5

Process 4…………………………………………………………………………………………………………………………….. 6

Process 5…………………………………………………………………………………………………………………………….. 7

Process Specifications…………………………………………………………………………………………………………. 8

Data Flow Descriptions ………………………………………………………………………………………………………. 12

Data Structures ………………………………………………………………………………………………………………….. 25

Element Descriptions …………………………………………………………………………………………………………. 31

Data Store Descriptions ……………………………………………………………………………………………………… 70

i

Insured/Claimant

Claim Processing Provider

Claim FormClaim Form

EOB/PaymentEOB/Payment

UtilizationReview

PreCertification

EOB/Denial Letter

No coverage letter

EOB/Denial letter

AccountManagement

Account Detail

1

ProcessPayment

5

AdjudicateClaim

4

EnterClaim

1

LoadClaim

2

CheckRepricing

3

CMSD1

Notice of Claim (2a)

Verified Claim Notice (3a)

Discounted Claim Notice (4a)

ClaimPayment

Detail (4k)

ClaimDetail(1d)

Insured ID (2c)

ClaimAssignment

(2d)

Claim Detail

(1d)

Repricing MasterD2

ProviderTax ID (3e)

DiscountRate (3b)

DiscountRate (3b)

Claim Detail (1d)

EOB/Payment

(5c)

Claim File MasterD3

Claim Image (1b)

DenialDetail

(4l)

EOB/DenialLetter(5d)

PreCert MasterD4

PreCertificationStatus (6b)

Group Number (2b)

Claim Image (1b)

Claim History (4e)

BatchNumber

(1c)

Claimant ID (2e)

No coverageLetter (2f)

NetworkID (3f)

Claim Number(2h)

Account MgtMaster

D5

Claim Payment Master

D6

EOB/Payment

Detail

(5a)

EOB/DenialDetail

(5b)

Benefits Code (4f)

Claim File (1e)

Claim Form (1a)

CoPay & deductible Limits (1f)

Precertification(6a)

ClaimDetail(1d)

2

EnterClaim

1.1

CMSD1


ClaimDetail(1d)

Claim File MasterD3

BatchNumber

(1c)

Claim Form (1a)Assign Batch

Number

1.2

Enter ClaimDetail

1.3

Claim File (1e) Claim File (1e)

Claim

File (1e)

Claim Image (1b)

Acct Mgt MasterD5

CoPay &DeductibleLimits (1f)

3

VerifyInsured

Claimant

2.1

AssignClaim

Number

2.2

Claim Mgt SysD1


Verification ofCoverage (2g)

Insured ID (2c)

Group Number (2b)

Account MgtMaster

D5

ClaimDetail(1d)

No coverageLetter (2f)

Verified Claim Notice (3a)

ClaimantID (2e)

Claim Detail(1d)

Claim number

(2h)

ClaimAssignment (2d)

AssignAdjuster

2.3

Claim Number (2h)

4

Claim Mgt SysD1

Discounted Claim Notice (4a)

Repricing MasterD2

DiscountRate (3b) Discount

Rate (3b)

Verified ClaimNotice (3a)

ObtainNetwork ID

3.1

ApplyDiscount

3.3

Discount Rate (3b)

Provider

Tax ID (3d)

Network

ID (3e)

Claim Detail (1d)

ObtainDiscount

Rate

3.2

Network ID (3e)

NetworkID (3e)

5

Verify Claim Data Entry

4.1

Claim Mgt SysD1D3

ClaimImage (1b)

ClaimDetail (1d)

AdjudicateClaim

4.6

ClaimPayment

Detail(4k)

DenialDetail

(4l)

ValidateProcedureCoverage

4.2

Verified Discounted Claim Notice (4b)

PreCert MasterD4

PreCertification Status (6b)

ApplyPenalty

4.5

Benefits Code (4f)

Benefits Applied (4g)

ProcedureCode (4d)

DiscountedClaim Notice (4a)

Penalty (4m)

Claim PaymentMaster

D6

Acct Mgt MasterD5

Claim File Master

CheckClaim

History

4.3

Claim

History (4e)

ProcedureApproval

(4c)

ProcedureApproval

(4c)

CheckPrecertification

4.4

ClaimHistory

Approval(4n)

Claim w/oPreCert Notice

(4h)

Claim w/Penalty

Notice

(4i)

Claim w/PreCert

Notice (4j)

BenefitsCode(4f)

Claim Detail (1d)

6

ProcessEOB/Payment

5.1

EOB/Payment

(5c)

EOB/DenialLetter(5d)

Claim Payment MasterD6

ProcessEOB/Denial

5.2

EOB/Payment

Detail

(5a)

EOB/DenialDetail

(5b)

7

8

Process Specification Forms

Process Specification Form

Process ID: 1.1 Process Name: Enter Claim

Description: Claim form detail is entered into the Claim File.

Input Data Flow(s): Process Description: Output Data Flow(s):

Claim form (1a)

IF claim image has not come in electronically THEN data enter into claim file ELSE IF scan claim image into D3 THEN data enter into claim file END IF

Claim image (1b) Claim file (1e)

Comments: Do process for every claim received.


Process ID: 1.2 Process Name: Assign Batch Number

Description: Claim files are grouped into batches of ten, and Batch Numbers are assigned in CMS.


Claim file (1e) Action 1: assign claim batch number in D1 Batch Numbers (1c)



Process ID: 1.3 Process Name: Enter Claim

Description: Batches of claims are then entered individually into Claim Detail in CMS.


Claim File (1e) CoPay & Deductible Limits (1f)

Action 1: Enter claim file into claim detail in CMS Action 2: Enter copay and deductible limits into claim detail in CMS Action 3: Input Notice of Claim into Claim Detail/CMS

Notice of claim (2a)



Process ID: 2.1 Process Name: Verify insured claimant

Description: Verifies that the claimant is covered under a policy, if not sends notification.

Input Data Flow: Process Description: Output Data Flow:

Notice of claim (2a) Group Number (2b) Insured ID (2c) Claimant ID (2e) Claim detail (1d)

IF no Insured ID in D5 THEN send No Coverage Letter ELSE IF no Claimant ID in D5 THEN send No Coverage Letter ELSE enter Ver. of Coverage in Claim Detail in D1 ENDIF

Verification of coverage (2g) No coverage letter (2f)

Comments: Conditional/decision structure.

