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Investigate the Health Insurance and Claims Data Model

Learning Objectives

After completing this unit, you’ll be able to:
  • Describe the Health Cloud health insurance and claims data model.
  • Explain the purpose of different objects used in the health insurance and claims data model.

Introduction

The health insurance and claims data model gives you insight into a patient’s or member’s insurance information. Health Cloud makes it easy to view, verify, or track details about membership, benefits, preauthorizations, and claims.

This diagram shows the health insurance and claims data model. For more detail about each object, see the Salesforce Health Cloud Developer Guide.

Diagram that shows the health insurance and claims data model.

Explore the Health Insurance and Claims Data Model

Bloomington Health Plans offers health insurance (Purchaser Plan) tailored to Get Cloudy Consulting (Account) for its California employees (Purchaser Group). As we learned in a previous unit, Charles is an employee of Get Cloudy Consulting and he’s based in California. Charles opted to enroll in Bloomington Health’s preferred provider plan (PPO), so he has great coverage through his policy (Member Plan). As part of his policy, Charles is entitled to Rehabilitative Services (Coverage Benefit), which includes up to 30 physical therapy visits per year (Coverage Benefit Item).

Health Cloud also provides visibility into Charles’s historical claim information

Health Cloud also provides visibility into Charles’s historical claim information. This diagram shows a claim for therapeutic exercise (Claim Line) provided by Sara Johnson (Claim Provider) to address Charles’s lower back pain (Claim Diagnosis). This gives you a holistic view of Charles’s insurance and claims information.

Diagram that illustrates how Charles’s insurance and claims information fits in the Health Cloud insurance and claims data model.

Here’s a look at the records, objects, and relationships in the health insurance and claims data model based on Sara Johnson’s claim for therapeutic exercise to help alleviate Charles’s lower back pain.

This Record... ...Is Related To
Get Cloudy Consulting
—Purchaser (Account) Bloomington Health Plan—Payer (Account)
Purchaser Group—Purchaser Plan Association (PurchaserPlanAssociation) US Employees 
Purchaser Group (Account)
Purchaser Group—Purchaser Plan Association (PurchaserPlanAssociation) Bloomington Health—Insurance Plan 
 (Purchaser Plan)
Purchaser Group—Member Association (AccountContactRelation) US Employees 
Purchaser Group (Account)
Purchaser Group—Member Association (AccountContactRelation) Charles Green 
Member (Person Account)
Charles’s Bloomington Health Policy
 (Member Plan) Charles Green 
Member (Person Account)
Charles’s Bloomington Health Policy
 (Member Plan) Bloomington Health—Insurance Plan
 (Purchaser Plan)
Bloomington Health—Insurance Plan
 (Purchaser Plan) Bloomington Health Plan
—Payer (Account)
Rehabilitative Services 
 (Coverage Benefit) Charles’s Bloomington Health Policy
 (Member Plan)
Physical Therapy 
 (Coverage Benefit Item) Rehabilitative Services
 (Coverage Benefit)
Claim #001 
 (Claim Header) Charles’s Bloomington Health Policy 
 (Member Plan)
Low back pain, M54.5
 (Claim Diagnosis) Claim #001
 (Claim Header)
Therapeutic Exercise, 
CPT 97110 
(Claim Line) Claim #001
 (Claim Header)
Sara Johnson—Rendering Provider
 (Claim Provider) Claim #001
 (Claim Header)

Now you’ve seen how the Health Cloud insurance and claims data model works, including insurance and claims information, coverage benefits, and preauthorization. Take the next unit on the Health Cloud care program data model to learn more about how a care program supports Charles on his health journey.