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
Notice of Claim (2a)
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
Notice of Claim (2a)
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 Specification Form
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.
Input Data Flow(s): Process Description: Output Data Flow(s):
Claim file (1e) Action 1: assign claim batch number in D1 Batch Numbers (1c)
Comments: Do process for every claim received.
Process Specification Form
Process ID: 1.3 Process Name: Enter Claim
Description: Batches of claims are then entered individually into Claim Detail in CMS.
Input Data Flow(s): Process Description: Output Data Flow(s):
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)
Comments: Do process for every claim received.
Process Specification Form
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 Specification Form
Process ID: 2.2 Process Name: Assign Claim Number
Description: Upon receipt of verification of coverage claim is assigned claim numbers and adjuster.
Input Data Flow: Process Description: Output Data Flow:
Verification of coverage (2g) Claim Detail (1d)
Action 1: Assign claim number in CMS Claim number (2h)
Comments: Sequential action.
Process Specification Form
Process ID: 2.3 Process Name: Assign Adjuster
Description: Upon receipt of verification of coverage claim is assigned claim numbers and adjuster.
Input Data Flow: Process Description: Output Data Flow:
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 Specification Form
Process ID: 3.1 Process Name: Obtain network ID
Description: Determines provider network via claim detail. Updates Claim detail with Network ID.
Input Data Flow: Process Description: Output Data Flow:
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)
Comments: Conditional/decision structure.
Process Specification Form
Process ID: 3.2 Process Name: Obtain discount rate
Description: Obtains discount rate per provider network. Updates Claims Detail.
Input Data Flow: Process Description: Output Data Flow:
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 Specification Form
Process ID: 3.3 Process Name: Apply discount
Description: Applies discount to claim charges and updates claim detail.
Input Data Flow: Process Description: Output Data Flow:
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 Specification Form
Process ID: 4.1 Process Name: Verify claim data entry
Description: Verifies claim data entry to insure claim image and claim detail harmonize accurately.
Input Data Flow: Process Description: Output Data Flow:
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 Specification Form
Process ID: 4.2 Process Name: Validate procedure coverage
Description: Check data store D1 & D5 to confirm procedures are covered under plan.
Input Data Flow: Process Description: Output Data Flow:
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 Specification Form
Process ID: 4.3 Process Name: Check claim history
Description: Check data store D1 & claim history to insure no duplicate charges are paid
Input Data Flow: Process Description: Output Data Flow:
Procedure approval (4c) Claimant history (4e)
IF no duplicate charges are found THEN approve charges ELSE deny charges END IF
Claim history approval (4n)
Comments: Decision structure.
Process Specification Form
Process ID: 4.4 Process Name: Check precertification
Description: Check data store D6 for precertification approval or denial.
Input Data Flow: Process Description: Output Data Flow:
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)
Comments: Decision structure.
11
Process Specification Form
Process ID: 4.5 Process Name: Apply penalty
Description: If claim has not been precertified, apply no discount or penalty as appropriate.
Input Data Flow: Process Description: Output Data Flow:
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)
Comments: Conditional/decision structure.
Process Specification Form
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.
Input Data Flow: Process Description: Output Data Flow:
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)
Comments: Decision structure.
Process Specification Form
Process ID: 5.1 Process Name: Process payment
Description: Prints and releases EOB, payment (check).
Input Data Flow: Process Description: Output Data Flow:
EOB/Claim payment detail (5a) 1. Check in payment detail 2. Print EOB/check 3. Mail
EOB/Payment (5c)
Comments: Action.
Process Specification Form
Process ID: 5.2 Process Name: Process denial
Description: Prints and mails EOB, denial letter.
Input Data Flow: Process Description: Output Data Flow:
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.
Data Flow Description
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.
Data Flow Description
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
Data Flow Description
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: X File Screen Report Form Internal
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.
Data Flow Description
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: X File Screen Report Form Internal
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.
Data Flow Description
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: X File Screen Report Form Internal
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
Data Flow Description
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: File X Screen Report Form Internal
Data Structure Traveling with the Flow: Group number Volume/Time: 1000+
Comments: Used by Eligibility to verify claimant’s group coverage.
Data Flow Description
ID: 2c Name: Insured ID Description: Primary insured’s unique identification number, social security number is used.