9


Process ID: 2.2 Process Name: Assign Claim Number

Description: Upon receipt of verification of coverage claim is assigned claim numbers and adjuster.


Verification of coverage (2g) Claim Detail (1d)

Action 1: Assign claim number in CMS Claim number (2h)

Comments: Sequential action.


Process ID: 2.3 Process Name: Assign Adjuster

Description: Upon receipt of verification of coverage claim is assigned claim numbers and adjuster.


Claim number (2h)

Action 1: Assign claim to adjuster in CMS Action 2: Update Claim Detail with VCN (3a)

Verified claim notice (3a) Claim assignment (2d)

Comments: Sequential actions.


Process ID: 3.1 Process Name: Obtain network ID

Description: Determines provider network via claim detail. Updates Claim detail with Network ID.


Verified claim notice (3a) Claim detail (1b)

Action 1: Read Provider Tax ID from Claim Detail Action 2: Query D2 for Network ID Action 3: Update Claim Detail w/Network ID

Network ID (3e)



Process ID: 3.2 Process Name: Obtain discount rate

Description: Obtains discount rate per provider network. Updates Claims Detail.


Network ID (3e) Action 1: Query D2 for Network ID Action 2: Obtain Discount Rate Action 3: Update Claim detail w/Discount Rate

Network ID (3e) Discount rate (3f)

Comments: Sequential structure.


Process ID: 3.3 Process Name: Apply discount

Description: Applies discount to claim charges and updates claim detail.


Discount rate (3b) Action 1: Apply discount rate to charges Action 2: Update claim detail w/discounted claim notice

Discounted claim notice (4a) Discount rate (3b)

Comments: Sequential structure.

10


Process ID: 4.1 Process Name: Verify claim data entry

Description: Verifies claim data entry to insure claim image and claim detail harmonize accurately.


Discounted claim notice (4a) Claim image (1b) Claim detail (1d)

Action 1: Check claim image against claim detail for errors Action 2: Correct any errors Action 3: Update claim detail with VDCN (4b)

Verified discounted claim notice (4b)

Comments: Sequential action.


Process ID: 4.2 Process Name: Validate procedure coverage

Description: Check data store D1 & D5 to confirm procedures are covered under plan.


Verif. disc. claim notice (4b) Procedure code (4d)

IF no coverage for procedure THEN deny procedure ELSE approve procedure END IF

Procedure approval (4c)

Comments: Decision structure.


Process ID: 4.3 Process Name: Check claim history

Description: Check data store D1 & claim history to insure no duplicate charges are paid


Procedure approval (4c) Claimant history (4e)

IF no duplicate charges are found THEN approve charges ELSE deny charges END IF

Claim history approval (4n)



Process ID: 4.4 Process Name: Check precertification

Description: Check data store D6 for precertification approval or denial.


Claim history approval (4n)

PreCert. Status (6b)

IF no precertification was approved THEN update claim detail w/o precert notice ELSE update claim detail w/precert notice END IF

Claim w/precert notice (4j) Claim w/o precert notice (4h)


11


Process ID: 4.5 Process Name: Apply penalty

Description: If claim has not been precertified, apply no discount or penalty as appropriate.


Claim w/o precert notice (4h)

IF no penalty applies THEN pass claim through w/o discount ELSE IF penalty applies THEN apply 50% penalty END IF

Claim w/penalty notice (4i) Penalty (4m)



Process ID: 4.6 Process Name: Adjudicate claim

Description: Inspects accumulated data to determine if payment is warranted and copay and deductible have been met, if payment is warranted issues check approval, if not denies claim.


Claim detail (1d) Claim w/penalty notice (4i) Claim w/precert notice (4j) Benefits code (4f)

IF All data entry and processes are correct THEN Apply benefits less copay and deductible ELSE Deny claim END IF

Claim payment detail (4k) Denial detail (4l)



Process ID: 5.1 Process Name: Process payment

Description: Prints and releases EOB, payment (check).


EOB/Claim payment detail (5a) 1. Check in payment detail 2. Print EOB/check 3. Mail

EOB/Payment (5c)

Comments: Action.


Process ID: 5.2 Process Name: Process denial

Description: Prints and mails EOB, denial letter.


EOB/Denial detail (5b) 1. Check in denial detail 2. Print EOB/denial letter 3. Mail

EOB/Denial letter (5d)

Comments: Action.

12

Data Flow Descriptions

Data Flow Description

ID: 1a Name: Claim Form Description: Contains the claimant identification, medical services provided, provider identification and billing charges which allows the insurer to process the claim.

Source: Claimant/Provider Destination: Process 1.1

Type of Data Flow: File Screen Report X Form Internal

Data Structure Traveling with the Flow: Claim File Volume/Time: 1000+ daily

Comments: Medical claim information for one claimant, one service, one provider: the claim may be received by mail or electronic submission.


ID: 1b Name: Claim image Description: Claim form scanned into system.

Source: Process 1.1 Destination: D3/Process 1.1/Process 4.1

Type of Data Flow: File X Screen Report Form Internal

Data Structure Traveling with the Flow: Claim image Volume/Time: 1000+ daily

Comments: Claim image is used to enter claim detail in system and by adjudication to verify claim detail.


ID: 1c Name: Batch Number Description: Batch numbers are a group of claims of the same type and received the same day. They are assigned in groups for claim file location and inventory.

Source: Process 1.2 Destination: D1

Type of Data Flow: X File Screen Report Form Internal

Data Structure Traveling with the Flow: Batch Number Volume/Time: 100+ daily

Comments: Batch numbers group similar claim types for ease of processing

13


ID: 1d Name: Claim detail Description: Claim detail is entered into CMS from the claim file information.

Source: Process 1.3/D1 Destination: D1/Process 2.1, 2.2/Process 3.1, 3.2/ Process 4.1


Data Structure Traveling with the Flow: Claim detail Volume/Time: 1000+ daily

Comments: Claim detail is essentially the data from the claim form input into assigned data fields in the Claim Mgt Sys database (D1) and is accessed and updated by all remaining processes. It is the central file for handling the claim from system input to output.


