Bridwell isad final_project

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

Utilization
Review

PreCertification

Claim Form Claim Form

Insured/ No coverage letter
Claim Processing EOB/Payment Provider
Claimant EOB/Payment
EOB/Denial letter EOB/Denial Letter

Account Detail

Account
Management

1

CoPay & deductible Limits (1f)

Account Mgt
D5
Master

Group Number (2b) Insured
ID (2c)
Benefits Code (4f)
No coverage
Letter (2f)

Claimant
ID (2e)
PreCertification
1 2 3 4 Status (6b)
Claim Form (1a) Notice of Claim (2a)
Enter Load Check Discounted Claim Adjudicate
Verified Claim Notice (4a)
Claim Claim Notice (3a) Repricing Claim
Claim Number D4 PreCert Master
(2h)
Claim
Claim Assignment Claim
Detail Denial
Image (1b) (2d)
Discount Detail
Claim (1d) Precertification
Claim Claim Rate (3b) (4l)
Detail Detail Provider (6a)
File (1e)
(1d) (1d) Tax ID (3e)
Claim
Network Payment
Batch ID (3f) Detail
Number (4k)
(1c)

D3 Claim File Master D1 CMS D2 Repricing Master
Discount
Rate (3b) Claim Payment
D6
Master
Claim Detail (1d)

EOB/ EOB/
Payment Denial
Claim History (4e) Detail Detail
(5a) (5b)

Claim Image (1b)
5

Process
Payment

EOB/
EOB/
Denial
Payment
Letter
(5c)
(5d)

2

1.1 1.2 1.3

Enter Assign Batch Enter Claim Notice of Claim (2a)
Claim Form (1a) Claim File (1e) Claim File (1e)
Claim Number Detail

Claim
Detail
(1d)
Claim CoPay &
Claim
Image (1b) Deductible
File (1e) Limits (1f)

Batch
Number
(1c)

D3 Claim File Master D1 CMS D5 Acct Mgt Master

3

Claimant
Account Mgt
D5
Master Insured ID (2e)
ID (2c)

2.1 2.2 2.3
Group Number (2b)
Verify Verification of Assign
Assign
Insured Coverage (2g) Claim Claim Number (2h) Verified Claim Notice (3a)
Adjuster
Claimant Number
Notice of Claim (2a)

Claim
Detail
(1d)

No coverage Claim
Claim Detail number
Letter (2f)
(1d) (2h)

Claim
D1 Claim Mgt Sys Assignment (2d)

4

3.1 3.2 3.3
Obtain
Verified Claim Obtain Discount Apply Discounted Claim
Network ID (3e) Discount Rate (3b)
Notice (3a) Network ID Discount Notice (4a)
Rate

Network
ID (3e)

Network Discount
ID (3e) Rate (3b) Discount
Rate (3b)

Provider
Tax ID (3d) D2 Repricing Master D1 Claim Mgt Sys

Claim Detail (1d)

5

4.1 4.2 4.3 4.4
Discounted Verified Discounted
Claim Notice (4a) Claim Notice (4b) Validate Procedure Check Claim
Verify Claim Data Approval History Check
Procedure Claim Approval
Entry (4c) Precertification
Coverage History (4n)
Claim Procedure
Image (1b) Code (4d)
Procedure
Approval
(4c)
Claim
History (4e)
Claim
Detail (1d)
Claim w/o
PreCert Notice
PreCertification (4h)
Benefits Status (6b)
D3 Claim File Master D1 Claim Mgt Sys Code D4 PreCert Master
(4f)

4.5 Claim w/PreCert
Notice (4j)
Penalty (4m)
Apply
Penalty

D5 Acct Mgt Master Claim
w/Penalty
Notice
(4i)

Benefits Code (4f)
4.6

Benefits Applied (4g)
Adjudicate
Claim Detail (1d)
Claim
Claim Payment
D6
Master

Claim
Payment
Detail
(4k)
Denial
Detail
(4l)

6

Claim Payment
D6 Master

EOB/ EOB/
Payment Denial
Detail Detail
(5a) (5b)

5.1 5.2

Process Process
EOB/Payment EOB/Denial

EOB/
EOB/ Denial
Payment Letter
(5c) (5d)

