RBA2000
Medical &
Dental Claims Processing Application
The
following is a partial list of features:
1.
Data integrity
Data
types and business rules are enforced every time a record is
written. This is true even if we use an editor to bypass the normal
screen processing.
2.
Powerful screen generator
The
layout and functionality of inquiry and entry screens are defined
and controlled using an in-house product called Screen Driver.
Screen Driver has both character and GUI options. Using the same
screen definition, one user can execute a character-based version
while another user executes a GUI version.
3. Audit
trail
Flags
direct the application to capture changes. Some flags are global
while others can be set for each operator and field. The application
stores the date, time, and operator, along with a before and after
image of the change.
The above
flags are useful when data is changed, but another set of flags
directs the application to record which screens were used by which
operators to look at which data. This is true even for inquiry only
screens.
For claim
processing the information stored is more comprehensive. Every time
a claim is adjudicated, the system stores the values that were used
in the calculation. For example, when a fee schedule is used, the
value from the fee schedule is stored in the claim. If we use the
provider's last name to calculate a claim, the system will store the
provider's last name (at the time of adjudication) in the claim. We
also keep the ids of which rules were used in the calculation. Thus
it becomes very easy to research how any claim was calculated. All
data used in the calculation are saved.
4. Rule
debugging screens
I've
often seen a benefit administrator scratch their head wondering how
the system ever came up the amount it wants to pay. RBA2000 provides
a high-level debugging option used by the benefit administrator for
setting up and maintaining the rules. When debugging is turned on
for an operator, the system pauses between the execution of each
rule to display the current amounts, accumulations, parameters, and
flags in formatted screens. This makes it very easy to discover
exactly why the copay was $10 or why a deductible was not taken.
5.
Comprehensive data definition table
Every
data field in every table is defined by an entry in a single data
definition table. Utility programs then use these definitions to
create and maintain dictionaries, indexes, named common blocks,
equates, cache variables, read and write routines, and triggers.
It's
really nice to be able to quickly answer questions like, "Which
files contain a key to the member file?" It also gives unprecedented
control to the database administrator. The system uses entries in
the data definition file to enforce data types, required fields,
referential integrity, unique or sorted multi-valued fields,
association of multi-valued fields, pattern matches, conversions,
and validations.
