Overview Top Package Entity

Business Data Model Data Model

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Entity Coverage Eligibility

Description

An agreement that summarizes the particulars of an Insured's policy as known by the organization.

Attributes

Assignment Of Benefits

Average Semi-Private Room Rate Amt

Baby Coverage Ind

Blood Deductible

Certification Required Ind

COBRA Ind

Coinsurance Amt

Combine Baby Bill Ind

Company Plan Code

Confidentiality Ind

Coordination Of Benefits Priority Cnt

Coordination Of Benefits Type

County Name

Coverage Agreement Type

Coverage Eligibility Source

Coverage Type

Daily Deductible Amt

Daily Deductible Applicable Days

Daily Deductible Delay Days

Delay Before LR Day

ER Copay Amt

Group Num

Group Status

Insurance Plan Num

Insurance State Name

IP Copay Amt

Lifetime Reserved Days Cnt

Max Private Room Rate Amt

MCP Copay Amt

Medicaid Case Num

Non-Certification Penalty Amt

Notice Of Admission Ind

Office Visit Copay Amt

Part A Termination Reason

Part B Termination Reason

Pharmacy Copay Amt

Pharmacy Join Ind

Plan Type

Policy Deductible Amt

Policy Max Limit Amt

Policy Max Limit Days

Policy Num

Policy Scope

Policy Source

Policy Type

Prior Plan Code Num

Release Of Information

Report Of Eligibility Ind

Room Coverage Amount Type

Room Coverage Amt

Room Coverage Type

Special Coverage Approval Title

Relationship

Provider Patient Insurance_Party Name_FK

Provider Patient Insurance_Employer_FK

Provider Patient Insurance_Insured_FK

Provider Patient Insurance_Party Name_FK1

Provider Patient Insurance_Party Name_FK2

Coverage Eligibility_Health Plan_FK

Generalization

Coverage Eligibility_Agreement_Gen

Dependencies

NONE

Reverse Dependencies

Attribute Details

 Assignment Of Benefits

Description	Indicates the insured's elected assignment of benefits. If the insured agreed to assign the insurance benefits to the healthcare provider, the insurance will pay the provider directly.
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

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 Average Semi-Private Room Rate Amt

Description	The average room rate that the policy covers.
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

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 Baby Coverage Ind

Description	Indicates whether or not the baby is included in the coverage. Y - baby coverage N - no baby coverage
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

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 Blood Deductible

Description	Use this field instead of UB1-2 - Blood Deductible, as the blood deductible can be associated with the specific insurance plan via this field.
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

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 Certification Required Ind

Description	Indicates whether certification is required. 1 - certification required 0 - certification not required
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

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 COBRA Ind

Description	Indicates if this eligibility is being retained under COBRA program.
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

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 Coinsurance Amt

Description	The amount of insurance liability assumed by the Member.
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

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 Combine Baby Bill Ind

Description	Indicates whether or not to combine baby bill. Y - combine bill N - normal billing
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

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 Company Plan Code

Description	Optional information to further define the data in Insurance Company Id.
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

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 Confidentiality Ind

Description	Indicates whether or not this member's data is confidential.
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

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 Coordination Of Benefits Priority Cnt

Description	If the insurance works in conjunction with other insurance plans, this field contains priority sequence. Values are: 1, 2, 3, etc.
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

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 Coordination Of Benefits Type

Description	Identifies whether this insurance works in conjunction with other insurance plans, or if it provides independent coverage and payment of benefits regardless of other insurance that might be available to the patient.  For example: CO - Coordination IN - Independent
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

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 County Name

Description	The name of the county for the address.
Data Type	Standards - Data Domains.ddm/Data Domains/Area Name [VARCHAR(50)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 Coverage Agreement Type

Description	Used to further identify an insurance plan. For example: S - Standard U - Unified M - Maternity
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

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 Coverage Eligibility Source

Description	Identifies of the source of Coverage Eligibility data. For example: Provider Payer
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

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 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

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 Daily Deductible Amt

Description	The amount of the 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

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 Daily Deductible Applicable Days

Description	The number of days to apply the deductible. If "number of days" is not valued, the deductible is ongoing.
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

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 Daily Deductible Delay Days

Description	The number of days after which the daily deductible begins.
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

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 Delay Before LR Day

Description	The delay before lifetime reserve days.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 ER Copay Amt

Description	Amount of the Copay for ER Visit expenses.
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

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 Group Num

Description	The group number of the insured's insurance.
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

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 Group Status

Description	Indicates the state or status of the plan member's health plan group.
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

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 Insurance Plan Num

Description	A unique identifier for the insurance plan associated with this coverage eligibility record.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 Insurance State Name

Description	The state of a country in which the insurance policy is underwritten.
Data Type	Standards - Data Domains.ddm/Data Domains/Area Name [VARCHAR(50)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 IP Copay Amt

