Claims Data Architecture
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This document provides an overview of the claims data flow and analysis of the as-is state for an external claims system. It includes a diagram showing the flow of claims and encounters from source systems like EMR and ambulance providers through various data stores and analytical tools to downstream customer reports and underwriting. The analysis notes that the 14-year-old claims engine does not support multi-tiered products, has no web capabilities, and upgrades have never been performed, posing vendor risk.
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Claims Data Architecture
- 1. Claims Data Flow Assessment As-Is Analysis External Claims Actuarial Customer Reports Claims Engine Underwriting Local DSS EMR Ad-hoc Reports Analytical Tools Claims Database Central DSS Ambulance Rx Send encounters Send adjudicated claim/encounter 120 day lag time Does not support multi-tiered products 14 year old system and never upgraded No web capabilities for providers Potential vendor risk Send benefits Send internal encounter Costing activities Pre-processing Receive claim Send remittance advice Self-Funded Source of claim or encounter Legacy claim system Send copay & cost share info: Member ID, Date of Service, Copay Send external claim *Diagram is not all inclusive for illustrative purposes Ambulance is under a national contract No access to data Source Systems Data Store Access