Bill Id Patient info D1 Patient Masters Credit Card Company Claim info Patient record 2.1 2 Receive Save Claims Check Claims Patient Infor Patient ID 2.3 Claim Status 2.4 Payment outcome Process Claim Process Payment Claim record Insurance Bills Master D3 Claims Master
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Draw an entity relationship diagram (ERD) for the following situation: Whenever new patients are seen for the first time, they complete a patient information form that asks for their name, address, phone number, and insurance carrier, all of which are stored in the patient information file. Patients can only be signed up with one carrier, but they must be signed up to be seen by the doctor. Each time a patient visits the doctor, an insurance claim is sent to the carrier for payment. The claim must contain information about the visit, such as the date, purpose, and cost. It would be possible for a patient to submit two claims on the same day.
Aarya B.
Liu Huang was seen for an outpatient visit at the Central Clinic and received a glenohumeral joint injection during the appointment. A claim was created for this visit and procedure and submitted to Liu's insurance company. The insurance company provided Central Clinic with the below Remittance Advice (known as an Explanation of Benefits (EOB) when provided to patients), indicating what they covered, and they also submitted payment for their share through Electronic Fund Transfer (EFT). Review the submitted claim under the Account section of Liu's chart. Then update the ledger to indicate the insurance adjustments and payments. Additional info: Liu has met his annual deductible. Any Provider Charges that exceed the insurance company's Allowed Charges were discounted and adjusted by the insurance company – neither the insurance company nor the patient will be responsible for any amount exceeding the Allowed Charges in this situation, and the provider will not receive payment for this amount. The insurance company then pays 80% of the Allowed Charges, and the remaining 20% is Liu's responsibility as coinsurance. Enter Provider Responsibility amounts as adjustment transactions from the insurance company as a credit without a balance transfer. Enter Paid Amounts as payer payments via EFT.
Akash M.
Exercise 4.30 Model the following business process. When a claim is received, it is first registered. After registration, the claim is classified leading to two possible outcomes: simple or complex. If the claim is simple, the insurance policy is checked. For complex claims, both the policy and the damage are checked inde- pendently. A possible outcome of the policy check is that the claim is invalid. In this case, any processing is canceled and a letter is sent to the customer. In the case of a complex claim, this implies that the damage checking is canceled if it has not been completed yet. After the check(s), an assessment is performed which may lead to two possible outcomes: positive or negative. If the assessment is positive, the garage is phoned to authorize the repairs and the payment is scheduled (in this order). In any case (whether the outcome is positive or negative), a letter is sent to the customer and the process ends. At any moment after the registration and before the end of the process, the customer may call to modify the details of the claim. If a modification occurs before the payment is scheduled, the claim is classified again (simple or complex) and the process is repeated. If a request to modify the claim is received after the payment is scheduled, the request is rejected
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