Source: D5 Destination: Process 2.1
Type of Data Flow: File X Screen Report Form Internal
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.
Data Flow Description
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: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Adjuster ID Volume/Time: 1000+ daily
Comments: Claim assignment assigns adjuster to handle claim adjudication.
15
Data Flow Description
ID: 2e Name: Claimant ID Description: D5 is checked to insure that claimant ID is identified as an insured claimant.
Source: D5 Destination: Process 2.1
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.)
Data Flow Description
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.
Data Flow Description
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.
Source: Process 2.1 Destination: D1/Process 2.2
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Verification of coverage. Volume/Time: 1000+ daily
Comments: None.
16
Data Flow Description
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.
Source: Process 2.2 Destination: D1/Process 2.3
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Claim number. Volume/Time: 1000+ daily
Comments: None.
Data Flow Description
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: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Verified claim notice Volume/Time: 1000+ daily
Comments: None.
Data Flow Description
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
Data Flow Description
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: File X Screen Report Form Internal
Data Structure Traveling with the Flow: Charge code Volume/Time: 1000+ daily
Comments: Numeric code.
Data Flow Description
ID: 3d Name: Provider Tax ID Description: Used to identify network provider belongs to, if any, and D2 is queried for applicable network ID.
Source: Process 3.1 Destination: D2
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Provider tax ID Volume/Time: 1000+ daily
Comments: D2 queried for network information and discount rate.
Data Flow Description
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: File X Screen Report Form Internal
Data Structure Traveling with the Flow: Network ID Volume/Time: 1000+ daily
Comments: D2 queried for network information.
18
Data Flow Description
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.
Source: Process 3.3 Destination: D1/Process 4.1
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Discounted claim notice. Volume/Time: 1000+ daily
Comments: Claim is marked as discounted and notice sent to adjudication.
Data Flow Description
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.
Source: Process 4.1 Destination: D1/Process 4.2
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Verified discounted claim notice.
Volume/Time: 1000+ daily
Comments: None.
Data Flow Description
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: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Procedure approval Volume/Time: 1000+ daily
Comments: Confirmation of procedure billed being eligible for coverage under plan.
19
Data Flow Description
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.
Source: D1 Destination: Process 4.2
Type of Data Flow: File X Screen Report Form Internal
Data Structure Traveling with the Flow: ICD9 codes Volume/Time: 1000+ daily
Comments: None.
Data Flow Description
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.
Source: D1 Destination: Process 4.3
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.
Data Flow Description
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: File X Screen Report Form Internal
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
Data Flow Description
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.
Source: Process 4.4 Destination: D1
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Benefits applied Volume/Time: 1000+ daily
Comments: Data entry updating claim detail is submitted to CMS.
Data Flow Description
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.
Source: Process 4.4 Destination: Process 4.5
Type of Data Flow: X File Screen Report Form Internal
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.
Data Flow Description
ID: 4i Name: Claim w/penalty notice Description: Claim detail updated to include penalty applied due to results of process 4.3.
Source: Process 4.5 Destination: Process 4.6
Type of Data Flow: X File Screen Report Form Internal
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
Data Flow Description
ID: 4j Name: Claim w/ PreCert notice Description: Claim detail updated to include precertification has been approved and applicable discounts applied.
Source: Process 4.4 Destination: Process 4.6
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Precertification confirmation Volume/Time: 300+ daily
Comments: Claims that have been precertified prior to beginning of treatment/service.
Data Flow Description
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.
Source: Process 4.6 Destination: D6
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Claim payment detail, EOB. Volume/Time: 1000+ daily
Comments: Payment detail for one claim.
Data Flow Description
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.
Source: Process 4.6 Destination: D6
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: EOB, denial letter. Volume/Time: 1000+ daily
Comments: Includes free text explanation of denial.
22
Data Flow Description
ID: 4m Name: Penalty Description: Claim detail is updated with non‐precertification penalties applied.
Source: Process 4.5 Destination: D1
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Penalty Volume/Time: 1000+ daily
Comments: Either penalty or no discount.
Data Flow Description
ID: 4n Name: Claim history approval Description: Claim detail is updated with notice that claim history has been checked.
Source: Process 4.3 Destination: Process 4.4
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Claim history approval Volume/Time: 1000+ daily
Comments: None.
