Group Benefits

During the process of obtaining the CORE certification for HIPAAsuite we worked with the test bed data CAQH prepared. This data comes in an Excel spreadsheet file is now distributed with the software and we took it as model to import covered membership records via spreadsheet.

One peculiarity about this approach is that it has group benefits. Most health plans set up group or plan benefits. This is a basket of benefits that members subscribe too. The spreadsheet contains tabs for each member and tabs for different benefits. We thought that importing this spreadsheet into the covered Members schema is a great way to facilitate the loading of membership data that is frequently necessary to preserve the acuity of eligibility responses.

In addition it was important to us to accept the complexity that this data model offered. A complexity that mirrors real life situations and a data model that was developed by top experts in the field.

While the schema of our covered members was sufficient because each member can have all their benefits individually assigned, it lacked benefit plans. We found it necessary to be able to define group benefits without changing the database.

We achieved this by creating a new class of benefit records. Benefit records that don't have a foreign key that points to a specific member and instead the field "PlanName" is populated.

To assign plan benefits to a member, create a single benefit record, typically with Service Type Code 30, and populate the "PlanName" field. When creating the 271 eligibility response record the program will go out and add also the group benefits that are listed under that plan name.

You can have additional benefits on the individual level or you can further define particular benefits on the individual level with remaining annual deductibles for example.

The CORE test bed data defining group benefits.

The CORE test bed data defining a member and further specifying benefits on the individual level.