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- Health Insurance Claims
- Data model and import order
The tables behind Health Insurance Claims
Health Insurance Claims ships with 15 tables, grouped here by the feature that uses them. Every record your team works with lives in one of them, and you can add fields and tables in Proto.
- Tables
- 15
- Features
- 6
- Change it
- Add fields and tables in Proto
How the model is organised
Policy and coverage:
Policies, policy coverages, policy endorsements and premium receipts retain effective terms and receipt evidence.
Policyholder and organization:
Organizations, Policyholders, team members and Users establish party and staff context.
Preauthorization review:
Preauthorizations records the policy-linked request; review decisions records a reviewer decision against the policy.
Claims assessment:
Claims and claim decisions separate the reported amount from the authorized benefit.
Benefit settlement:
Claim payments links paid provider events to both Claims and claim decisions.
Review and evidence:
Record attachments and operation receipts retain supporting files and operation results.
Every table, by feature
- Policy and coverage6
- Policyholder and organization5
- Preauthorization review6
- Claims assessment5
- Benefit settlement4
- Review and evidence6
- Policies
Policies records; retain actual linked evidence and role scope.
Linked to Organizations, Team members, Policyholders - Policy coverages
Policy Coverages records; retain actual linked evidence and role scope.
Linked to Policies - Policy endorsements
Policy Endorsements records; retain actual linked evidence and role scope.
Linked to Policies - Review decisions
Review Decisions records; retain actual linked evidence and role scope.
Linked to Policies, Team members - Operation receipts
Operation Receipts records; retain actual linked evidence and role scope.
Linked to Policies
- Organizations
Organizations records; retain actual linked evidence and role scope.
- Policyholders
Policyholders records; retain actual linked evidence and role scope.
Linked to Organizations - Team members
Team Members records; retain actual linked evidence and role scope.
Linked to Organizations, Users - Users
Users
Linked to Users - Policies
Policies records; retain actual linked evidence and role scope.
Linked to Organizations, Team members, Policyholders
- Policies
Policies records; retain actual linked evidence and role scope.
Linked to Organizations, Team members, Policyholders - Organizations
Organizations records; retain actual linked evidence and role scope.
- Review decisions
Review Decisions records; retain actual linked evidence and role scope.
Linked to Policies, Team members - Record attachments
Record Attachments records; retain actual linked evidence and role scope.
Linked to Policies, Team members - Operation receipts
Operation Receipts records; retain actual linked evidence and role scope.
Linked to Policies
- Claims
Claims records; retain actual linked evidence and role scope.
Linked to Policies - Claim decisions
Claim Decisions records; retain actual linked evidence and role scope.
Linked to Claims - Policies
Policies records; retain actual linked evidence and role scope.
Linked to Organizations, Team members, Policyholders - Policy coverages
Policy Coverages records; retain actual linked evidence and role scope.
Linked to Policies - Record attachments
Record Attachments records; retain actual linked evidence and role scope.
Linked to Policies, Team members
- Claims
Claims records; retain actual linked evidence and role scope.
Linked to Policies - Claim decisions
Claim Decisions records; retain actual linked evidence and role scope.
Linked to Claims - Claim payments
Claim Payments records; retain actual linked evidence and role scope.
Linked to Claims, Claim decisions - Operation receipts
Operation Receipts records; retain actual linked evidence and role scope.
Linked to Policies
- Review decisions
Review Decisions records; retain actual linked evidence and role scope.
Linked to Policies, Team members - Record attachments
Record Attachments records; retain actual linked evidence and role scope.
Linked to Policies, Team members - Operation receipts
Operation Receipts records; retain actual linked evidence and role scope.
Linked to Policies - Policies
Policies records; retain actual linked evidence and role scope.
Linked to Organizations, Team members, Policyholders - Team members
Team Members records; retain actual linked evidence and role scope.
Linked to Organizations, Users
Keys and references
Keep Organizations.Code and Policyholders.Code stable during import. Policies.record number identifies the policy; Claims.claim number identifies the reported loss. Claims.Policy, Preauthorizations.Parent and policy coverages.Parent preserve the policy relationship. Claim payments references both Claims and claim decisions so a provider event can be checked against the benefit it pays. Keep provider event ID stable across retries.
Review decisions.source revision and operation receipts.expected revision must refer to the state actually reviewed or attempted. Operation receipts.operation key identifies a retryable action. Store the original key and effect references when an operation needs investigation. A review decisions entry belongs to Policies through Parent. Match its operation key and receipt effects to the specific preauthorization before applying that outcome. Claim benefit authority is recorded separately in claim decisions.
Migration order
- Load Organizations, Users, team members and Policyholders with stable source codes.
- Load Policies and policy coverages, then dated policy endorsements and premium receipts.
- Load record attachments and the reviewed policy decisions where history is available.
- Load Preauthorizations, Claims and claim decisions with their original policy references.
- Load claim payments and operation receipts, then reconcile provider events and revision references before use.
Set up Health Insurance Claims your way.
Start free, then use Proto to change fields, steps and approvals before your team goes live.