Description	Amount of the Copay for Inpatient Visit expenses.
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

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 Lifetime Reserved Days Cnt

Description	The number of days left for a certain service to be provided or covered under an insurance policy.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 Max Private Room Rate Amt

Description	The maximum private room rate that the policy covers.
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

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 MCP Copay Amt

Description	Amount of the Copay for Managed Care Program.
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

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 Medicaid Case Num

Description	The Medicaid case number, defined by CMS or other regulatory agencies, which uniquely identifies a patient's Medicaid policy.
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

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 Non-Certification Penalty Amt

Description	The penalty that will be assessed if the pre-certification is not performed. Can be an absolute value or a percentage.
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

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 Notice Of Admission Ind

Description	Indicates whether or not the insurance company requires a written notice of admission from the healthcare provider. Y - written notice of admission required N - no notice required
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

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 Office Visit Copay Amt

Description	Amount of the Copay for Office Visit expenses.
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

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 Part A Termination Reason

Description	Indicates the reason that the Medicare Part A coverage ended for the plan member.
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

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 Part B Termination Reason

Description	Indicates the reason that the Medicare Part B coverage ended for plan member.
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

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 Pharmacy Copay Amt

Description	Amount of the Copay for Pharmacy expenses.
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

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 Pharmacy Join Ind

Description	Indicates whether or not the plan member has joined a pharmacy program.
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

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 Plan Type

Description	Indicates the type of health plan. For example: Medicare Medicaid Blue Cross HMO
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

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 Policy Deductible Amt

Description	The amount specified by the insurance plan that is the responsibility of the guarantor (i.e. deductible, excess, etc.).
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

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 Policy Max Limit Amt

Description	The maximum amount that the insurance policy will pay. In some cases, the limit may be for a single encounter.
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

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 Policy Max Limit Days

Description	The maximum number of days that the insurance policy will cover.
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

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 Policy Num

Description	The individual policy number of the insured to uniquely identify this patient's plan.
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

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 Policy Scope

Description	Identifies the extent of the coverage for a participating member. For example: Single Family
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

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 Policy Source

Description	Indicates how or from what source the policy information was established.
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

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 Policy Type

Description	Indicates the type of the policy covered by the insurance. For example: Ancillary Major medical
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

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 Prior Plan Code Num

Description	Uniquely identifies the prior insurance plan when the plan ID changes.
Data Type	Standards - Data Domains.ddm/Data Domains/Alphanumeric [VARCHAR(80)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

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 Release Of Information

Description	An indicator to show whether or not the provider has a signed statement on file permitting the release of medical data to other organizations. For example: - Appropriate Release of Information on File at Healthcare Service Provider or at Utilization Review Organization - Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes - The Provider has Limited or Restricted Ability to Release Data Related to a Claim - No, Provider is Not Allowed to Release Data - On file at Payor or at Plan Sponsor - Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
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

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 Report Of Eligibility Ind

Description	Indicates whether or not this insurance carrier sends a report that indicates that the patient is eligible for benefits and whether it identifies those benefits. Y - eligibility report is sent N - no eligibility report is sent
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

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 Room Coverage Amount Type

Description	Indicates the type of amount covered by the insurance. For example: Limit Percentage
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

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 Room Coverage Amt

Description	The amount covered by the insurance for a room.
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

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 Room Coverage Type

Description	Indicates the room type covered by the insurance. For example: Private Semi-private
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

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 Special Coverage Approval Title

Description	The title of the person who approves special coverage.
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

Relationship Details

 Provider Patient Insurance_Party Name_FK

Is Identifying Relationship	false
Child Table	Coverage Eligibility
Child Role Name	has group name
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	Party Name
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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 Provider Patient Insurance_Employer_FK

Is Identifying Relationship	false
Child Table	Coverage Eligibility
Child Role Name	has group employer
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	Employer
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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 Provider Patient Insurance_Insured_FK

Is Identifying Relationship	false
Child Table	Coverage Eligibility
Child Role Name	has insured
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	Insured
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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 Provider Patient Insurance_Party Name_FK1

Is Identifying Relationship	false
Child Table	Coverage Eligibility
Child Role Name	has medicaid case name
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	Party Name
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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 Provider Patient Insurance_Party Name_FK2

Is Identifying Relationship	false
Child Table	Coverage Eligibility
Child Role Name	has special coverage approver
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	Party Name
Parent Multiplicity	ZERO_TO_ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

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 Coverage Eligibility_Health Plan_FK

Is Identifying Relationship	false
Child Table	Coverage Eligibility
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 Plan
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Generalization Details

 Coverage Eligibility_Agreement_Gen

Supertype	Agreement
Subtype	Coverage Eligibility
Transform As	TABLE

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Overview Top Package Entity

Business Data Model Data Model