ID: 1e Name: Claim file Description: Claim file is the result of process 1.1. Claim form data entered manually. It is read by all of Process 1 directly and loaded into CMS as part of Claim Detail (1d).

Source: Process 1.1 Destination: D3/Process 1.2, 1.3


Data Structure Traveling with the Flow: Claim file Volume/Time: 1000+

Comments: Used to input claim data into CMS and claim detail file. Serves as archive of original claim data submitted to claim department.


ID: 2a Name: Notice of Claim Description: Contains update to claim detail and trigger notification of new claim to the claim department.

Source: Process 1.3 Destination: D1/Process 2.1


Data Structure Traveling with the Flow: Claim notice. Volume/Time: 1000+ daily

Comments: The notice of claim is sent electronically to the eligibility process via a batch file daily. It is updated once claim entry is completed.

14


ID: 2b Name: Group Number Description: Group number is a unique identification number for each insured group.

Source: D5 Destination: Process 2.1


Data Structure Traveling with the Flow: Group number Volume/Time: 1000+

Comments: Used by Eligibility to verify claimant’s group coverage.


ID: 2c Name: Insured ID Description: Primary insured’s unique identification number, social security number is used.



Data Structure Traveling with the Flow: Insured ID Volume/Time: 1000+ daily

Comments: Used to identify and confirm coverage and plan assignment for claim and claimant.


ID: 2d Name: Claim assignment Description: Assignment of claim to an adjuster for adjudication. Claim detail is updated to assign claim to adjuster.

Source: Process 2.2 Destination: Process 2.3


Data Structure Traveling with the Flow: Adjuster ID Volume/Time: 1000+ daily

Comments: Claim assignment assigns adjuster to handle claim adjudication.

15


ID: 2e Name: Claimant ID Description: D5 is checked to insure that claimant ID is identified as an insured claimant.


Type of Data Flow: x File X Screen Report Form Internal

Data Structure Traveling with the Flow: Claimant ID Volume/Time: 1000+ daily

Comments: Claimant ID can be the same or different from Insured ID (spouse, child, same person, etc.)


ID: 2f Name: No coverage letter Description: Letter sent to insured/claimant that person identified on claim is not enrolled in groups’ insurance policy. Claimant is informed to contact Account Mgt to update records if applicable.

Source: Process 2.1 Destination: Insured/Claimant

Type of Data Flow: x File Screen Report X Form Internal

Data Structure Traveling with the Flow: No coverage letter Volume/Time: 10+ daily

Comments: Letter used to alert claimant, insured of no such person enrolled in plan.


ID: 2g Name: Verification of coverage Description: Once claimant is identified as covered claim is released to Process 2.2 via Claim Detail update in D1.



Data Structure Traveling with the Flow: Verification of coverage. Volume/Time: 1000+ daily

Comments: None.

16


ID: 2h Name: Claim number Description: Claim is assigned a unique internal number for processing and CMS identification of claim in system. It becomes part of Claim Detail.



Data Structure Traveling with the Flow: Claim number. Volume/Time: 1000+ daily

Comments: None.


ID: 3a Name: Verified claim notice Description: Claim marked as verified for coverage in claim detail and sent on to processing.

Source: Process 2.3 Destination: D1, Process 3.1


Data Structure Traveling with the Flow: Verified claim notice Volume/Time: 1000+ daily

Comments: None.


ID: 3b Name: Discount rate Description: Contracted rate between provider and network is read from D3 and forwarded to process 3.3

Source: D2/Process 3.2/Process 3.3 Destination: Process 3.2/Process 3.3/D1

Type of Data Flow: X File X Screen Report Form Internal

Data Structure Traveling with the Flow: Discount rate Volume/Time: 1000+ daily

Comments: None.

17


ID: 3c Name: Charge code Description: Professional or institutional services charge assessed by physician or facility, coding is read from claim detail and D2 is queried for applicable discount. It is a line item charge on the claim form coded for claim processing.

Source: D1 Destination: Process 3.2/D2


Data Structure Traveling with the Flow: Charge code Volume/Time: 1000+ daily

Comments: Numeric code.


ID: 3d Name: Provider Tax ID Description: Used to identify network provider belongs to, if any, and D2 is queried for applicable network ID.



Data Structure Traveling with the Flow: Provider tax ID Volume/Time: 1000+ daily

Comments: D2 queried for network information and discount rate.


ID: 3e Name: Network ID Description: Used to identify network and network discounts, if any.

Source: D2/Process 3.1 Destination: Process 3.1/Process 3.2


Data Structure Traveling with the Flow: Network ID Volume/Time: 1000+ daily

Comments: D2 queried for network information.

18


ID: 4a Name: Discounted claim notice Description: D1 and claim detail are updated with notification that discount has been applied and claim is ready for adjudication. Notice is sent to Process 4.1.



Data Structure Traveling with the Flow: Discounted claim notice. Volume/Time: 1000+ daily

Comments: Claim is marked as discounted and notice sent to adjudication.


ID:4b Name: Verified discounted claim notice Description: After confirmation of claim data entry accuracy, resulting confirmed or verified claim is approved for adjudication as a result of previous processes. All necessary information to adjudicate claim is in the system and it is ready for the adjuster to process the claim. Claim detail is updated and adjuster is notified via CMS.



Data Structure Traveling with the Flow: Verified discounted claim notice.

Volume/Time: 1000+ daily

Comments: None.


ID: 4c Name: Procedure approval Description: Procedure code is read from claim detail and validated against D5 and policy information (benefit code) to validate coverage of procedure by benefit plan.

Source: Process 4.2 Destination: D1/Process 4c


Data Structure Traveling with the Flow: Procedure approval Volume/Time: 1000+ daily

Comments: Confirmation of procedure billed being eligible for coverage under plan.

19


ID: 4d Name: Procedure code Description: Medical codes entered during claim entry which signify type of procedure(s) performed. They are used to verify charges are covered by plan.



Data Structure Traveling with the Flow: ICD9 codes Volume/Time: 1000+ daily

Comments: None.


ID: 4e Name: Claim history Description: Record of previous claims submitted and processed for each claimant. This information of used to identify duplicate billing and duplicate payment.


Type of Data Flow: File Screen X Report Form X Internal

Data Structure Traveling with the Flow: Claim details (past) Volume/Time: 1000+ daily

Comments: Individual record of past claims submitted by this claimant to this plan.


