Investigate the Health Insurance and Claims Data Model

Get Cloudy Consulting is a global company that has purchased a health insurance plan for its US-based employees.

The Account object with a Business record type (1) represents the organization (purchaser) that purchases the health plan. 

The Account object also represents purchaser groups that are subsets of the purchaser (2).  

For example, an organization may have employee groups in different countries or different regions of a country. Each purchaser group can have separate options for insurance plans. 

The account record for the purchaser group references the account record for the parent organization.

Bloomington Health Plans offers health insurance tailored to Get Cloudy Consulting for its US-based employees, such as a Preferred Provider Plan (PPO).

Purchaser Plan (3) represents the plan that a purchaser makes available to its members and members’ dependents. 

A purchaser plan record references a purchaser or purchaser group record and the payer record.

Bloomington Health Plans is a payer organization that provides health insurance plans.

The Account object with a Business record type (4) represents the payer organization that helps cover the cost of member care. 

Bloomington Health Plans offers Rehab Services as a benefit.

Plan Benefit (5) represents the standard benefits available under a plan that the purchaser offers to their members. 

A plan benefit record references a purchaser plan record.

Bloomington Health Plans offers physical therapy visits as part of its Rehab Services benefit.

Plan Benefit Item (6) represents the details of a benefit. 

A plan benefit item record references a plan benefit record.

Charles Green is a member who is covered under an insurance plan.

The Account object with a Person record type (1) represents a member.  

A member has a relationship with the purchasing organization (2). For example, the member is an employee and the organization is their employer. 

Charles enrolled in Bloomington Health Plan’s preferred provider plan (PPO).

Member Plan (3) represents details about the insurance coverage for a member. 

A member plan record includes data such as the plan effective dates, the group number or policy number of the primary member, and the plan’s verification status.

A member plan record references a purchase plan record (4) and the payer organization (5).

As part of his policy, Charles is entitled to Rehabilitative Services.

Coverage Benefit (6) represents the coverage benefits that a member plan provides to a covered member. 

A coverage benefit record includes data such as the benefit period start and end dates, the coverage type (Dental, Medical, Vision), and deductible limits. 

Each coverage benefit has a benefit item. 

This benefit includes up to 30 physical therapy visits per year.

Coverage Benefit Item (7) represents the specific services that a member plan covers. 

A coverage benefit item record includes data such as the type of service it provides, and whether or not the service must be preauthorized before use. 

Sara Johnson is the physical therapist who provides therapeutic exercises to Charles.

Claim Provider (1) represents information about a provider of a service, equipment or medication.

Sara files a claim for providing this service.

Claim Header (2) contains summary information about the claim, such as the payment amount, specified medications, and billing data. 

A claim record references the provider who’s submitting the claim (1), and the member (3), member plan (4), and payer organization (5).  

Claim Line represents a line item in a claim record (6).  In this example, the claim is for the Therapeutic Exercises that Sara provided. 

A claim line record references a claim diagnosis record.

The therapeutic exercises are to help Charles with his back pain.

Claim Diagnosis (7) represents the clinical diagnosis for which the service, equipment, or medication was provided. In this example, Back Pain is the diagnosis.