Appeal Reason TxtClaim Appeal ReasonDescrNameStart DateUrgent Ind
| Business Data Model Data Model |
| Description | A formal assertion that a health plan member or healthcare provider makes that a claim was incorrectly adjudicated. |
| Attributes | |
| Appeal Reason Txt |
|
| Claim Appeal Reason |
|
| Descr |
|
| Name |
|
| Start Date |
|
| Urgent Ind |
|
| Relationship | |
 Claim Appeal_Plan Member_FK |
|
| Claim Appeal_Provider_FK |
|
| Claim Appeal_Claim_FK |
|
| Claim Appeal_Communication_FK |
|
| Claim Appeal_Claim Line_FK |
|
| Dependencies | |
 NONE |
|
| Reverse Dependencies | |
| |
|
| Attribute Details |
Appeal Reason Txt
| Description | A free-form textual description of why the claim is appealed. |
| 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 |
Claim Appeal Reason
| Description | Indicates the reason for challenging the claim adjudication. |
| 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 |
Descr
| Description | The textual representation of information about a claim appeal. |
| 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 |
Name
| Description | The word or phrase identifying a claim appeal. |
| Data Type | Standards - Data Domains.ddm/Data Domains/String [VARCHAR(255)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Start Date
| Description | The date upon which the claim appeal is considered to have commenced. |
| 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 |
Urgent Ind
| Description | Indicates that the claim appeal needs to be processed urgently, often owing to the immediate or emergency nature of the service originally authorized by appealed authorization result. 0 = Not urgent 1 = Urgent |
| 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 |
| Relationship Details |
Claim Appeal_Plan Member_FK
| Is Identifying Relationship | false |
| Child Table | Claim Appeal |
| 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 | Plan Member |
| 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 |
Claim Appeal_Provider_FK
| Is Identifying Relationship | false |
| Child Table | Claim Appeal |
| 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 |
Claim Appeal_Claim_FK
| Is Identifying Relationship | false |
| Child Table | Claim Appeal |
| Child Role Name | is appealed for |
| 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 | Claim |
| Parent Role Name | is appealed in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Claim Appeal_Communication_FK
| Is Identifying Relationship | false |
| Child Table | Claim Appeal |
| 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 | Communication |
| Parent Multiplicity | ZERO_TO_MANY |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Claim Appeal_Claim Line_FK
| Is Identifying Relationship | false |
| Child Table | Claim Appeal |
| 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 | Claim Line |
| Parent Multiplicity | ZERO_TO_MANY |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
| Business Data Model Data Model |