7

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 Claim image (1b)
        THEN data enter into claim file    Claim file (1e)
ELSE IF  scan claim image into D3
        THEN data enter into claim file
END IF
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) Action 1: Enter claim file into claim detail in CMS Notice of claim (2a)
CoPay & Deductible Action 2: Enter copay and deductible limits into claim
Limits (1f)                  detail in CMS
Action 3: Input Notice of Claim into Claim Detail/CMS

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) IF no Insured ID in D5 Verification of coverage (2g)
Group Number (2b)     THEN send No Coverage Letter No coverage letter (2f)
Insured ID (2c) ELSE IF no Claimant ID in D5
Claimant ID (2e)     THEN send No Coverage Letter
Claim detail (1d) ELSE enter Ver. of Coverage in Claim Detail in D1
ENDIF
Comments: Conditional/decision structure.

8

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) Action 1: Assign claim number in CMS Claim number (2h)
Claim Detail (1d)
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 Verified claim notice (3a)
Action 2: Update Claim Detail with VCN (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) Action 1: Read Provider Tax ID from Claim Detail Network ID (3e)
Claim detail (1b) Action 2: Query D2 for Network ID
Action 3: Update Claim Detail w/Network ID

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 Network ID (3e)
Action 2: Obtain Discount Rate Discount rate (3f)
Action 3: Update Claim detail w/Discount Rate
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 Discounted claim notice (4a)
Action 2: Update claim detail w/discounted Discount rate (3b)
claim notice
Comments: Sequential structure.

9

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) Action 1: Check claim image against Verified discounted claim
Claim image (1b) claim detail for errors notice (4b)
Claim detail (1d) Action 2: Correct any errors
Action 3: Update claim detail with
VDCN (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) IF no coverage for procedure Procedure approval (4c)
Procedure code (4d)     THEN deny procedure
    ELSE approve procedure
END IF
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) IF no duplicate charges are found Claim history approval (4n)
Claimant history (4e)    THEN approve charges
   ELSE deny charges
END IF

Process ID: 4.4 Process Name: Check precertification
Description: Check data store D6 for precertification approval or denial.
Claim history approval (4n) IF no precertification was approved Claim w/precert notice (4j)
PreCert. Status (6b)    THEN update claim detail w/o Claim w/o precert notice (4h)
precert notice
   ELSE update claim detail w/precert
notice
END IF

10

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 Claim w/penalty notice (4i)
    THEN pass claim through w/o Penalty (4m)
discount
ELSE IF penalty applies
    THEN apply 50% penalty
END IF

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) IF All data entry and processes are correct Claim payment detail (4k)
Claim w/penalty notice (4i)     THEN Apply benefits less copay and Denial detail (4l)
Claim w/precert notice (4j) deductible
Benefits code (4f)     ELSE Deny claim
END IF

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 EOB/Payment (5c)
2. Print EOB/check
3. Mail
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 EOB/Denial letter (5d)
2. Print EOB/denial letter
3. Mail
Comments: Action.

11

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

12

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
Type of Data Flow:
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
Type of Data Flow:
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
Type of Data Flow:
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.

13

ID: 2b
Name: Group Number
Description: Group number is a unique identification number for each insured group.
Source: D5 Destination: Process 2.1
Type of Data Flow:
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.
Type of Data Flow:
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
Type of Data Flow:
Data Structure Traveling with the Flow: Adjuster ID Volume/Time: 1000+ daily
Comments: Claim assignment assigns adjuster to handle claim adjudication.

14

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
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
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.
Type of Data Flow:
Data Structure Traveling with the Flow: Verification of coverage. Volume/Time: 1000+ daily
Comments: None.

15

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.
Type of Data Flow:
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
Type of Data Flow:
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.

16

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
Type of Data Flow:
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.
Type of Data Flow:
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
Type of Data Flow:
Data Structure Traveling with the Flow: Network ID Volume/Time: 1000+ daily
Comments: D2 queried for network information.

17

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.
Type of Data Flow:
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.
Type of Data Flow:
Data Structure Traveling with the Flow: Verified discounted claim Volume/Time: 1000+ daily
notice.
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
Type of Data Flow:
Data Structure Traveling with the Flow: Procedure approval Volume/Time: 1000+ daily
Comments: Confirmation of procedure billed being eligible for coverage under plan.

