| Business Data Model Data Model |
| Description | A method that is used by a health plan organization to ensure that the total amount paid is not greater than the expenses incurred when a member is covered by more than one policy. The order of liability for each policy is determined by the coverage precedence. Coordination of benefits (COB) applies, for example, to a family where both spouses have group coverage through their employers or to an individual who has Medicare and an individual insurance policy. |
| Dependencies | |
 NONE |
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| Reverse Dependencies | |
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| Attribute Details |
Actual End Date
| Description | Actual date upon which the activity was ended. |
| 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 |
Actual Labor Hours
| Description | Actual number hours that it took to perform the activity. |
| 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 |
Actual Start Date
| Description | Actual date upon which the activity was started. |
| 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 |
Actual Time Spent
| Description | The actual time spent performing the activity. This differs from the labor hours by describing the elapsed time over which the labor hours were spread. For example, an activity may involve 4 hours actual work over 3 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 |
Claim Coverage Precedence Alteration Date
| Description | The date upon which the change to coverage precedence was actually made, which may or may not be the date from which it becomes effective. |
| 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 |
Coordination Of Benefits Reason
| Description | Indicates why the member has multiple coverage. |
| 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 Precedence Alteration Reason
| Description | Indicates why a change in coverage precedence may be made. |
| 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 |
Delay Reason
| Description | Indicates the cause of any discrepancy between planned and actual end dates. |
| 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 |
Name
| Description | A word or phrase identifying the activity. |
| Data Type | Standards - Data Domains.ddm/Data Domains/Name [VARCHAR(30)] |
| Is Part Of PrimaryKey | false |
| Is Required | false |
| Is Derived | false |
| Is Surrogate Key | false |
Other Carrier Claim Adjusted Ind
| Description | Indicates that the other payer had previously paid this claim and then has re-adjudicated the claim and is sending the adjusted payment information. Therefore this claim is an adjustment of a previously adjudicated claim. 1 Yes 0 No |
| 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 |
Other Carrier Health Plan Product
| Description | The health benefits plan or other insurance plan of the other carrier. |
| 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 |
Other Coverage Precedence Type
| Description | indicates the precedence type of health plan organizations other than the modeled organization. |
| 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 |
Our Coverage Precedence Type
| Description | Indicates the precedence type of the modeled health plan organization. |
| 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 |
Planned Duration
| Description | The time planned for the performing of the activity. This is the total elapsed time over which the activity is expected to be performed and not the planned labor hours. |
| 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 |
Planned End Date
| Description | Date upon which the activity is planned to end. |
| 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 |
Planned Manpower
| Description | The planned labor hours required for the activity. |
| 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 |
Planned Start Date
| Description | Date upon which the activity is planned to start. |
| 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 |
| Relationship Details |
Coordination Of Benefits_Claim_FK
| Is Identifying Relationship | false |
| Child Table | Coordination Of Benefits |
| Child Role Name | involves |
| 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 involved in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Coordination Of Benefits_Plan Member_FK1
| Is Identifying Relationship | false |
| Child Table | Coordination Of Benefits |
| Child Role Name | has for other carrier Member |
| 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 other carrier member in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Coordination Of Benefits_Organization_FK
| Is Identifying Relationship | false |
| Child Table | Coordination Of Benefits |
| Child Role Name | has other carrier of |
| 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 | Organization |
| Parent Role Name | is other carrier in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Coordination Of Benefits_Plan Member_FK
| Is Identifying Relationship | false |
| Child Table | Coordination Of Benefits |
| Child Role Name | involves |
| 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 involved in |
| Parent Multiplicity | ZERO_TO_ONE |
| Parent Referential Integrity: On Delete | NONE |
| Parent Referential Integrity: On Insert | NONE |
| Parent Referential Integrity: On Update | NONE |
Coordination Of Benefits_Insurance Policy_FK
| Is Identifying Relationship | false |
| Child Table | Coordination Of Benefits |
| 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 |
| Business Data Model Data Model |