Data Flow Description
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.
Source: D6 Destination: Process 5.1
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: Payment detail, explanation of benefits.
Volume/Time: 1000+
Comments: None.
23
Data Flow Description
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.
Source: D6 Destination: Process 5.2
Type of Data Flow: X File Screen Report Form Internal
Data Structure Traveling with the Flow: EOB, denial detail. Volume/Time: 200+
Comments: None.
Data Flow Description
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: File Screen Report X Form Internal
Data Structure Traveling with the Flow: Payment detail, explanation of benefits, check.
Volume/Time: 1000+
Comments: None.
Data Flow Description
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: File Screen Report X Form Internal
Data Structure Traveling with the Flow: EOB, denial detail. Volume/Time: 200+
Comments: None.
24
Data Flow Description
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: X File Screen Report Form Internal
Data Structure Traveling with the Flow: PreCertification, precert number
Volume/Time: 100+ daily
Comments: None.
Data Flow Description
ID: 6b Name: Precertification status Description: D4 is checked and claim detail updated to reflect that precertification has been obtained or not.
Source: D4 Destination: Process 4.4
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.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 7 Dec. Pt.: 9999.99 Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9999.99 Lower Limit: ≥ 0000.01
Discrete Value: Meaning:
Comments: Generally in increments of $20.00 USD.
32
Element Description Form
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
Element Characteristics
Required: Optional: Length: 7 Dec. Pt.: 9999.99 Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9999.99 Lower Limit: ≥ 0000.01
Discrete Value: Meaning:
Comments: Generally $500.00 or $1000.00 USD.
Element Description Form
ID: Name: Other credits Alias: Alias: Description: Any other credits applied to claimant account, i.e. overpayment of copay. Keyed in by process 1.
Element Characteristics
Required: Optional: Length: 7 Dec. Pt.: 9999.99 Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9999.99 Lower Limit: ≥ 0000.01
Discrete Value: Meaning:
Comments: None.
33
Element Description Form
ID: Name: Other insurance Alias: Alias: Description: Payments made by other insurance covering claimant at time of service. Keyed in by process 1.
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Total paid Alias: Alias: Description: Total amount paid by claimant at time of service. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.00
Discrete Value: Meaning:
Comments: None.
34
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.00
Discrete Value: Meaning:
Comments: None.
Element Description Form
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).
Element Characteristics
Required: Optional: Length: 8 Dec. Pt.: Input Format: X (8) Output Format: X (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Prefix Three letter prefix of plan name Seq # 5 digit number assigned by account management
Comments: None.
35
Element Description Form
ID: Name: Cause of condition Alias: Cause Alias: Description: Causality of current diagnosis/condition/treatment. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: O Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: O Other E Employment A Auto accident
Comments: None.
Element Description Form
ID: Name: Account number Alias: Patient account number Alias: Description: Patients account number with the provider. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: X (18) Output Format: X (18) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: VarChar Can be any combination of aplhanumeric char.
Comments: None.
Element Description Form
36
ID: Name: Check number Alias: Alias: Description: Number assigned to a claim payment check. Sequentially assigned by process 5.1
Element Characteristics
Required: Optional: Length: 6 Dec. Pt.: Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999 Lower Limit: ≥ 000001
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Date Alias: Alias: Description: Date check printed
Element Characteristics
Required: Optional: Length: 8 Dec. Pt.: Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 01012100 Lower Limit: ≤ 01012010
Discrete Value: Meaning:
Comments: None.
37
Element Description Form
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
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Predefined Name of insurer
Comments: None.
Element Description Form
ID: Name: Provider name Alias: Alias: Description: Name of either institution of professional rendering services. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
38
Element Description Form
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
Element Characteristics
Required: Optional: Length: 13 Dec. Pt.: Input Format: 9 (13) Output Format: 9 (13) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9999999999999 Lower Limit: ≥ 0000000000001
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Total payment Alias: Check amount Alias: Description: Total payment being made for this claim. Keyed in by process 4.6
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.00
Discrete Value: Meaning:
Comments: None.
39
Element Description Form
ID: Name: Adjuster ID Alias: Alias: Description: Used to indetify adjust in the system. Keyed in by process 2.3
Element Characteristics
Required: Optional: Length: 3 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: XXX Adjuster initials (First Mid Last)
Comments: Adjuster's first middle and last initials are used.
