What are the business rules that companies are using for claims processing?
This is a common question when it comes to performing analysis on claims data and is becoming increasingly important with regulations on billing transparency on the way. The logic used for claims processing is typically embedded in code and is not transparent to those reporting on claims data.
Complex rules surround provider contracts, billing service levels, clinical codes, and member coverage. These rules change frequently, making it increasingly difficult to reconcile billing all the way through claims adjudication. As a result, it is critical to utilize key data governance practices in the 5 following ways:
- Create a business glossary and context diagram
- Identifies and defines a business description of each discrete business term used in claims processing as well as their relationships
- Develop a data dictionary
- Defines each of the tables and fields used in the database to support the data elements in claims processing
- Define relationships between the business glossary and data dictionary
- Shows how business terms map onto the tables and fields in the database
- Generate data lineage
- Shows where and how code is using the tables and fields, defined in the data dictionary, in the entire claims processing flow
- Reveal the data governance metadata to end-users in a meaningful way
The objective is to enable you to understand how and why the data changes across each step of the claims process. This will provide deeper insight into billing and collections errors, revenue cycle management, and proactively monitor the entire claims process.
