Business Data Model Data Model

Entity

Entity Insurance Policy

Description

An agreement (individual agreement or group agreement) between a healthcare insurer and a member based on a health plan product. The agreement specifies the obligation of the healthcare insurer to pay benefits and of the premium payer to pay premiums.

Attributes
Additional Fee Amt
Annual Deductible Amt
Annual Deductible Carryover Amt
Annual Deductible Out-of-Network Amt
Annual Out-of-Pocket Maximum Amt
Annual Out-of-Pocket Maximum Out-of-Network Amt
Contract Year To Date Benefit Amt
Contract Year To Date Premium Amt
Co-Payment Amt
Co-Payment Out-of-Network Amt
Coverage Out-of-Network Pct
Coverage Pct
Discount Amt
Discount Category
Entry Code
Gross Premium Amt
Maximum Benefit Amt
Membership Card Ind
Membership Eligibility
Net Premium Amt
Number of Beneficiaries
Premium Payment Frequency
Premium Payment Method
Rate Class
Renewal Ind
Risk Type

Relationship
Insurance Policy_Reinsurance Agreement_FK
Insurance Policy_Health Plan Product_FK
Insurance Policy_Explanation of Payment_FK

Generalization
Insurance Policy - Agreement

Dependencies
NONE

Reverse Dependencies

Attribute Details

Additional Fee Amt

Description	Identifies additional fees that are related to the policy, above those normally incorporated in the premium amount.
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 Amt

Description	The self-insured risk portion or amount of money that the policyholder is required to pay in a contract year before insurance policy benefits take effect. This amount applies to medical services or products received by an in-network provider 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 Carryover Amt

Description	The deductible amount carried over from another insurance policy. For example where a policy switch occurs. Applies to benefits in-network 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 self-insured risk portion or amount of money that the policyholder is required to pay in a contract year before insurance policy benefits take effect. This amount applies to medical services or products received by an out-of-network provider.
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 Out-of-Pocket Maximum Amt

Description	The maximum amount payable as deductibles and co-payments in a contract year, under this insurance policy. Applies to medical services and products received by an in-network provider, 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 Out-of-Pocket Maximum Out-of-Network Amt

Description	The maximum amount payable as deductibles and co-payments in a contract year, under this insurance policy. Applies to medical services and products received by an out-of-network provider.
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 Benefit Amt

Description	The total benefits paid year-to-date for this insurance policy.
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 Premium Amt

Description	The total premium paid year-to-date for this insurance policy.
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

Co-Payment Amt

Description	The specific co-payment amount applying to all benefits under the coverage.
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

Co-Payment Out-of-Network Amt

Description	The co-payment amount that applies covered medical services and products received from an out-of-network provider, under this insurance policy.
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	Percent of charges payable under the contract, for covered medical services or products delivered by and out-of-network provider, under this insurance policy.
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	Percent of charges payable under the contract, for 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

Discount Amt

Description	Identifies the discount amount applicable to the policy premium.
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

Discount Category

Description	Indicates a discount category that determines the reductions in premium or price from the standard rating structure based on the presence of factors that reduce the risk or increase profitability. For example: No claim No Discount Percentage of Usual and Customary Fee
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

Entry Code

Description	Identifies whether the insurance policy was entered by an external party or by a party within the modeled organization. For example: Agency entered Branch entered
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

Gross Premium Amt

Description	The premium amount for the policy for its effective period.
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

Maximum Benefit Amt

Description	The maximum amount that can be paid out in benefits under this insurance policy. The Limit Applicability Type (supported by Stipulation Applicability Type) specifies whether the maximum amount is applicable to a life-time or annual limit.
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

Membership Card Ind

Description	Indicates whether membership cards are to be issued to members under the policy. For example: Not required. To be issued.
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

Membership Eligibility

Description	The qualification conditions for membership to an insurance policy. For example: Full-time Employees Full-time Employees Only Subscriber and Dependents Subscriber and Spouse Subscriber Only
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

Net Premium Amt

Description	Net premium for the policy for its effective period, when certain deductions are applied, for example, net of re-insurance amounts.
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

Number of Beneficiaries

Description	The number of persons receiving benefits under the insurance policy.
Data Type	Standards - Data Domains.ddm/Data Domains/Small Counter [SHORT]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Premium Payment Frequency

Description	Indicates the frequency with which the payment of the premium will occur. For example: Annually
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

Premium Payment Method

Description	Indicates the payment method that will be used to pay the premiums for the policy. For example: Check Direct debit mandate Electronic funds transfer
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

Rate Class

Description	Indicates the category that determines premium rates or rating structures for the insurance policy. For example: Single Male Principal Operator Age 20-25
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

Renewal Ind

Description	Indicates whether or not the insurance policy is a renewal. If not, it indicates that the insurance policy is in its first renewal period.
Data Type	Standards - Data Domains.ddm/Data Domains/Boolean Indicator [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

Risk Type

Description	Indicates the types of risk or financial exposure to the health plan.
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

Insurance Policy_Reinsurance Agreement_FK

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

Insurance Policy_Health Plan Product_FK

Is Identifying Relationship	false
Child Table	Insurance Policy
Child Role Name	is based on
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 Role Name	is product basis for
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Insurance Policy_Explanation of Payment_FK

Is Identifying Relationship	false
Child Table	Insurance Policy
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	Explanation of Payment
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

Insurance Policy - Agreement

Supertype	Agreement
Subtype	Insurance Policy
Transform As	TABLE

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