Policy & Contract Management Master Data & Configuration

Master Data Inventory

Note: Payers, insurance plans, contracts, fee schedules, coverage rules, etc. are operational master entities owned by this module and defined in 05-data-model.md. This document focuses on reference/lookup/configuration data that supports those entities.

Setup Sequence

The following dependency order ensures that all reference data is available before payer onboarding and contract configuration.

Narrative Load Order

1. Foundation (shared): Facilities, departments, users/roles from ../ehr-patient-mgmt/05-data-model.md.
2. Internal financial framework: Contract Types (MD-PCM-004), Rate Methodologies (MD-PCM-005), Network Tiers (MD-PCM-007), Authorization Method Types (MD-PCM-009).
3. Clinical coding base: CPT Code Master (MD-PCM-008) — required for tariffs, fee schedules, coverage rules.
4. Regulatory tariffs: DHA Tariff Schedule (MD-PCM-001), DOH Tariff Schedule (MD-PCM-002) — map to CPT codes.
5. Service taxonomy: Service Categories (MD-PCM-006) — map to CPT and tariff items.
6. Payer classification & rule taxonomies: Payer Classification Codes (MD-PCM-003), Coverage Rule Types (MD-PCM-013), Prior Auth Rule Categories (MD-PCM-014).
7. Payer Master: Payer records (MD-PCM-010) including DHA/DOH license and eClaimLink/Shafafiya identifiers.
8. Insurance Plan Master: Plans (MD-PCM-011) linked to payers and network tiers.
9. Operational configuration: Contracts, contract fee schedules, coverage rules, prior auth rules.

Master Data Specifications

MD-PCM-001: DHA Tariff Schedule

Purpose

DHA-published standard tariff for services in Dubai, used as:

• Base for percentage-of-tariff contracts.
• Reference for expected reimbursement and underpayment detection.
• Required for DHA eClaimLink compliance.

Logical Table: md_dha_tariff

Schema

Sample Data

Data Governance

• Owner: RCM Manager (Dubai operations).
• Source: Official DHA tariff files (Excel/CSV/XML) from DHA portal.
• Approval process: 1. RCM Manager downloads new tariff release. 2. Finance Director reviews sample mappings and impact analysis. 3. System Administrator imports into staging, RCM validates. 4. Finance Director approves promotion to production.
• Update frequency: At each DHA release (typically annual; ad-hoc updates possible).
• Change notification:
• Email + in-system notification to Billing, Patient Access, and Contract teams.
• Summary report of top 100 services with rate changes.

Validation Rules

• dha_code must be unique per dha_version.
• effective_date < expiry_date when expiry_date is not NULL.
• base_rate > 0.
• service_category_code must exist in md_service_categories.
• is_active = TRUE only when current date between effective_date and expiry_date (or expiry NULL).
• For rows with cpt_code not NULL, cpt_code must exist in md_cpt_master.

MD-PCM-002: DOH Tariff Schedule

Purpose

DOH (Abu Dhabi) standard tariff used for:

• Percentage-of-tariff contracts for Shafafiya/eClaims.
• Expected reimbursement calculations for Abu Dhabi encounters.
• Compliance with DOH pricing regulations.

Logical Table: md_doh_tariff

Schema

Sample Data

Data Governance

• Owner: RCM Manager (Abu Dhabi operations).
• Source: Official DOH tariff files from Shafafiya/eClaims portal.
• Approval process: Same as DHA tariff, with DOH-specific impact analysis.
• Update frequency: At each DOH release.
• Change notification: Same pattern as DHA; Abu Dhabi-specific communication.

Validation Rules

• doh_code unique per doh_version.
• base_rate > 0.
• service_category_code exists in md_service_categories.
• effective_date < expiry_date when not NULL.
• cpt_code (if present) must exist in md_cpt_master.

MD-PCM-003: Payer Classification Codes

Purpose

Standard classification of payers used for:

• Payer mix analysis and reporting.
• Contract strategy (e.g., government vs private).
• Routing rules for eligibility and claims (e.g., THIQA vs other DOH plans).

Logical Table: md_payer_classifications

Schema

Sample Data

Data Governance

• Owner: RCM Manager.
• Approval: Finance Director for new or changed categories.
• Update frequency: Quarterly review; ad-hoc when new government schemes appear.
• Change notification: Email to Billing, Patient Access, and Denial Analysis; update in payer onboarding SOP.

Validation Rules

• code unique and immutable once used by any payer.
• category_group limited to controlled list: {GOVERNMENT, PRIVATE, SELF_PAY, CORPORATE, OTHER}.
• At least one active government classification must exist.
• sort_order must be unique among active records.

