A Sample Data Model
David Hay
BlueCross
BlueShield
of Arizona

Data Model . . .
 Conceptual entity/relationship model is a
graphic description of:
 The things of significance to the enterprise,
 “Entities” and “Entity classes”
 Relationships between pairs of them,
 “Relationships”
 The information required about each one.
 “Attributes”

Kinds of data models . . .
 Conceptual entity/relationship model
 Describes the fundamental architecture of the
organization’s data.
 Classes: Classes of things of significance to the
business.
 Logical data model
 Describes data in terms manipulated by a data
management technology (object-orientation or a
relational database management system).
 Physical data model
 Describes data in terms of its manipulation by a
computer. (Table spaces, DASD drives, etc.)

Example of data structure . . .
 The following is a set of drawings to
present a sample conceptual data model of
(a very tiny part of) the insurance industry.
 It is based on
 An insurance policy from Southwest Insurance,
Inc.
 Dave Hay’s understanding of the nature of
contracts.

About the session . . .
 It is intended to capture the language of
the business.
 It is fundamentally about the assertions
made, not the drawing.
 “Intended” is the critical concept.
 We are here to be wrong.
 It is much cheaper for us to fix a model
than for a programmer to fix a piece of
installed software.

People and Organizations . . .
PARTY
# PARTY ID
ORGANIZATION
* NAME
COMPANY
Customers INTERNAL
ORGANIZATION
Client
companies GOVERNMENT
AGENCY
Employees HOUSEHOLD
Regulatory OTHER
agencies
ORGANIZATION
PERSON
o FIRST NAME
* LA ST NAME
* BIRTHDA TE

Policies . . .
PARTY
Each Policy must be sold by one ORGANIZATION
* NAME
and only one Party.
COMPANY
Each Party may be seller of one
or more Policies INTERNAL
ORGANIZATION
GOVERNMENT
POLICY sold by AGENCY
# POLICY NUMBER
o POLICY STA RT DA TE seller of
o POLICY MAXIMUM AMOUNT
HOUSEHOLD
held by
holder of
PERSON
o FIRST NAME
* LA ST NAME
Each Policy must be held by one * BIRTHDA TE
and only one Party.
Each Party may be holder of
one or more Policies

Roles and relationships . . .
PARTY
ORGANIZATION
* NAME
played by
POLICY ROLE
Policy Role Type: * EFFECTIVE DATE
o UNTIL DATE
player of
Sales Agent * POLICY ROLE TY PE COMPANY
Beneficiary for
etc. INTERNAL
ORGANIZATION
managed via GOVERNMENT
AGENCY
sold by
POLICY
# POLICY NUMBER
o POLICY STA RT DA TE
seller of
o POLICY MAXIMUM AMOUNT held by HOUSEHOLD
holder of
PERSON
o FIRST NAME
Party Relationship Type:
* LA ST NAME
* BIRTHDA TE
Spouse
Member of Household PARTY to
Employee of Company RELATIONSHIP on the other
etc. # EFFECTIVE DA TE
o UNTIL DATE side of
* PA RTY RELATIONSHIP TYPE
from
on one side of

Underwriting . . .
POLICY ROLE PARTY
* EFFECTIVE DATE played by # PARTY ID
o UNTIL DATE
* POLICY ROLE TYPE
player of
for for
managed via
RISK EVALUATION ELEMENT RISK EVALUATION
# SEQUENCE NUMBER part of # EVALUATION ID
o SCORE * EVALUATION START DATE`
composed of o EVALUATION END DATE
o AGGREGATE SCORE
o CONCLUSION DESCRIPTION
o CONCLUSTION TYPE
an an an an an an
evaluation evaluation evaluation evaluation evaluation evaluation
of of of of of of
evaluated via evaluated via evaluated via ORGANIZATION
* NAME
MEDICATION PROCEDURE CONDITION/
# NAME # NAME
* DESCRIPTION * DESCRIPTION
AILMENT
# NAME COMPANY
o DESCRIPTION
INTERNAL
evaluated via evaluated via evaluated via ORGANIZATION
FACILITY SPECIALTY OTHER
# NAME for GOVERNMENT
# NAME
* DESCRIPTION
SERVICE AGENCY
o DESCRIPTION # NAME
* DESCRIPTION managed via
HOUSEHOLD
CONTRACT
# POLICY NUMBER
o POLICY START DATE bought by
o POLICY MAXIMUM AMOUNT
buyer of
evaluated via
PERSON
POTENTIAL POLICY sold by o FIRST NAME
o GRANTED/REJECTED INDICATOR * LAST NAME
seller of * BIRTHDATE

