Class: Insurance_certification

Description of: Insurance_certification

Class steward is Patient Administration
An affirmation by an insurance company that it will pay for a specified service.

Attribute definitions for: Insurance_certification

appeal_reason_cd ::

A code depicting the reason an appeal was made on a non-concur for certification.

OpenIssue: Need example codes.

|IN3^17^00518^Appeal Reason|

certification_duration_qty ::

A count of the number of days for which this certification is valid.

|IN3^11^00512^Days|

effective_tmr ::

The date range during which this certification is effective.

|IN3^6^00507^Certification Date/Time| |IN3^9^00510^Certification Begin Date|

id ::

A unique identifier for the certification assigned by the certification agency.

|IN3^2^00503^Certification Number|

insurance_verification_dttm ::

The data and time the insurance coverage was verified.

|IN1^29^00454^Verification Date/Time|

modification_dttm ::

The date/time that the certification was modified.

|IN3^7^00508^Certification Modify Date/Time|

non_concur_cd ::

A code depicting the reason or kind of denied request.

OpenIssue: Need code examples (#55).

|IN3^12^00513^Non-Concur Code/Description|

non_concur_effective_dttm ::

The date of the non-concurrence classification.

|IN3^13^00514^Non-Concur Effective Date/Time|

penalty_amt ::

The dollar amount of the penalty that will be assessed if the precertification is not performed.

|IN3^5^00506^Penalty|

report_of_eligibility_dttm ::

The date a report of eligibility (ROE) was received.

Rationale: IN1-26

OpenIssue: should it be placed in Preauthorization.authorized_period_begin_dt instead? If so then Healthcare_benefit_plan.report_of_eligibility_ind should be moved to that class as well.

|IN1^26^00451^Rpt of Eligibility Date|

report_of_eligibility_ind ::

An indication of whether the insurance carrier sent a report of eligibility identifying the benefits the patient is eligible for.

|IN1^25^00450^Rpt of Eligibility Flag|

Association definitions for: Insurance_certification

has_contact (1,n) :: Insurance_certification_contact :: is_contact_for (1,1)

provides_validation_for (1,1) :: Healthcare_benefit_coverage_item :: is_validated_by (0,n)

Rationale: This class now contains the attributes of a "master" class; insurance certification is associated with coverage_item.

OpenIssue: Are the multiplicities correct? Should there be an additional connection to Patient? Should there be an additional association to Healthcare_benefit_product? Or an association with a new class representing a Patient instance of a benefit product?

includes (0,n) :: Certification_additional_opinion :: provides_opinion_on (1,1)

affirms_insurance_coverage_for (1,1) :: Guarantor_contract :: has_coverage_affirmed_by (0,n)

is_issued_by (1,1) :: Insurer :: issues (0,n)