Element Description Form
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.
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: A Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: D Denied, charge already paid A Approved, charge not paid
Comments: None.
40
Element Description Form
ID: Name: Claim number Alias: Alias: Description: Claim number assigned and keyed in by process 2.2.
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 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.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Released to process 4.4 N Pending in process 4.3
Comments: None
41
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Released to process 4.4 N Pending in process 4.3
Comments: None
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: Input Format: 9 (9) Output Format: 9 (9) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9 Lower Limit: ≥ 0
Discrete Value: Meaning:
Comments: None.
42
Element Description Form
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
Element Characteristics
Required: Optional: Length: 2 Dec. Pt.: Input Format: 9 (2) Output Format: 9 (2) Default Value: 00 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 99 Lower Limit: ≥ 00
Discrete Value: Meaning:
Comments: Contracted service rates based on provider network set up by account management.
Element Description Form
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.
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Claim is released to process 4.1 N Claim is pending in process 3
Comments: None.
43
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Notice of claim Alias: Alias: Description: Alerts process 2.1 of claim. Keyed in by process 1.3
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: Penalty for non‐precertified services is based on policy/plan. Generally either 25%, 50% or 80%.
Element Description Form
ID: Name: Plan name Alias: Alias: Description: Name of particular plan group coverage is written in. Keyed in by Account Management.
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Plan name Assigned by Account Management
Comments: None.
45
Element Description Form
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.
Element Characteristics
Required: Optional: Length: 12 Dec. Pt.: Input Format: X (12) Output Format: X (12) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Group ID Assigned group initials Year 4 digit year policy began Sequential Chronological number
Comments: None.
Element Description Form
ID: Name: PreCertification status Alias: Alias: Description: Process 4.4 reads PreCert Database maintained by Utilization Review (external entity).
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: A Treatment precertified D Treatment not precertified
Comments: None.
46
Element Description Form
ID: Name: Procedure approval Alias: Alias: Description: Approval of procedures billed per insured policy. Keyed in by process 4.2
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: X (1) Output Format: X (1) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Release to process 4.3 N Pend in process 4.2
Comments: None.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: P Professional I Institutaional
Comments: None.
47
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Claimant in system N Letter sent
Comments: None.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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
Element Description Form
ID: Name: Amount paid Alias: Patient payment Alias: Description: Amount paid by claimant at time of service. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 7 Dec. Pt.: 9999.99 Input Format: 9 (6) Output Format: 9 (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9999.99 Lower Limit: ≥ 0000.01
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Balance due Alias: Amount now due Alias: Description: Amount being billed to insurance for current claim. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: None.
49
Element Description Form
ID: Name: Claimant gender Alias: Sex Alias: Description: Gender of the claimant. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: M Male F Female
Comments: None.
Element Description Form
ID: Name: Diagnosis code Alias: ICD9 code Alias: Description: Diagnosis codes for this claim. Can be repeated. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 5 Dec. Pt.: X99V99 Input Format: X99.99 Output Format: X99.99 Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: X99.99 First char can be alpha, remaining are digits.
Comments: None.
50
Element Description Form
ID: Name: Employer name Alias: Alias: Description: Name of employer who group insurance is provided by. Keyed in by Account Management.
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Employment status Alias: Alias: Description: Used to determine employment status of claimant. Keyed in by external entity, Account Management.
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: 9 (1) Output Format: 9 (1) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: 1 Employed 2 Unemployed 3 Full time student 4 Part time student
Comments: None.
51
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: Input Format: 9 (9) Output Format: 9 (9) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9 Lower Limit: ≥ 0
Discrete Value: Meaning:
Comments: Standard US social security number, used as Insured ID and/or Claimant ID
Element Description Form
ID: Name: Modifier Alias: Alias: Description: Modifier code further identifies the procedure code. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 2 Dec. Pt.: Input Format: 9 (2) Output Format: 9 (2) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 99 Lower Limit: ≥ 01
Discrete Value: Meaning:
Comments: None.
52
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: N Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Yes, has other coverage N No, no other coverage
Comments: None.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: Input Format: 9 (9) Output Format: 9 (9) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999999 Lower Limit: ≥ 000000000
Discrete Value: Meaning:
Comments: None.
