Question
Please draw a process model with organizational units, processes, stores, and data flows. Health Care Plus is a supplemental health insurance company that pays claims
Please draw a process model with organizational units, processes, stores, and data flows.
Health Care Plus is a supplemental health insurance company that pays claims after its policyholders' primary insurance benefits through their employer or another policy have been exhausted. The following narrative partially describes its claims processing system. Policyholders must submit an EXPLANATION OF HEALTH CARE BENEFITS (EOHCB) along with proof that their primary health policy claim has been paid. All CLAIMS are mailed to the claims processing department. CLAIMS are initially sorted by the claims screening clerk. This clerk returns all requests that do not include the EOHCB. For those requests returned, a PENDING CLAIM IS created, dated, and sorted by date. Once each week, the clerk deletes all tickets that are more than 45 days old and sends a letter to the policyholders notifying them that their case has been closed. Requests that include the EOHCB are then sorted according to the type of claim. Requests that include an EOHCB REFERENCE NUMBER are matched up with an EOHCB form, which is pulled from the OPEN CLAIMS file. At the end of each day, all these claims are forwarded to the preprocessing department. In the preprocessing department, clerks screen the EOHCB for missing data. They complete the form if possible. Otherwise, a copy of the claim is returned to the policyholder with a letter requesting the missing data. The original EOHCB is placed in the OPEN CLAIMS file , and a PENDING CLAIM is sent to the claims screening clerk. Completed claims are assigned a claim number,and the claim is microfilmed and filed for archival purposes. A different clerk checks to see if the PROOF OF PRIMARY HEALTH CARE POLICY PAYMENT was included or is on file in the PRIMARY PAYMENT file. If it is not available, the policyholder is sent a letter requesting the proof. The EOHCB is placed in a PENDING PROOF file. Claims are automatically purged if they remain in this file for more than 14 days (a letter is sent to policyholders whose claims have been purged). If proof is available, another clerk pulls the policyholder's policy record from the POLICY file, records policy and action codes on the EOHCB, and refiles the policy. At the end of the day, all preprocessed claims are forwarded to Information Systems.
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