Insurance

Introduction

The Insurance data model plays a pivotal role in healthcare information systems by capturing and managing essential information related to a patient's insurance coverage. This model focuses on the IN1 (Insurance) and IN2 (Insurance Additional Information) segments of HL7 messages, providing comprehensive details about a patient's insurance policy and its handling by healthcare providers. It is a critical component in ensuring accurate billing, claims processing, and coordination of benefits.

Use Case

Developers can leverage the capabilities of the Insurance data model for various technical use cases, enabling efficient management of insurance-related data within healthcare systems:

Insurance Verification: Developers can use this model to query insurance IDs and patient IDs, allowing them to verify the insurance coverage of a patient. This is crucial for ensuring that patients have valid insurance at the time of service.
Claims Processing: Healthcare systems often require accurate and timely claims processing. Developers can extract insurance-related information, such as group numbers and policy numbers, to support the creation and submission of insurance claims.
Coordination of Benefits: In cases where a patient has multiple insurance policies, developers can use this model to determine the coordination of benefits. By querying insurance IDs and patient IDs, they can identify which insurance plan is primary and which is secondary, streamlining the claims process.
Patient Billing: Developers can extract insurance company names and policy numbers to facilitate patient billing. This ensures that the correct insurance information is used for billing purposes, reducing errors and delays.
Insurance Coverage Details: Developers can access detailed insurance coverage information, including coverage types and effective dates, to determine the extent of a patient's coverage. This information aids in understanding which services are covered by the insurance plan.
Insurance Company Integration: Developers can integrate with insurance companies and use this model to exchange insurance-related data electronically. This allows for real-time eligibility verification and claims adjudication.
Patient Financial Counseling: Hospitals and healthcare facilities often provide financial counseling to patients. Developers can use this model to access insurance-related data, enabling financial counselors to provide accurate information about patient responsibilities and co-pays.
Insurance Analytics: Researchers and analysts can query insurance-related data for research and analytics purposes. This data can be used to analyze trends in insurance coverage, claims denial rates, and the impact of insurance on healthcare outcomes.
Compliance and Auditing: Developers can use this model to support compliance with healthcare regulations by querying insurance data for auditing and reporting purposes. This helps ensure that insurance-related processes adhere to regulatory requirements.
Telemedicine and Remote Services: In telemedicine and remote healthcare scenarios, developers can access insurance information to determine coverage for remote services and tele-health consultations.

