Claim Management System

Health4U wants to develop a cloud-based claim management system (CMS) that will help improve efficiency of claim processes for insurance companies. The system shall support individual clients to submit their claims, monitor the status of submitted claims, and check claim history. In order to submit a claim, a client must have an account with an insurance company from which insurance policies are purchased. Each policy has an unique policy number and could encompass a variety of insured services including medical, dental, eye care, physiotherapy, and so on. Each service would have its own claim requirements such as required document(s) for submitted claims, qualifications required from service providers, the maximum dollar amount covered for per visit, and maximum number of visits per year.

To create an account, a client must not only provide personal information (e.g., name, address, phone number, email address, gender, date of birth) but also his or her insurance policy number. If the client has a group policy (which is purchased by his or her organization for its employees), then the client shall use use the group policy number instead and also provide employee number. Both numbers are provided by the HR department of the organization.

The client could make a claim for him/herself and dependents (e.g., spouse, child) covered by the insurance policy. To submit a claim, the client needs to first sign in, and then indicate to submit a claim. The client shall specify the service type (e.g., dental, medical, physio), and provide the following information including the date and the time of the services provided, total amount paid, the name of the client for whom the service was provided, receipt(s) from the service provider and all other required documents. In addition, the information of the service provider (e.g., physician, massage therapist, dentist) should also be provided including the providers name, address, and phone number. Once a claim is submitted, the system generates a claim number which can be used later for checking claim status.

To search a claim, the client must first sign in and enter either the claim number or specify a date range. If it is the latter, the system would generate all claims submitted in the time period. A claim could have multiple statuses including New, In process, On Hold, and Approved/Rejected. Once a claim is processed, the system will send an email notification informing the individual of the final decision. The rejection letter explaining how the decision was made can be found along with the claim.

Once a claim is submitted, it appears in the new claim list which is accessible by all client representatives. A client representative who does not have any claims in process can select a new claim from the list. Once the claim is selected, it will be on the task list for the client representative and the claim status is changed from New to In Process. The rep will check the submitted documents, its correctness, completeness, and compliance against the clients insurance policy based on the policy number.

If there are any missing documents, the rep will put the claim on hold, and email the client to submit requested documents. Having acquired the requested documents, the client will sign in, select the claim on hold, and submit the documents. The rep will be notified when the new documents come in, and proceed to process the claim. If a claim is rejected, it will be archived. In other words, it cannot be modified or resubmitted. If the client wants to make a claim based on the same service, the client needs to create another claim.

The system also allows clients to submit an estimate, a document produced by a service provider as to details of a service needed for a client, reasons for the service, and cost estimate for the service. An estimate is treated as a claim, so will be reviewed and approved/rejected. A record of the decision letter will be kept along with the estimate in the claim management system.

Required Content:

• Assumptions (Optional)
• Domain Class diagram - Draw a domain class diagram for the system
• Use case diagram - Based on the above project case description, develop a use case diagram containing all major (e.g., create xxx, update xxx, search xxx) use cases of the system.

Select three use cases and use these three use cases for the following diagrams and descriptions.

• Use case description - Write a fully detailed use case description for each use case in the use case diagram.
• Activity diagram - Develop one activity diagram for each use case description

The table below summarizes the number of diagrams needed for project phase I

Diagrams	Domain class diagram	Use case diagram	Use case description	Activity diagram
No. of diagram that needs to be produced	1	1	3*	3*

* If a use case has more than one scenario, then the number of use case description needed will depend on the number of scenarios. For example, if a use case has two scenarios, then the number of use case descriptions and activity diagrams shall be two for that use case. As a result, the total number of use case descriptions and activity diagrams for your project shall be changed to 4 instead of 3.