ID: 4f Name: Benefits code Description: Coding identifying benefits claimant is eligible for under current plan. It is used to confirm that benefits applied are correct and due claimant per policy.

Source: D6 Destination: Process 4.2, 4.6


Data Structure Traveling with the Flow: Benefits code Volume/Time: 1000+ daily

Comments: Benefits code is used to determine coverage of services under insured’s plan.

20


ID: 4g Name: Benefits applied Description: Results of adjudication (approval/denial/payment amount) are entered into D1 CMS, and applied to current claim and claimant history.



Data Structure Traveling with the Flow: Benefits applied Volume/Time: 1000+ daily

Comments: Data entry updating claim detail is submitted to CMS.


ID: 4h Name: Claim w/o PreCert notice Description: Claim that has not been precertified that is required by the policy to have precertification prior to admittance or treatment. As a result of Process 4.2 claim detail is updated and sent to process 4.3 for application of penalty.



Data Structure Traveling with the Flow: PreCertification Confirmation Volume/Time: 300+

Comments: Claims that are not approved prior to treatment are assessed a penalty or denial of discount.


ID: 4i Name: Claim w/penalty notice Description: Claim detail updated to include penalty applied due to results of process 4.3.



Data Structure Traveling with the Flow: Penalty applied notice Volume/Time: 200+ daily

Comments: Claims that have not been precertified and now have penalty applied.

21


ID: 4j Name: Claim w/ PreCert notice Description: Claim detail updated to include precertification has been approved and applicable discounts applied.



Data Structure Traveling with the Flow: Precertification confirmation Volume/Time: 300+ daily

Comments: Claims that have been precertified prior to beginning of treatment/service.


ID: 4k Name: Claim Payment Detail Description: Claim detail is updated with adjudication results and payment detail and is used to print explanation of benefits and payment check. It is sent to payment processing to generate check and EOB.



Data Structure Traveling with the Flow: Claim payment detail, EOB. Volume/Time: 1000+ daily

Comments: Payment detail for one claim.


ID: 4l Name: Denial detail Description: Claim detail is updated and denial detail contains claim denial reason codes and their explanation (EOB). It is sent to payment processing to generate EOB/Denial letter.



Data Structure Traveling with the Flow: EOB, denial letter. Volume/Time: 1000+ daily

Comments: Includes free text explanation of denial.

22


ID: 4m Name: Penalty Description: Claim detail is updated with non‐precertification penalties applied.



Data Structure Traveling with the Flow: Penalty Volume/Time: 1000+ daily

Comments: Either penalty or no discount.


ID: 4n Name: Claim history approval Description: Claim detail is updated with notice that claim history has been checked.



Data Structure Traveling with the Flow: Claim history approval Volume/Time: 1000+ daily

Comments: None.


ID: 5a Name: EOB/Payment detail Description: EOB/Payment detail is the explanation of benefits and payment details for one claim. It is used to prepare and print the EOB form and check.



Data Structure Traveling with the Flow: Payment detail, explanation of benefits.

Volume/Time: 1000+

Comments: None.

23


ID: 5b Name: EOB/Denial Detail Description: Contains claim EOB and denial information. It is sued to prepare and print EOB form and denial letter.



Data Structure Traveling with the Flow: EOB, denial detail. Volume/Time: 200+

Comments: None.


ID: 5c Name: EOB/Payment Description: EOB/Payment includes the explanation of benefits and payment details for one claim, and the check issued in the amount of payable benefits for one claim.

Source: Process 5.1 Destination: Claimant/Provider


Data Structure Traveling with the Flow: Payment detail, explanation of benefits, check.

Volume/Time: 1000+

Comments: None.


ID: 5d Name: EOB/Denial letter Description: Contains claim EOB and denial information in letter form.

Source: Process 5.2 Destination: Claimant/Provider


Data Structure Traveling with the Flow: EOB, denial detail. Volume/Time: 200+

Comments: None.

24


ID: 6a Name: PreCertification Description: Approval of services obtained prior to treatment per policy requirements. Obtained by external entity/vendor.

Source: Utilization review (external entity) Destination: D4


Data Structure Traveling with the Flow: PreCertification, precert number

Volume/Time: 100+ daily

Comments: None.


ID: 6b Name: Precertification status Description: D4 is checked and claim detail updated to reflect that precertification has been obtained or not.


Type of Data Flow: File X Screen Report Form X Internal

Data Structure Traveling with the Flow: Precertification confirmation Volume/Time: 300+ daily

Comments: None.

25

Data Structures

Account details= Group number+

Insured ID+

Claimant ID+

Copay & deductible limits+

Benefits code

Batch number= Year+

Julian date+

Sequential number

Benefits applied= CoPay+

Deductable+

Other credits+

Other insurance+

Total paid+

Patient responsibility

Benefits code= Plan name abbreviation+

Sequential number

Cause of condition= [employment|auto accident|other]

Charge code= [1|2]

Check= Account number +

Check number+

Date+

Insurer address+

Insurer Name+

Provider address+

Provider name+

Routing number+

Total payment

Claim Detail= Adjuster ID+

Batch Number+

Benefits applied+

Charge code+

Claim File+

Claim history approval+

Claim number+

Claim w/ penalty notice+

Claim w/ Precert notice+

26

Claimant ID+

Discount rate+

Discounted claim notice+

Discounted unit amount+

Notice of claim+

Penalty +

Plan name+

Policy number+

PreCertification Status+

Procedure approval+

Type of service+

Verification of coverage+

Verified claim notice

Claim File= Account number+

Amount paid+

Balance due+

Cause of condition+

Claimant Address+

Claimant date of birth+

Claimant Gender+

Claimant Name+

(Claimant Telephone)+

Co‐Pay+

Diagnosis code+

Employer name+

(Employment status)+

From date of service+

Insured address+

Insured date of birth+

Insured gender+

Insured ID+

Insured name+

(Insured telephone)+

(Marital status)+

Modifier+

(Other health plan)+

(Plan name)+

Policy number+

Procedure code+

27

Provider address+

Provider name+

Provider tax ID+

Relationship to insured+

Release on file+

Service charges+

To date of service+

Total charges+

Units

Claim history= Claimant name+

Claimant ID+

1{Claim detail }

Claim image= [HCFA|UB]