18

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.
Type of Data Flow:
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
Type of Data Flow:
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.

19

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.
Type of Data Flow:
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.
Type of Data Flow:
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.
Type of Data Flow:
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.

20

ID: 4j
Name: Claim w/ PreCert notice
Description: Claim detail updated to include precertification has been approved and applicable
discounts applied.
Type of Data Flow:
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.
Type of Data Flow:
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.
Type of Data Flow:
Data Structure Traveling with the Flow: EOB, denial letter. Volume/Time: 1000+ daily
Comments: Includes free text explanation of denial.

21

ID: 4m
Name: Penalty
Description: Claim detail is updated with non‐precertification penalties applied.
Type of Data Flow:
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.
Type of Data Flow:
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.
Type of Data Flow:
Data Structure Traveling with the Flow: Payment detail, explanation of Volume/Time: 1000+
benefits.
Comments: None.

22

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.
Type of Data Flow:
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
Type of Data Flow:
Data Structure Traveling with the Flow: Payment detail, explanation of Volume/Time: 1000+
benefits, check.
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
Type of Data Flow:
Data Structure Traveling with the Flow: EOB, denial detail. Volume/Time: 200+
Comments: None.

23

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
Type of Data Flow:
Data Structure Traveling with the Flow: PreCertification, precert Volume/Time: 100+ daily
number
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.

24

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+

25

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+

26

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+

27

(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

28

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+

29

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]

30

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: Alphabetic:
Length: 11          Dec. Pt.:   Alphanumeric:
Input Format: 9 (11)   Date:
Output Format: 9 (11)   Numeric:
Default Value:      Base:          Derived:
Continuous:      Discrete:
Validation Criteria
Continuous Discrete
Upper Limit:      Value:                              Meaning:
Lower Limit:   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
Length: 7          Dec. Pt.: 9999.99 Alphanumeric:
Validation Criteria
Continuous Discrete
Upper Limit: ≤ 9999.99   Value:                    Meaning:
Lower Limit: ≥ 0000.01

Comments: Generally in increments of $20.00 USD.

31

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
Continuous Discrete

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
Continuous Discrete

Comments: None.

32

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
Continuous Discrete

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
Continuous Discrete

Comments: None.

33

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
Continuous Discrete

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).
Input Format: X (8)   Date:
Output Format: X (8)   Numeric:
Validation Criteria
Continuous Discrete
Lower Limit:   Prefix                     Three letter prefix of plan name
Seq #                      5 digit number assigned by account management
Comments: None.

34

ID:
Name: Cause of condition
Alias: Cause
Alias:
Description: Causality of current diagnosis/condition/treatment. Keyed in by Process 1.1
Input Format: Char   Date:
Output Format: Char   Numeric:
Default Value: O   Base:          Derived:
Validation Criteria
Continuous Discrete
Lower Limit:   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
Input Format: X (18)   Date:
Output Format: X (18)   Numeric:
Validation Criteria
Continuous Discrete
Lower Limit:   VarChar                     Can be any combination of aplhanumeric char.

Comments: None.


35

ID:
Name: Check number
Alias:
Alias:
Description: Number assigned to a claim payment check. Sequentially assigned by process 5.1
Validation Criteria
Continuous Discrete
Upper Limit: ≤ 999999   Value:                    Meaning:
Lower Limit: ≥ 000001

Comments: None.

ID:
Name: Date
Alias:
Alias:
Description: Date check printed
Validation Criteria
Continuous Discrete
Lower Limit: ≤ 01012010

Comments: None.

36

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
Validation Criteria
Continuous Discrete
Lower Limit:   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 Discrete
Upper Limit: ≤ Z   Value:                    Meaning:
Lower Limit: ≥ A

Comments: None.

37

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
Continuous Discrete
Lower Limit: ≥ 0000000000001

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
Continuous Discrete

Comments: None.

38

ID:
Name: Adjuster ID
Alias:
Alias:
Description: Used to indetify adjust in the system. Keyed in by process 2.3
Validation Criteria
Continuous Discrete
Lower Limit:   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.
Default Value: A   Base:          Derived:
Validation Criteria
Continuous Discrete
Lower Limit:   D                           Denied, charge already paid
A                           Approved, charge not paid
Comments: None.

39

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