MD-PCM-004: Contract Types

Purpose

Defines allowed contract types for contracts.contract_type, ensuring consistent financial modeling and reporting.

Logical Table: md_contract_types

Schema

Sample Data

Data Governance

• Owner: Finance Director.
• Approval: CEO / Board Finance Committee for new contract types.
• Update frequency: Rare; only when new financial models are adopted.
• Change notification: Formal memo to RCM and Billing; HIS configuration change log.

Validation Rules

• code unique and cannot be changed once used.
• Exactly one of the boolean flags should be TRUE for each record (enforced by application logic).
• At least one active fee-for-service type must exist.

MD-PCM-005: Rate Methodologies

Purpose

Defines how contracted rates are derived from tariffs or base rates (e.g., 120% of DHA tariff, 80% of DOH tariff).

Logical Table: md_rate_methodologies

Schema

Sample Data

Data Governance

• Owner: Finance Director.
• Approval: Finance Director; documented in pricing policy.
• Update frequency: Rare; when new standard multipliers are introduced.
• Change notification: Email to Contract Managers; update contract templates.

Validation Rules

• base_reference must be one of the controlled values.
• If base_reference in (DHA_TARIFF, DOH_TARIFF), default_multiplier must be > 0.
• code unique.

MD-PCM-006: Service Categories

Purpose

Standard service categories used to:

• Group CPT and tariff items for reporting and contract clauses.
• Drive prior authorization rules by service category.
• Align with DHA/DOH classification (e.g., radiology, laboratory).

Logical Table: md_service_categories

Schema

Sample Data

Data Governance

• Owner: RCM Manager.
• Approval: RCM Manager + Medical Director for new categories.
• Update frequency: On regulatory changes or new service lines.
• Change notification: Communicated to Coding, Billing, and Contract teams.

Validation Rules

• code unique.
• At least one of is_inpatient or is_outpatient must be TRUE.
• sort_order unique among active records.

MD-PCM-007: Network Tiers

Purpose

Defines network tiers used in payer_networks.network_tier and insurance plan configuration.

Logical Table: md_network_tiers

Schema

Sample Data

Data Governance

• Owner: Contract Manager.
• Approval: Finance Director.
• Update frequency: Rare; when network strategy changes.
• Change notification: Communicated to Patient Access and Billing for estimation logic.

Validation Rules

• code unique.
• default_patient_copay_pct between 0 and 100.
• At least one active in-network tier must exist.

MD-PCM-008: CPT Code Master

Purpose

Master list of CPT codes used across:

• Fee schedules and contract fee schedule items.
• Coverage and prior authorization rules.
• Claims generation and mapping to DHA/DOH tariffs.

Logical Table: md_cpt_master

Schema

Sample Data

Data Governance

• Owner: RCM Coding Team Lead.
• Source: Official AMA CPT release (licensed).
• Approval: RCM Manager.
• Update frequency: Annual (new CPT year) plus ad-hoc corrections.
• Change notification: Coding circular; training sessions for coders.

Validation Rules

• cpt_code unique.
• effective_date < expiry_date when expiry not NULL.
• category must be from controlled list (E&M, Surgery, Radiology, Lab, etc.).
• At least one of is_surgical or is_diagnostic must be TRUE.

MD-PCM-009: Authorization Method Types

Purpose

Defines allowed methods for obtaining prior authorization, used in prior_auth_rules.auth_method.

Logical Table: md_auth_method_types

Schema

Sample Data

Data Governance

• Owner: Utilization Management Lead.
• Approval: RCM Manager.
• Update frequency: Rare; when new channels are introduced or retired.
• Change notification: Communicated to authorization team and IT.

Validation Rules

• code unique.
• At least one of is_electronic or is_manual TRUE.
• sort_order unique among active records.

MD-PCM-010: Payer Master (Reference View)

Core schema is defined in 05-data-model.md. Below focuses on reference/lookup aspects relevant to master data.

Purpose

Canonical list of payers and TPAs used across the HIS for eligibility, claims, and reporting.

Primary Table: payers

Key Fields (Reference-Oriented)

Sample Data

Data Governance

• Owner: RCM Manager.
• Approval: Finance Director for new payers.
• Update frequency: As new payers/TPAs are onboarded or licenses change.
• Change notification: Payer onboarding checklist; integration team for connectivity updates.

Validation Rules

• payer_name_en unique for active payers.
• payer_class must exist in md_payer_classifications.
• At least one of dha_license or doh_license required for regulated payers (non-self-pay).

MD-PCM-011: Insurance Plan Master (Reference View)

Purpose

Defines insurance plans/products per payer, used for eligibility, coverage rules, and estimation.