Claim number= Year+

Julian date+

Sequential number

Claim Payment detail= Account number+

Benefit code+

Check number+

Co‐pay+

Date+

Deductible+

Eligible amount+

Insurer address+

Insurer Name+

Other credits or adjustments+

Patient responsibility+

Penalty+

Provider address+

Provider name+

Routing number+

Total payment

Claim w/ penalty notice= [yes|no]

Claim w/ Precert notice= [yes|no]

Claimant address = Street+

(apartment)+

City+

State+

Zip+

28

(Zip expansion)

Claimant Date of Birth= Day+

Month+

Year

Claimant Gender= [Male|Female]

Claimant ID= social security number

Claimant Name = First name+

([middle name|middle initial])+

Last name

Claimant Telephone= Area code+

Local number

CoPay & Deductible Limits= CoPay+

Deductible

Denial detail= Explanation of benefits+

Denial letter

Diagnosis code= 1{ICD9 Code}

Discounted claim notice= [yes|no]

Discounted unit amount= 1{Unit discount amount}

Employment status= [employed|full time student|part time student]

Explanation of benefits= Claim payment detail+

Reason code+

Reason code description

From Date of Service= Day+

Month+

Year

Group Number= Three letter prefix+

Year coverage began+

Sequential number

Institutional charge= 1{(CPT code)}

Insured date of birth= Day+

Month+

Year

Insured gender= [male|female]

Insured ID = social security number

Insured name= First name+

([middle name|middle initial])+

Last name

Insured telephone= Area code+

Local number

29

Insurer address= Street+

(apartment)+

City+

State+

Zip+

(Zip expansion)

Marital status= [single|married|other]

Network ID= Network abbreviation+

Sequential number

Notice of claim = [Yes|No]

Number of units= 1{Units}

Other health plan= [yes|no]

Policy number= Group ID+

Year+

Sequential number

PreCertification= Cause of condition+

Claimant Address+

Claimant date of birth+

Claimant Gender+

Claimant ID+

Claimant Name+

(Claimant Telephone)+

Date of notification+

Diagnosis code+

Employer name+

From date of service+

Insured address+

Insured date of birth+

Insured gender+

Insured ID+

Insured name+

(Insured telephone)+

(Marital status)+

Modifier+

(Other health plan)+

Patient account number+

(Plan name)+

Policy number+

Precertification number+

30

Precertification Status+

Procedure approval+

Procedure code+

Provider address+

Provider tax ID+

Relationship to insured+

To date of service+

(Type of service)+

Units

PreCertification Status= [A|D]

Procedure approval= [yes|no]

Procedure code= CPT code

Provider address= Street+

City+

State+

Zip+

(Zip extension)

Provider Tax ID= [federal tax ID|social security number]

Relationship to Insured= [self|spouse|child|other]

Release on file= [yes|no]

Service charges= 1{charge amount}

To Date of Service= Day+

Month+

Year

Verification of coverage= [yes|no]

Verified claim notice= [yes|no]

31

Element Descriptions

Element Description Form

ID: Name: Batch number Alias: Alias: Description: Batch numbers are assigned during process 1 to organize incoming clains into batches for easier processing. Keyed in by processs 1.2

Element Characteristics

Required: Optional: Length: 11 Dec. Pt.: Input Format: 9 (11) Output Format: 9 (11) Default Value: Continuous: Discrete:

Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:

Validation Criteria

Continuous Upper Limit: Lower Limit:

Discrete Value: Meaning: Year Four digit year, current Julian Date Three digit day of year Sequential Number Four digit number assigned in sequence

Comments: None.


ID: Name: CoPay Alias: Alias: Description: Amount to be paid by claimant at time of service per policy/plan, keyed in by process 1.1


Required: Optional: Length: 7 Dec. Pt.: 9999.99 Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:


Validation Criteria

Continuous Upper Limit: ≤ 9999.99 Lower Limit: ≥ 0000.01

Discrete Value: Meaning:

Comments: Generally in increments of $20.00 USD.

32


ID: Name: Deductable Alias: Alias: Description: Amount claimant must pay out of pocket before benefits are applied per policy/plan. Keyed in from policy info in D5 by process 1.3 and read by process 4.6




Validation Criteria



Comments: Generally $500.00 or $1000.00 USD.


ID: Name: Other credits Alias: Alias: Description: Any other credits applied to claimant account, i.e. overpayment of copay. Keyed in by process 1.




Validation Criteria



Comments: None.

33


ID: Name: Other insurance Alias: Alias: Description: Payments made by other insurance covering claimant at time of service. Keyed in by process 1.




Validation Criteria



Comments: None.


ID: Name: Total paid Alias: Alias: Description: Total amount paid by claimant at time of service. Keyed in by process 1.1




Validation Criteria



Comments: None.

34


ID: Name: Patient responsibility Alias: Alias: Description: Amount after all other benefits and payments applied is payable/responsibility of claimant. Keyed in by process 4.4




Validation Criteria



Comments: None.


ID: Name: Benefits code Alias: Plan code Alias: Description: Read by process 4.6 to confirm benefits applied by prior processes. Keyed in by account management (external entity).


Required: Optional: Length: 8 Dec. Pt.: Input Format: X (8) Output Format: X (8) Default Value: Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: Prefix Three letter prefix of plan name Seq # 5 digit number assigned by account management

Comments: None.

35


ID: Name: Cause of condition Alias: Cause Alias: Description: Causality of current diagnosis/condition/treatment. Keyed in by Process 1.1


Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: O Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: O Other E Employment A Auto accident

Comments: None.


ID: Name: Account number Alias: Patient account number Alias: Description: Patients account number with the provider. Keyed in by process 1.1




Validation Criteria


Discrete Value: Meaning: VarChar Can be any combination of aplhanumeric char.

Comments: None.


36

ID: Name: Check number Alias: Alias: Description: Number assigned to a claim payment check. Sequentially assigned by process 5.1




Validation Criteria

Continuous Upper Limit: ≤ 999999 Lower Limit: ≥ 000001


Comments: None.


ID: Name: Date Alias: Alias: Description: Date check printed




Validation Criteria

Continuous Upper Limit: ≤ 01012100 Lower Limit: ≤ 01012010


Comments: None.

