Insurance Claims and Payments

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Insurance Claims and Payments

Post  sgrover3 on Tue May 10, 2011 12:40 pm

Hi All,
I am designing a star schemas in Claims (Premiums and claims). I have a Claim Transaction Fact table which captures all the claim amounts (claims, reserves etc.) using Transaction Type dimension. In the business requirement, there is also a need to capture payments in detail that were made to different people/organizations as part of that claim. Insurance companies might pay medical service providers, Attorneys, Auto Repairs etc as part of a claim. In addition to claim amounts (which is captured in the claim transaction), I also need to capture details of payments made by insurance companies. My question is: Are these payments (that are made to Attorney, medical providers etc) different Transaction Types, so all these can be captured in one star schema (Claims Transactions) or do I need a seperate star schema to capture payment details?
I also need to capture service type, diagnosis, miles from provider (medical or legal), frequency of office visits for these payments.

Please suggest

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Re: Insurance Claims and Payments

Post  ngalemmo on Tue May 10, 2011 1:06 pm

Recording/adjudicating a claim and paying a claim are separate processes that have their own dimension and dependencies. They should be separate facts.

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Re: Insurance Claims and Payments

Post  sgrover3 on Tue May 10, 2011 5:47 pm

Hi, thanks for the reply.

I am a bit confused. In Dr. Kimball's book (Chapter-15). He listed different types of Claim Transaction types such as Open Claim, Reopen Claim, Close Claim and Make Payment, Receive Payment.
For the "Make Payment" transaction type, isn't this the same as Paying for Medical Service Providers and Legal Services and Auto Repairs. I can add a Type of Service dimension to my current Claim Transaction Star and handle the different type of services and their amount.
My understanding is if the Insurance company pays $200 for claims to me, I then paid Arm Specialist $100 and Leg Specialist $100 (adding up to 200) b/c I was hurt in the accident. I want to capture the type of service detail in the model.

Please help me understand.

Thanks in Advance!

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