Primary Table: insurance_plans

Key Fields (Reference-Oriented)

Sample Data

Data Governance

• Owner: Contract Manager.
• Approval: Finance Director.
• Update frequency: On payer plan changes; at least annual review.
• Change notification: Eligibility and Patient Access teams; update estimation rules.

Validation Rules

• (payer_id, plan_code) combination unique.
• copay_percentage between 0 and 100.
• annual_maximum NULL allowed for unlimited plans (e.g., THIQA).

MD-PCM-012: Coverage Rule Types

Purpose

Standardizes types of coverage rules used in coverage_rules.rule_type for reporting and maintenance.

Logical Table: md_coverage_rule_types

Schema

Sample Data

Data Governance

• Owner: Contract Analyst.
• Approval: RCM Manager.
• Update frequency: Rare.
• Change notification: Coverage rule builder documentation updated.

Validation Rules

• code unique.
• severity_level from controlled list {HARD_DENY, SOFT_WARN, INFO}.

MD-PCM-013: Prior Auth Rule Categories

Purpose

Categorizes prior authorization rules for reporting and workflow routing.

Logical Table: md_prior_auth_rule_categories

Schema

Sample Data

Data Governance

• Owner: Utilization Management Lead.
• Approval: RCM Manager.
• Update frequency: Rare.
• Change notification: UM SOPs updated; training for UM staff.

Validation Rules

• code unique.
• default_turnaround_days >= 0.

Configuration Parameters

Data Load Procedures

1. Initial Load

a. CPT Code Master (MD-PCM-008)

• Source: AMA CPT master file (CSV/XML).
• Process: 1. Import into staging table stg_cpt_master. 2. Validate code format and uniqueness. 3. Map categories based on AMA sections. 4. Load into md_cpt_master.
• Validation:
• Reject rows with invalid CPT format.
• Ensure no duplicates.
• Log retired codes separately.

b. DHA & DOH Tariffs (MD-PCM-001, MD-PCM-002)

• Source: DHA/DOH official tariff files (Excel/CSV).
• Process: 1. Import into stg_dha_tariff / stg_doh_tariff. 2. Map to md_cpt_master.cpt_code where possible. 3. Map to md_service_categories based on DHA/DOH category. 4. Load into md_dha_tariff / md_doh_tariff with version tags.
• Validation:
• Check that all referenced CPT codes exist.
• Ensure no overlapping effective periods for same code and version.
• Spot-check rates against official documents.

c. Service Categories, Contract Types, Rate Methodologies, Network Tiers, Auth Method Types

• Source: Internal configuration spreadsheets approved by Finance/RCM.
• Process:
• Manual entry via admin UI or CSV import.
• Validation:
• Enforce uniqueness of codes.
• Cross-check with policy documents.

d. Payer Classification Codes

• Source: DHA/DOH payer lists + internal mapping.
• Process:
• Build mapping table; import into md_payer_classifications.
• Validation:
• Ensure all existing payers (if any) can be mapped to a classification.

e. Payer & Plan Master

• Source: Existing payer spreadsheets, DHA/DOH registries.
• Process: 1. Import payers into payers (staging then production). 2. Import plans into insurance_plans.
• Validation:
• Check license numbers format (DHA/DOH).
• Ensure each plan references a valid payer.

2. Ongoing Synchronization

• CPT Master: Annual bulk update; compare AMA versions; mark retired codes with expiry_date.
• Tariffs:
• New DHA/DOH releases imported into staging.
• Run impact analysis on top 500 CPT codes by volume.
• After approval, set dha_tariff_version_active / doh_tariff_version_active.
• Payers & Plans:
• Onboarding workflow (WF-PCM-001) creates/updates records via UI.
• Periodic reconciliation with DHA/DOH payer registries.

3. Import/Export Formats

• Imports:
• CPT, tariffs: CSV (UTF-8), with header row.
• Internal master data: CSV templates with predefined columns.
• Exports:
• Fee schedules per contract: CSV/Excel for review.
• Payer and plan lists: CSV for sharing with other systems.

4. Validation on Import

Common validation rules applied to all imports:

• Mandatory fields not NULL.
• Code fields (e.g., CPT, payer_class, service_category) must exist in corresponding master tables.
• Date ranges must not overlap for the same code/version combination.
• Numeric fields (rates, percentages) within configured bounds.
• All errors logged with row number and reason; import aborted or partial depending on severity threshold.

5. UAE Regulatory & PDPL Considerations

• Tariff and payer master data generally not personal data; however:
• Access to contract financial terms restricted to authorized roles (RCM Manager, Finance Director).
• Audit logs maintained for all changes to master data (PDPL accountability).
• Integration with DHA eClaimLink and DOH eClaims must use officially assigned payer and tariff codes to remain compliant with DHA/DOH regulations.