37


ID: Name: Insurer name Alias: Insurer Alias: Description: Name of insurance company issuing payment. Keyed in by account management. Printed by process 5.1 & 5.2


Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: Predefined Name of insurer

Comments: None.


ID: Name: Provider name Alias: Alias: Description: Name of either institution of professional rendering services. Keyed in by Process 1.1




Validation Criteria

Continuous Upper Limit: ≤ Z Lower Limit: ≥ A


Comments: None.

38


ID: Name: Routing number Alias: Alias: Description: Routing number for bank. Keyed in by account management and assigned by banking institution (external entities). Printed by process 5.1




Validation Criteria



Comments: None.


ID: Name: Total payment Alias: Check amount Alias: Description: Total payment being made for this claim. Keyed in by process 4.6




Validation Criteria



Comments: None.

39


ID: Name: Adjuster ID Alias: Alias: Description: Used to indetify adjust in the system. Keyed in by process 2.3




Validation Criteria


Discrete Value: Meaning: XXX Adjuster initials (First Mid Last)

Comments: Adjuster's first middle and last initials are used.


ID: Name: Claim history approval Alias: History check Alias: Description: Process 4.3 checks claim charges against claimant claim history to prevent duplicate bill payments.


Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: A Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: D Denied, charge already paid A Approved, charge not paid

Comments: None.

40


ID: Name: Claim number Alias: Alias: Description: Claim number assigned and keyed in by process 2.2.




Validation Criteria


Discrete Value: Meaning: Year Four digit year Julian number Numerical day of year Seq number Sequential number assigned by process 2.2

Comments: Claim number is used to bring up claim from process 2.2 on.


ID: Name: Claim w/ penalty notice Alias: Alias: Description: Claim that has had penalty applied for non‐precert services and is now released to process 4.6. Keyed in by process 4.5


Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: Y Released to process 4.4 N Pending in process 4.3

Comments: None

41


ID: Name: Claim w/ precert notice Alias: Alias: Description: Claim that has been precertified and is now released to process 4.6. Keyed in by process 4.4




Validation Criteria


Discrete Value: Meaning: Y Released to process 4.4 N Pending in process 4.3

Comments: None


ID: Name: Claimant ID Alias: Social security number Alias: Description: Each covered individual uses their social security number for a claimant number. It is used to identify them in the CMS and their claim form. Keyed in by process 1.3




Validation Criteria



Comments: None.

42


ID: Name: Discount rate Alias: Discount Alias: Discount percentage Description: Percentage discount applied to services provided by in‐network providers. Read by process 3.2 and keyed into Claim detail by process 3.3


Required: Optional: Length: 2 Dec. Pt.: Input Format: 9 (2) Output Format: 9 (2) Default Value: 00 Continuous: Discrete:


Validation Criteria



Comments: Contracted service rates based on provider network set up by account management.


ID: Name: Discounted claim notice Alias: Alias: Description: Keyed in by process 3.3 to release claim to process 4.1 upon completion of repricing.




Validation Criteria


Discrete Value: Meaning: Y Claim is released to process 4.1 N Claim is pending in process 3

Comments: None.

43


ID: Name: Discounted unit amount Alias: Unit discount amount Alias: Description: Amount of service charge after discount applied in USD. Keyed in by process 3.3




Validation Criteria



Comments: None.


ID: Name: Notice of claim Alias: Alias: Description: Alerts process 2.1 of claim. Keyed in by process 1.3




Validation Criteria


Discrete Value: Meaning: Y Claim is released to process 2.1 N Claim is pended in process 1

Comments: Claim is by default pended for completion of process 1. Once process one is completed Notice of Claim is sent by keying in "Y."

44


ID: Name: Penalty Alias: Alias: Description: Amount not covered by policy/plan. Keyed in by account management (external entity) and read by process 4.5




Validation Criteria



Comments: Penalty for non‐precertified services is based on policy/plan. Generally either 25%, 50% or 80%.


ID: Name: Plan name Alias: Alias: Description: Name of particular plan group coverage is written in. Keyed in by Account Management.




Validation Criteria


Discrete Value: Meaning: Plan name Assigned by Account Management

Comments: None.

45


ID: Name: Policy number Alias: Alias: Description: Unique number code assigned by Account Management to identify the group coverage plan claimant is covered by. Keyed in by Account Management.




Validation Criteria


Discrete Value: Meaning: Group ID Assigned group initials Year 4 digit year policy began Sequential Chronological number

Comments: None.


ID: Name: PreCertification status Alias: Alias: Description: Process 4.4 reads PreCert Database maintained by Utilization Review (external entity).




Validation Criteria


Discrete Value: Meaning: A Treatment precertified D Treatment not precertified

Comments: None.

46


ID: Name: Procedure approval Alias: Alias: Description: Approval of procedures billed per insured policy. Keyed in by process 4.2




Validation Criteria


Discrete Value: Meaning: Y Release to process 4.3 N Pend in process 4.2

Comments: None.


ID: Name: Type of service Alias: Alias: Description: Type of service rendered, either professional (Doctor) or Institutional (i.e. hospital). Keyed in by Utilization Review (external entity). Entered into claim detail by process 4.4




Validation Criteria


Discrete Value: Meaning: P Professional I Institutaional

Comments: None.

47


ID: Name: Verification of coverage Alias: Alias: Description: Either claimant is found in CMS and claim is sent to process 2.2 or claimant is not found and No Coverage letter is sent to claimant seeking further information or contact Account Management (external entity). Keyed in by process 2.1




Validation Criteria


Discrete Value: Meaning: Y Claimant in system N Letter sent

Comments: None.


ID: Name: Verified claim notice Alias: Alias: Description: Once claim is loaded, claim number assigned and adjuster assigned claim is released to process 3.1. Keyed in by process 2.2




Validation Criteria


Discrete Value: Meaning: Y Claim is release to process 3.1 N By default claim is pended until process 2.2 completed

Comments: None.

48


ID: Name: Amount paid Alias: Patient payment Alias: Description: Amount paid by claimant at time of service. Keyed in by process 1.1




Validation Criteria



Comments: None.


ID: Name: Balance due Alias: Amount now due Alias: Description: Amount being billed to insurance for current claim. Keyed in by process 1.1




Validation Criteria



Comments: None.