Data Fields

Attribute Name	Description	HL7 Mapping	Data Type	Label	Use Case
insurance_id	Id of Insurance	IN1+MSH-10	string	Insurance ID	The insurance ID is used to accurately identify the patient's insurance coverage. It is crucial during the admission process to link the patient with their insurance information.
patient_id	This is patient_id attribute	PID-3-1	string	Patient ID	The patient ID is a unique identifier assigned to a patient within the healthcare system. It is used to accurately identify and link a patient's medical records, treatments, and history.
insured_ssn	Social Security Number of Insured	IN2-2	string	Insured's Social Security Number	The insured SSN is used to uniquely identify the insured individual within the context of their insurance coverage. It helps ensure that the correct insurance information is associated with the right person.
visit_number	Id of the visit	PV1-19-1	string	Visit Number	The visit number serves as a unique identifier for a specific patient visit or encounter within a healthcare facility. It distinguishes one visit from another.
bundle_id	ID of bundle	MSH-10	string	Bundle ID	“bundle ID" typically refers to a unique identifier assigned to a group or bundle of related messages or data elements. This identifier is used to associate multiple messages or pieces of information that are related to a specific patient, event, or transaction.
insured_relationship_to_patient	Patient's Relationship to Insured	IN2-72	string	CMS Patient's Relationship to Insured	This field provides information about the relationship between the insured person and the patient. It specifies how the individual named in the insurance coverage is related to the patient.
mail_claim_party	Mail Claim Party of insurance	IN2-5	string	Mail Claim Party	This field specifies the contact information of the party responsible for handling claims-related correspondence and documentation.
bedside_datetime	Bed side Date and time	PV1-44	date	Bedside Datetime	This field captures the date and time of specific bedside events or actions related to patient care, such as procedures, assessments, or vital sign measurements.
insurance_company_name	Company Name of Insurance	IN1-4	string	Insurance Company Name	This field specifies the name of the insurance company or provider responsible for the patient's coverage. It helps identify the insurer associated with the patient's policy.
insurance_company_id	Company Id of Insurance	IN1-3	string	Insurance Company ID	This field specifies a unique identifier for the insurance company or provider responsible for the patient's coverage. It helps identify the insurer associated with the patient's policy.
medicare_health_ins_card_number	Medicare Health Ins Card Number of insurance	IN2-6	string	Medicare Health Ins Card Number	This field specifies the unique identification number assigned to a patient's Medicare health insurance card. This number is critical for identifying patients with Medicare coverage.
insured_phone_number	Contact Person Phone Number of insured	IN2-58	string	Insured's Contact Person Phone Number	This field specifies the phone number of the insured individual or policyholder. It serves as a contact point for communication regarding insurance-related matters.
patient_member_number	Patient Member Number of Insurance	IN2-61	string	Patient Member Number	This field specifies a unique identifier assigned to the patient by the insurance plan. It helps identify the patient as a member of the insurance plan.
group_number	Group Number of Insurance	IN1-8-1	string	Group Number	This field specifies a unique identifier for the insurance group associated with the patient's coverage. It helps identify the specific group within an insurance plan.
policy_number	Policy Number of Insurance	IN1-36	string	Policy Number	This field specifies a unique identifier for the insurance policy associated with the patient's coverage. It helps identify the specific insurance policy held by the patient.
insurance_company_address	Company Address of Insurance	IN1-5	json	Insurance Company Address	This field specifies the physical address of the insurance company or provider responsible for the patient's coverage. It serves as a contact point for written communication or inquiries related to insurance.
alternate_visit_id	Alternative visit id	PV1-50/PID-18	string	Alternate Visit Id	This field provides an alternate identifier for a patient's visit. It is used for tracking and cross-referencing patient visits and records, especially in scenarios requiring multiple identifiers or references. This field is recorded during patient registration and aids in accurate record linkage.
xc_visit_id	XC visit id	Based on alternate_visit_id followed by visit_number followed by system generated ID	string	XC visit id	The "xc_visit_id" is a unique identifier used to group together all the interactions, procedures, tests, and check-ups associated with a single patient visit in a healthcare setting. This identifier helps in organising and managing various activities and data related to that specific patient encounter.
company_plan_code	Company Plan Code of Insurance	IN1-35	string	Company Plan Code	This field specifies a code or identifier that represents the specific insurance plan or policy under which the patient is covered. It helps identify the unique plan associated with the patient's coverage.
lineage	This is lineage attribute	Fixed - HL7	string	Lineage	"lineage" refers to the information about the origin or source of a message. It helps trace the path of the message, indicating where it originated, how it was transmitted, and any intermediate systems or components it passed through before reaching its destination.
coord_of_ben_priority	Coord Of Ben. Priority	IN1-22	string	Coord Of Ben. Priority	The "Coordination of Benefits Priority" field specifies the priority order in which different insurance plans should be coordinated when multiple insurance plans cover a patient's healthcare expenses. It helps determine which insurance plan should be the primary payer and which should be secondary or tertiary.
batch_id	Batch id	System Generated	string	Batch ID	"batch ID" is a unique identifier assigned to a group of messages that are logically grouped together for processing or transmission. Batching messages is a common practice in healthcare systems to efficiently manage and transmit multiple messages as a single unit
coverage_type	Coverage Type of Insurance	IN1-47	string	Coverage Type	This field specifies the type or classification of the insurance coverage held by the patient. It helps differentiate between different types of insurance plans, such as commercial, government-sponsored, or private plans.
plan_effective_date	Plan Effective Date of Insurance	IN1-12	date	Plan Effective Date	This field specifies the date on which the patient's insurance coverage under the specified plan becomes effective. It marks the start of the coverage period.

Similar Models

Here are the models that are similar to the current data model

Insurance_Identifier - It identifies and gives information regarding the patient's insurance coverage and their handling by healthcare providers

Encounter Provider

Insurance Identifier