Coverage . . .
PARTY
ORGANIZATION
* NAME
played by
POLICY ROLE
* EFFECTIVE DATE
o UNTIL DATE
player of
* POLICY ROLE TY PE
COMPANY
for
INTERNAL
ORGANIZATION
managed via GOVERNMENT
AGENCY
sold by
POLICY
COVERAGE part of # POLICY NUMBER
seller of
o POLICY STA RT DA TE
# LINE NUMBER
held by HOUSEHOLD
o BENEFIT LIMIT composed of o POLICY MAXIMUM AMOUNT
* DEDUCTIBLE
holder of
to provide
provided via PERSON
o FIRST NAME
* LA ST NAME
BENEFIT DETAIL BENEFIT * BIRTHDA TE
# SEQUENCE NUMBER part of # BENEFIT ID
* NAME * NAME
* DESCRI TION
P composed of * DESCRIPTION
* BENEFIT DETAIL TYPE
PARTY to
RELATIONSHIP on the other side of
Benefit: # EFFECTIVE DA TE
o UNTIL DATE from
Hospital for brain tumor, * PA RTY RELATIONSHIP TYPE
on one side of
Doctor’s visit,
etc.

More on benefit details . . .
If … a resident bed patient within a Hospital under the
care and attendance of a licensed Physician,
The Company will pay
the regular and customary charges incurred …, but not COVERAGE part of
POLICY
# POLICY NUMBER
to exceed a per Hospital confinement aggregate of the # LINE NUMBER
o BENEFIT LIMIT composed of
o POLICY STA RT DA TE
o POLICY MAXIMUM AMOUNT
* DEDUCTIBLE
… benefit, set out in the schedule, times the number of
days confined. to provide
provided via
BENEFIT DETAIL BENEFIT
# BENEFIT ID
# SEQUENCE NUMBER * NAME
*
*
NAME
DESCRIPTION
part of * DESCRIPTION
o COST LIMIT
o
o
IN TERMS OF
QUANTITY LIMIT
composed
* REGULAR AND CUSTOMARY INDICATOR of
o CO-INSURANCE PERCENTAGE
to pay for to pay for to pay for to pay for to pay for
paid for
paid for via via
PROCEDURE CONDITION/AILMENT
# NAME # NAME
* DESCRIPTION o DESCRIPTION
paid for via paid for via paid for via
FACILITY SPECIALTY OTHER SERVICE
# NAME
# NAME # NAME * DESCRIPTION
o DESCRIPTION * DESCRIPTION

Claims

Claims . . .
PARTY
CLAIM DISPOSITION ROLE played by
# EFFECTIVE DAT E
o UNTIL DATE player of
* CLAIM DISPOSITION ROLE TYPE
for
ORGANIZATION
* NAME
managed via
CLAIM DISPOSITION SERVICE PROVIDED by COMPANY
* DISPOSITION DATE # BEGIN DATE
o STATUS
* CLAIM DISPOSITION TYPE
o END DATE performer of
INTERNAL
charged to ORGANIZATION
CLAIM ELEMENT in
# SEQUENCE NUMBER response to pay
o ACCEPTED AMOUNT managed via to for
o CHARGED AMOUNT GOVERNMENT
o COPAY AMOUNT AGENCY
o ASSURANT PAID AMOUNT CLAIM POLICY ROLE played by
o NUMBER OF ADMITS part of # CLAIM NUMER * EFFECTIVE DATE
o UNTIL DATE
o NUMBER OF DRUGS * DESCRIPTION * POLICY ROLE TY PE
player of
HOUSEHOLD
o TOTAL COST OF RX composed of o PAYMENT AMOUNT
o REFUSED AMOUNT o REFUSED AMOUNT
o REFUSAL REASON for
for based on managed via
the basis for
sold by PERSON
POLICY o FIRST NAME
COVERAGE part of # POLICY NUMBER
seller of * LA ST NAME
# LINE NUMBER o POLICY STA RT DA TE * BIRTHDA TE
o BENEFIT LIMIT composed of o POLICY MAXIMUM AMOUNT held by
* DEDUCTIBLE
holder of
to provide
PARTY to
paid for via provided via
RELATIONSHIP on the other side of
# EFFECTIVE DA TE
BENEFIT DETAIL part of BENEFIT o UNTIL DATE from
# BENEFIT ID * PA RTY RELATIONSHIP TYPE
# SEQUENCE NUMBER
* NAME composed * NAME on one side of
* DESCRIPTION * DESCRIPTION
* BENEFIT DETAIL TYPE of
to pay for to pay for to pay for to pay for to pay for to pay for
paid for via paid for via paid for via
MEDICATION PROCEDURE CONDITION/
# NAME # NAME
* DESCRIPTION * DESCRIPTION AILMENT
# NAME
o DESCRIPTION
paid for via paid for via paid for via
FACILITY SPECIALTY OTHER SERVICE
# NAME # NAME # NAME
o DESCRIPTION * DESCRIPTION * DESCRIPTION

Questions?
???