Business Data Model Data Model

Entity

Entity Coverage Agreement

Description

An agreement detailing the circumstances and mechanisms under which healthcare benefits (money or services) will be delivered. Each benefit category in a benefit schedule will have an entry in coverage agreement that specifies the parameters for that benefit category.

For example:
Dental care coverage
Prenatal care
Routine exams

Attributes
Additional Member Designation
Annual Deductible Amt
Annual Deductible Out-of-Network Amt
Annual Maximum Benefit Amt
Benefit Delivery Frequency
Benefit Maximum Amt
Benefit Unit of Measure
Co-Insurance Pct
Contract Year To Date Deductible Amt
Contract Year To Date Deductible Out-of-Network Amt
Coverage Co-Payment Amt
Coverage Co-Payment Out-Of-Network Amt
Coverage Out-of-Network Pct
Coverage Pct
Coverage Priority
Coverage Type
Dependent Coverage Age Limit
Eligibility Period
Eligibility Period Unit
Exposure Amount Unit Of Measure
Exposure Amt
Extended Reporting Period
Lifetime Maximum Benefit Amt
Plan Network Ind
Remaining Benefit Amt
Remaining Deductible Amt
Retroactive Start Date
Waiting Period
Waiting Period Unit

Relationship
Coverage Agreement_Insurance Policy_FK
Provider Network contains Coverage Agreement
Coverage Agreement_Health Plan Product_FK

Generalization
Coverage Agreement - Agreement

Dependencies
NONE

Reverse Dependencies

Attribute Details

Additional Member Designation

Description	Indicates how any additional members are identified. For example: By name Spouse and children
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Annual Deductible Amt

Description	The deductible amount to be applied under this coverage agreement in the contract year for 'in-network' benefits, where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Annual Deductible Out-of-Network Amt

Description	The deductible amount to be applied under this coverage agreement in the contract year for 'out-of-network' benefits.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Annual Maximum Benefit Amt

Description	The maximum amount that can be paid out in benefits under this coverage agreement in the contract year.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Benefit Delivery Frequency

Description	Indicates the benefit delivery frequency of coverage agreement. For example: - 1 exam every calendar year for mammograms - 6 exams from birth to 1 year of age for Well Child Care
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Benefit Maximum Amt

Description	The maximum amount that can be received in eligible benefits under the coverage agreement.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Benefit Unit of Measure

Description	Indicates the unit of measure of the coverage agreement benefit.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Co-Insurance Pct

Description	The specific co-insurance percentage applying to the coverage agreement on the policy. In other words the percentage of covered benefits that the member will be liable for up to their out-of-pocket or other maximums.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Year To Date Deductible Amt

Description	Amount of covered medical expenses deductible already paid by the members for the coverage agreement during the contract year. Applies to 'in-network' benefits, where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Contract Year To Date Deductible Out-of-Network Amt

Description	Amount of covered medical expenses deductible already paid by the members for the coverage agreement during the contract year. Applies to 'out-of-network' benefits, where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Co-Payment Amt

Description	The specific co-payment amount applying to all benefits under the coverage agreement. Applies to 'in-network' benefits where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Co-Payment Out-Of-Network Amt

Description	The specific co-payment amount applying to all benefits under the coverage agreement. Applies to 'out-of-network' benefits.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Out-of-Network Pct

Description	The percentage of eligible benefits that will be paid for under the coverage agreement. Applies to 'out-of-network' benefits, where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Pct

Description	The percentage of eligible benefits that will be paid for under the coverage agreement. Applies to 'in-network' benefits, where applicable.
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Priority

Description	Indicates the priority of the coverage in relation to other insurance policies that cover the same member for the same risks.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Coverage Type

Description	Indicates the type of the benefit coverage. For example: Dental Coverage Hospital Indemnity Coverage Pharmacy Coverage Well-baby Care Preventive Care (such as exams)
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Dependent Coverage Age Limit

Description	The maximum age that a person can attain before becoming ineligible to receive benefits under this coverage.
Data Type	Standards - Data Domains.ddm/Data Domains/Number Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Eligibility Period

Description	Time following the eligibility date during which the member may apply for insurance without evidence of insurability. For example: 31 days
Data Type	Standards - Data Domains.ddm/Data Domains/Number Decimal Large [DECIMAL(15,6)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Eligibility Period Unit

Description	Eligibility period unit specifies the unit of the coverage agreement eligibility period.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Exposure Amount Unit Of Measure

Description	Exposure amount unit of measure specifies the unit of measure of the coverage agreement exposure amount.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Exposure Amt

Description	A number that represents the exposure on coverage based on units, number of employees, predicted healthcare costs, for example. The basis for this number can be found in health plan product. For example: 10 (Full-time employees ) 10, 000 (n USD 100's of insurance)
Data Type	Standards - Data Domains.ddm/Data Domains/Number Integer [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Extended Reporting Period

Description	Period following the termination date of the policy or coverage in which a claim can still be accepted, provided the claimed loss has occurred during the coverage period. For example: 2 years
Data Type	Standards - Data Domains.ddm/Data Domains/Number Decimal Large [DECIMAL(15,6)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Lifetime Maximum Benefit Amt

Description	Total maximum benefit amount reimbursable in a member's lifetime.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Plan Network Ind

Description	Indicates whether or not the related benefits are restricted to in-plan network providers. For example: Yes No
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric Small [VARCHAR(6)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Remaining Benefit Amt

Description	Remaining amount of benefit that can be paid out for a coverage agreement with a periodic maximum benefit.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Remaining Deductible Amt

Description	Remaining amount of deductible for a coverage agreement with a periodic maximum deductible.
Data Type	Standards - Data Domains.ddm/Data Domains/Currency Amount [DECIMAL(14,2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Retroactive Start Date

Description	Start date of policy coverage chosen as a date in the past preceding the policy inception date. For example: 1 June 2004 where inception date is 1 March 2005
Data Type	Standards - Data Domains.ddm/Data Domains/Date [DATE]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Waiting Period

Description	The period of time after the start date of the coverage agreement during which the member is not covered. Any loss occurring before the end of the waiting period will not be subject to a benefit.
Data Type	Standards - Data Domains.ddm/Data Domains/Number Decimal Large [DECIMAL(15,6)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Waiting Period Unit

Description	Specifies the unit of measure of the coverage agreement waiting period.
Data Type	Standards - Data Domains.ddm/Data Domains/Enumeration [VARCHAR(20)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Relationship Details

Coverage Agreement_Insurance Policy_FK

Is Identifying Relationship	false
Child Table	Coverage Agreement
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Insurance Policy
Parent Multiplicity	ZERO_TO_MANY
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Provider Network contains Coverage Agreement

Is Identifying Relationship	false
Child Table	Coverage Agreement
Child Role Name	is contained in
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Provider Network
Parent Role Name	contains
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Coverage Agreement_Health Plan Product_FK

Is Identifying Relationship	false
Child Table	Coverage Agreement
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Health Plan Product
Parent Multiplicity	ZERO_TO_MANY
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Generalization Details

Coverage Agreement - Agreement

Supertype	Agreement
Subtype	Coverage Agreement
Transform As	TABLE

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