49


ID: Name: Claimant gender Alias: Sex Alias: Description: Gender of the claimant. Keyed in by Process 1.1




Validation Criteria


Discrete Value: Meaning: M Male F Female

Comments: None.


ID: Name: Diagnosis code Alias: ICD9 code Alias: Description: Diagnosis codes for this claim. Can be repeated. Keyed in by process 1.1


Required: Optional: Length: 5 Dec. Pt.: X99V99 Input Format: X99.99 Output Format: X99.99 Default Value: Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: X99.99 First char can be alpha, remaining are digits.

Comments: None.

50


ID: Name: Employer name Alias: Alias: Description: Name of employer who group insurance is provided by. Keyed in by Account Management.




Validation Criteria



Comments: None.


ID: Name: Employment status Alias: Alias: Description: Used to determine employment status of claimant. Keyed in by external entity, Account Management.




Validation Criteria


Discrete Value: Meaning: 1 Employed 2 Unemployed 3 Full time student 4 Part time student

Comments: None.

51


ID: Name: Insured ID Alias: Social security number Description: Unique identifying number of primary insured (i.e. employee) who has taken out the policy, it need not be the claimant who submits the claim. Keyed in by Process 1.1




Validation Criteria



Comments: Standard US social security number, used as Insured ID and/or Claimant ID


ID: Name: Modifier Alias: Alias: Description: Modifier code further identifies the procedure code. Keyed in by process 1.1




Validation Criteria



Comments: None.

52


ID: Name: Other health plan Alias: Other coverage Alias: Description: Indicates if claimant has any other health insurance coverage. Keyed in by Process 1.1




Validation Criteria


Discrete Value: Meaning: Y Yes, has other coverage N No, no other coverage

Comments: None.


ID: Name: Provider Tax ID Alias: Federal tax ID Alias: Social security number Description: Number used to identify provider in system. Keyed in by process 1.1




Validation Criteria



Comments: None.

53


ID: Name: Relationship to insured Alias: Alias: Description: Used for relationship to insured. Keyed in from claim form by process 1.1




Validation Criteria


Discrete Value: Meaning: 1 Self 2 Spouse 3 Child 4 Other

Comments: Used to identify whom the claimant is in relationship to the policy holder/insured.


ID: Name: Release on file Alias: Alias: Description: Claimant has signed release of medical records on file with company. Keyed in by Account Management.




Validation Criteria


Discrete Value: Meaning: Y Yes, release on file N No, release not on file

Comments: None

54


ID: Name: Service charges Alias: Charge amount Alias: Description: Amount charged per unit of service (Unit). Keyed in by process 1.1




Validation Criteria



Comments: None.


ID: Name: Total charges Alias: Alias: Description: Total charges being billed on one claim. Keyed in by process 1.1


Required: Optional: Length: 9 Dec. Pt.: 999999V99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:


Validation Criteria



Comments: None.

55


ID: Name: Units Alias: Number of units Alias: Description: Number of a particular service rendered under one claim. Keyed in by process 1.1


Required: Optional: Length: 3 Dec. Pt.: Input Format: 999 Output Format: 999 Default Value: 001 Continuous: Discrete:


Validation Criteria



Comments: None.


ID: Name: HCFA Alias: Health Claim Form Alias: Description: Form used to submit professional (doctors) charges. It is scanned into D3 for archival purposes and to use for data entry. It is a PDF file.


Required: Optional: Length: X Dec. Pt.: Input Format: X Output Format: X Default Value: Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: Img PDF image of claim form

Comments: None.

56


ID: Name: UB Alias: Alias: Description: Form used to submit institutional (hospital, facility, pharmacy) charges. It is scanned into D3 for archival purposes and to use for data entry. It is a PDF file.


Required: Optional: Length: X Dec. Pt.: Input Format: X Output Format: X Default Value: Continuous: Discrete:


Validation Criteria


Discrete Value: Meaning: Img PDF image of claim form

Comments: None.


ID: Name: Eligible amount Alias: Alias: Description: Amount of charges covered by insurance before repricing. Keyed in by process 4.4




Validation Criteria



Comments: None.

57


ID: Name: Other credits or adjustments Alias: Alias: Description: Other deductions not covered by entries or codes. Keyed in by process 4.6


Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: 00.00 Continuous: Discrete:


Validation Criteria



Comments: None.


ID: Name: Street Alias: Avenue Alias: Road Description: Number and street name of insured, claimant, provider. Keyed in by Process 1.1




Validation Criteria

Continuous Upper Limit: < XXXXXXXXXXXXXXXXXX Lower Limit: >X


Comments: None.

58


ID: Name: Apartment Alias: Unit Alias: Description: Apartment letter or number. Keyed in by Process 1.1




Validation Criteria

Continuous Upper Limit: < XXXXXX Lower Limit:


Comments: None.


ID: Name: City Alias: Town Alias: Village Description: City of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None.

59


ID: Name: State Alias: Alias: Description: State of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria


Discrete Value: Meaning: Table 1 Table of State Abbreviations

Comments: None.


ID: Name: Zip Alias: Zip Code Alias: Description: Zip code of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None.

60


ID: Name: Zip Expansion Alias: Zip+4 Alias: Description: Expanded zip code of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None.


ID: Name: Day Alias: Alias: Description: Date of the month. Used for date elements. Keyed in by various processes.




Validation Criteria



Comments: None.

61


ID: Name: Month Alias: Alias: Description: Used for date elements. Keyed in by various process.




Validation Criteria

Continuous Upper Limit: ≤ 12 Lower Limit: ≥01


Comments: None.


ID: Name: Year Alias: Alias: Description: Used for date element. Keyed in by various processes.




Validation Criteria

Continuous Upper Limit: < 2099 Lower Limit: >1900


Comments: None.

62


ID: Name: First name Alias: Given name Alias: Description: First name of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None


ID: Name: Middle name Alias: Alias: Description: Middle name of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None

63


ID: Name: Middle initial Alias: Alias: Description: Middle initial of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None


ID: Name: Last name Alias: Surname Alias: Description: Last name of insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None.

64


ID: Name: Area code Alias: Alias: Description: Telephone area code for insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria


Discrete Value: Meaning: Table 2 Table of valid area codes.