53
Element Description Form
ID: Name: Relationship to insured Alias: Alias: Description: Used for relationship to insured. Keyed in from claim form by process 1.1
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: 9 (1) Output Format: 9 (1) Default Value: 1 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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.
Element Description Form
ID: Name: Release on file Alias: Alias: Description: Claimant has signed release of medical records on file with company. Keyed in by Account Management.
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Y Yes, release on file N No, release not on file
Comments: None
54
Element Description Form
ID: Name: Service charges Alias: Charge amount Alias: Description: Amount charged per unit of service (Unit). Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Total charges Alias: Alias: Description: Total charges being billed on one claim. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999V99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.01
Discrete Value: Meaning:
Comments: None.
55
Element Description Form
ID: Name: Units Alias: Number of units Alias: Description: Number of a particular service rendered under one claim. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 3 Dec. Pt.: Input Format: 999 Output Format: 999 Default Value: 001 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999 Lower Limit: ≥ 001
Discrete Value: Meaning:
Comments: None.
Element Description Form
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.
Element Characteristics
Required: Optional: Length: X Dec. Pt.: Input Format: X Output Format: X Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Img PDF image of claim form
Comments: None.
56
Element Description Form
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.
Element Characteristics
Required: Optional: Length: X Dec. Pt.: Input Format: X Output Format: X Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Img PDF image of claim form
Comments: None.
Element Description Form
ID: Name: Eligible amount Alias: Alias: Description: Amount of charges covered by insurance before repricing. Keyed in by process 4.4
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.00
Discrete Value: Meaning:
Comments: None.
57
Element Description Form
ID: Name: Other credits or adjustments Alias: Alias: Description: Other deductions not covered by entries or codes. Keyed in by process 4.6
Element Characteristics
Required: Optional: Length: 9 Dec. Pt.: 999999.99 Input Format: 9 (8) Output Format: 9 (8) Default Value: 00.00 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 999999.99 Lower Limit: ≥ 000000.00
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Street Alias: Avenue Alias: Road Description: Number and street name of insured, claimant, provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: X (18) Output Format: X (18) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: < XXXXXXXXXXXXXXXXXX Lower Limit: >X
Discrete Value: Meaning:
Comments: None.
58
Element Description Form
ID: Name: Apartment Alias: Unit Alias: Description: Apartment letter or number. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 6 Dec. Pt.: Input Format: X (6) Output Format: X (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: < XXXXXX Lower Limit:
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: City Alias: Town Alias: Village Description: City of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 17 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
59
Element Description Form
ID: Name: State Alias: Alias: Description: State of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 2 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Table 1 Table of State Abbreviations
Comments: None.
Element Description Form
ID: Name: Zip Alias: Zip Code Alias: Description: Zip code of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 5 Dec. Pt.: Input Format: 9 (5) Output Format: 9 (5) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9 Lower Limit: ≥ 0
Discrete Value: Meaning:
Comments: None.
60
Element Description Form
ID: Name: Zip Expansion Alias: Zip+4 Alias: Description: Expanded zip code of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 4 Dec. Pt.: Input Format: 9 (4) Output Format: 9 (4) Default Value: 0000 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9 Lower Limit: ≥ 0
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Day Alias: Alias: Description: Date of the month. Used for date elements. Keyed in by various processes.
Element Characteristics
Required: Optional: Length: 2 Dec. Pt.: Input Format: 9 (2) Output Format: 9 (2) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 31 Lower Limit: ≥ 01
Discrete Value: Meaning:
Comments: None.
61
Element Description Form
ID: Name: Month Alias: Alias: Description: Used for date elements. Keyed in by various process.
Element Characteristics
Required: Optional: Length: 2 Dec. Pt.: Input Format: X (2) Output Format: X (2) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 12 Lower Limit: ≥01
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: Year Alias: Alias: Description: Used for date element. Keyed in by various processes.
Element Characteristics
Required: Optional: Length: 4 Dec. Pt.: Input Format: X (4) Output Format: X (4) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: < 2099 Lower Limit: >1900
Discrete Value: Meaning:
Comments: None.
