| Business Data Model Data Model |
| Description | An inquiry into whether a member is eligible to receive a specific healthcare benefits. Such an inquiry will normally occur between a healthcare provider and a health plan organization. |
| Dependencies | |
 NONE |
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| Reverse Dependencies | |
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| Attribute Details |
Enquiring Provider Role
| Description | The healthcare function of the party making the inquiry, where the inquirer is a healthcare provider. For example: Admitting Attending Billing Consulting Covering Home Healthcare Hospital Laboratory Other Physician Performing Pharmacist Pharmacy Primary Care Physician Referring Rural Health Clinic Skilled Nursing Facility Submitting Supervising |
| 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 |
Enquiry Response
| Description | A textual or codified response to the inquiry. For example: Active coverage Cannot process Inactive pending investigation Not deemed a medical necessity |
| Data Type | Standards - Data Domains.ddm/Data Domains/Text Medium [VARCHAR(255)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Medicaid Spend Down Amt
| Description | In the content of the United States Medicaid Program, the total healthcare costs that must be met personally before an individual qualifies for Medicaid coverage. This can be the amount that was effective at the time the inquiry was made or the amount by which the individual's spend-down amount should be decreased as a result of this medical service occurring. |
| 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 |
Patient Is Subscriber Ind
| Description | An indicator that shows whether the subject of the inquiry is the subscriber or the dependent. |
| 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 |
Proposed Admission Date
| Description | The date proposed for the admission where an admission is inquired about. |
| 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 |
Proposed Eligibility End Date
| Description | The end of the period for which the inquiring party wants to confirm whether an individual has healthplan membership entitlements. |
| 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 |
Proposed Eligibility Start Date
| Description | The start of the period for which the inquiring party want to confirm whether an individual has healthplan membership entitlements. |
| 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 |
Proposed Healthcare Facility Type
| Description | Place of Service (POS) codes are two-digit codes that are typically placed on healthcare professional claims to indicate the setting in which a healthcare task was executed. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes. This relates to a specific medical service that is proposed or inquired about. For example: 11 OFFICE 53 COMMUNITY MENTAL HEALTH CENTER |
| 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 |
Proposed Healthcare Task Date
| Description | The date proposed for a healthcare task, where a particular healthcare task is inquired about. |
| 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 |
Proposed Healthcare Task Type
| Description | The type of healthcare task that is inquired about. For example: Anesthesia Blood Charges Consultation Diagnostic Lab Diagnostic X-Ray Medical Care Other Medical Radiation Therapy Surgical Surgical Assistance Used Durable Medical Equipment |
| 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 |
Proposed Provider Role
| Description | The role of the proposed provider in relation to the medical service that is subject to the inquiry. For example: Admitting Attending Billing Consulting Covering Home Healthcare Hospital Laboratory Other Physician Performing Pharmacist Pharmacy Primary Care Physician Referring Rural Health Clinic Skilled Nursing Facility Submitting Supervising |
| 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 |
Proposed Provider Specialty
| Description | The medical specialty required by a healthcare provider to carry out the medical service being inquired about. |
| 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 |
Type Of Enquiry
| Description | The nature of the benefit eligibility inquiry. |
| 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 |
Provider submits Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | is submitted by |
| 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 |
| Parent Role Name | submits |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Provider proposed in Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | has a proposed |
| 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 |
| Parent Role Name | is proposed in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Location is proposed in Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | has a proposed |
| 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 | Location |
| Parent Role Name | is proposed in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Diagnosis is basis for Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | has for basis |
| 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 | Diagnosis |
| Parent Role Name | is 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 |
Patient Referral is basis for Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| 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 | Patient Referral |
| Parent Role Name | is 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 |
Procedure Code is proposed in Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | has a proposed |
| 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 | Procedure Code |
| Parent Role Name | is proposed in |
| 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 is basis for Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| 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 | Insurance Policy |
| Parent Role Name | is 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 |
Plan Member is basis for Benefit Eligibility Enquiry
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| 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 | Plan Member |
| Parent Role Name | is 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 |
Benefit Eligibility Enquiry_Coverage Eligibility_FK
| Is Identifying Relationship | false |
| Child Table | Benefit Eligibility Enquiry |
| Child Role Name | results 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 | Coverage Eligibility |
| Parent Role Name | is result of |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
| Business Data Model Data Model |