Comments: None.


ID: Name: Local number Alias: Phone number Alias: Description: Local phone number for insured, claimant or provider. Keyed in by Process 1.1




Validation Criteria



Comments: None.

65


ID: Name: Denial letter Alias: Alias: Description: Free text letter explaining the reason claim is being denied with explination of ways to appeal the decision. Keyed in by process 4.6




Validation Criteria



Comments: None.


ID: Name: ICD9 Code Alias: Alias: Description: ICD9 code identifies diagnosis. Keyed in by process 1.1




Validation Criteria


Discrete Value: Meaning: XXX.XX First char can be alpha, remaining are digits.

Comments: None.

66


ID: Name: Reason code Alias: Alias: Description: The reason code is to alert the claimant to any deduction or denial and the reason for that decision. Keyed in by process 4.6




Validation Criteria


Discrete Value: Meaning: 0 Claim is paid/covered 1 Denial ‐ other insurance 2 Denial ‐ Auto accident 3 Denial ‐ Work accident 4 Denial ‐ Other insurance

Comments: None.


ID: Name: Reason code description Alias: Alias: Description: Free text area for adjuster to explain the reason claim is being denied in more detail. Keyed in by process 4.6




Validation Criteria



Comments: None.

67


ID: Name: Group number Alias: Alias: Description: Group number used to identify insured group. Keyed in by Account Management (external entity) but read by process 2.1




Validation Criteria


Discrete Value: Meaning: Prefix Three letter prefix derived from company name Year Four digit year Seq # Sequential number assigned by Account Mgt

Comments: Group number is generally based on company that provides health coverage.


ID: Name: CPT code Alias: Alias: Description: CPT code signifies the exact procedure performed. Keyed in by process 1.1




Validation Criteria



Comments: None.

68


ID: Name: Marital Status Alias: Alias: Description: Indicates marital status of claimant. Keyed in by Process 1.1




Validation Criteria


Discrete Value: Meaning: M Married S Single

Comments: None.


ID: Name: Network ID Alias: Alias: Description: Unique number used to identify the provider network provider blongs to, it identifies what discount rate to apply to charges. Keyed in by Utilization Review (external entity) read by process 3.2




Validation Criteria


Discrete Value: Meaning: Prefix First three letter od network name Number 5 digit sequential number

Comments: None.

69


ID: Name: Date of notification Alias: Alias: Description: Date that precert was requested/granted, used by process 4.4 to confirm treatment that requires precert was in fact precertified. Keyed in by Utilization Review (external entity).




Validation Criteria


Discrete Value: Meaning: Date MMDDYYYY

Comments: None.


ID: Name: Precertification number Alias: Precert number Alias: Description: Number provided by Utilization Review (external entity) when they confirm precertification of treatment. Keyed in by Utilization review.




Validation Criteria


Discrete Value: Meaning: X99999 Alpha + five digits

Comments: None.

70

Data Store Descriptions

Data Store Description Form

ID: D1 Name: Claim Management System Alias: CMS Description: Contains all records pertaining to the managing of each claim. Data keyed in by process 4.6 and read by processes 5.1 & 5.2.

Data Store Characteristics

File Type: File Format:

Computer Manual: Database: Indexed: Sequential: Direct:

Record Size (Characters): 1000 Number of Records: Maximum 90,000 Percent Growth Per Year: 400

Block Size: Average:

Data Set Name: ClaimDetail.mst Copy Member: ClaimMgtSys Data Structure: Claim Detail Primary Key: Claim number Secondary Key(s): Claimant ID & Batch number

Comments: CMS is backed up every evening. Active claims are held live until they close out. Closed claim EOBs are compiled and retained while remainder of data are pruged from CMS and archived.


ID: D2 Name: Repricing Master Alias: Network DB Description: Repricing DB is comprised of a listing of providers and the networks they belong to. This file is maintained by Account Management and only read by Claims.






Data Set Name: network.mst Copy Member: netmast Data Structure: Repricing Primary Key: Provider ID Secondary Key(s): Provider Name

Comments: The Network Master file is maintained by an external entity. It is read by processes 3.1 & 3.2. The file is updated on an as needed basis as provider join or switch networks. A complete maintenance cycle is performed annually as network agreements are renewed.

71


ID: D3 Name: Claim File Master Alias: Claim File Description: Claim Master file holds all claim images and data entered claim file data. It is dedicated to the claims forms and the information they contain.






Data Set Name: claim.img Copy Member: ClaimImage Data Structure: Claim File Primary Key: Claimant ID Secondary Key(s): Claimant Name, Insured ID

Comments: The Imaging master records are archived once a month for closed claims.


ID: D4 Name: PreCertification Master Alias: PreCert Description: Contains records of precertification approval or denial for all treatment/services that require precertification approval for coverage. It is maintained by an outside vender but read by process 4.4.






Data Set Name: PreCert.MST Copy Member: Precertmast Data Structure: PreCertification Primary Key: PreCertification Number Secondary Key(s): Claimant ID

Comments: PreCertification Master records are retained for 30 days at which time any treatment not begun is required to reapply for PreCertification and the original record is archived. All completed PreCert records are archived every 90 days.

72


ID: D5 Name: Account Management Master Alias: Account Master Description: Contains policy information for all insured claimants and their covered dependents as well as group numbers, insured numbers and claimant numbers, and coverage status/dates. Maintained by Account Management (external entity) read by processes 1.3, 2.1 4.2 & 4.6.






Data Set Name: AcctMgt.MST Copy Member: Acctmast Data Structure: Account Management Primary Key: Group Number Secondary Key(s): Insured ID, Claimant ID

Comments: Account Management Master file is maintained by external entity Account Management. It is purged of records once annually and groups that discontinue coverage are archived.


ID: D6 Name: Claim Payment Master Alias: Payment File Description: Contains all necessary information to process Explination of Benefits, Payment Check or Denial Letter. Information is input by Process 4.4 and read by Process 5.






Data Set Name: ClaimPay.MST Copy Member: Claimpaymast Data Structure: Claim payment detail, Check, EOB, Denial Detail Primary Key: Claim number Secondary Key(s): Claimant name

Comments: Claim payment master file contains all data related to processing payment, EOB and denial letter.

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