62
Element Description Form
ID: Name: First name Alias: Given name Alias: Description: First name of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None
Element Description Form
ID: Name: Middle name Alias: Alias: Description: Middle name of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None
63
Element Description Form
ID: Name: Middle initial Alias: Alias: Description: Middle initial of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None
Element Description Form
ID: Name: Last name Alias: Surname Alias: Description: Last name of insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 18 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
64
Element Description Form
ID: Name: Area code Alias: Alias: Description: Telephone area code for insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 3 Dec. Pt.: Input Format: 9 (3) Output Format: 9 (3) Default Value: 000 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Table 2 Table of valid area codes.
Comments: None.
Element Description Form
ID: Name: Local number Alias: Phone number Alias: Description: Local phone number for insured, claimant or provider. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 7 Dec. Pt.: Input Format: 9 (7) Output Format: 9 (7) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 9 Lower Limit: ≥ 0
Discrete Value: Meaning:
Comments: None.
65
Element Description Form
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
Element Characteristics
Required: Optional: Length: 640 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
Element Description Form
ID: Name: ICD9 Code Alias: Alias: Description: ICD9 code identifies diagnosis. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 6 Dec. Pt.: Input Format: X (6) Output Format: X (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: XXX.XX First char can be alpha, remaining are digits.
Comments: None.
66
Element Description Form
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
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: 9 (1) Output Format: 9 (1) Default Value: 0 Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 180 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ Z Lower Limit: ≥ A
Discrete Value: Meaning:
Comments: None.
67
Element Description Form
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
Element Characteristics
Required: Optional: Length: 11 Dec. Pt.: Input Format: X (11) Output Format: X (11) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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.
Element Description Form
ID: Name: CPT code Alias: Alias: Description: CPT code signifies the exact procedure performed. Keyed in by process 1.1
Element Characteristics
Required: Optional: Length: 5 Dec. Pt.: Input Format: 9 (5) Output Format: 9 (5) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: ≤ 99999 Lower Limit: ≥ 00001
Discrete Value: Meaning:
Comments: None.
68
Element Description Form
ID: Name: Marital Status Alias: Alias: Description: Indicates marital status of claimant. Keyed in by Process 1.1
Element Characteristics
Required: Optional: Length: 1 Dec. Pt.: Input Format: Char Output Format: Char Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: M Married S Single
Comments: None.
Element Description Form
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
Element Characteristics
Required: Optional: Length: 8 Dec. Pt.: Input Format: X (8) Output Format: X (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Prefix First three letter od network name Number 5 digit sequential number
Comments: None.
69
Element Description Form
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).
Element Characteristics
Required: Optional: Length: 8 Dec. Pt.: Input Format: 9 (8) Output Format: 9 (8) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
Discrete Value: Meaning: Date MMDDYYYY
Comments: None.
Element Description Form
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.
Element Characteristics
Required: Optional: Length: 6 Dec. Pt.: Input Format: X (6) Output Format: X (6) Default Value: Continuous: Discrete:
Alphabetic: Alphanumeric: Date: Numeric: Base: Derived:
Validation Criteria
Continuous Upper Limit: Lower Limit:
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.
Data Store Description Form
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 Store Characteristics
File Type: File Format:
Computer Manual: Database: Indexed: Sequential: Direct:
Record Size (Characters): 300 Number of Records: Maximum 100,000 Percent Growth Per Year: 10
Block Size: Average:
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
Data Store Description Form
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 Store Characteristics
File Type: File Format:
Computer Manual: Database: Indexed: Sequential: Direct:
Record Size (Characters): 525 Number of Records: Maximum 90,000 Percent Growth Per Year: 400
Block Size: Average:
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.
Data Store Description Form
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 Store Characteristics
File Type: File Format:
Computer Manual: Database: Indexed: Sequential: Direct:
Record Size (Characters): 430 Number of Records: Maximum 10,000 Percent Growth Per Year: 20
Block Size: Average:
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
Data Store Description Form
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 Store Characteristics
File Type: File Format:
Computer Manual: Database: Indexed: Sequential: Direct:
Record Size (Characters): 1000 Number of Records: Maximum 30,000 Percent Growth Per Year: 10
Block Size: Average:
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.
Data Store Description Form
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 Store Characteristics
File Type: File Format:
Computer Manual: Database: Indexed: Sequential: Direct:
Record Size (Characters): 1053 Number of Records: Maximum 90,000 Percent Growth Per Year: 400
Block Size: Average:
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.