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Health Care Insurance Claim Application Test Cases

Based on the Health Care Insurance Claim Application Data Model, you can create following test cases. 

As a System Administrator, the user

  • can create a new hospital information 
  • can update an existing hospital information
  • can delete an existing hospital information
  • can create a new insurance company information
  • can update an existing insurance company information
  • can setup a new insurance claim processor staff
  • can update an insurance claim processor staff information
  • can delete a staff
  • can assign a claim to staff for processing

 As a Claim Processor Staff, the user

  • can update claim status
  • can request more information about the claim

As a Patient, the user

  • can setup patient profile online
  • can submit health care claims online
  • can request claim documentations
  • can upload requested documentations to the claim
  • can submit dispute to the claim resolution status

 As a Insurance Company admin, the user

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Health Insurance Claims Application Data Structure

Below is  a Health Care Claims Application data model structure. 

Hospitals
  • Hospital_ID
  • Hospital_Name
  • Other_Hospital_Details
Claims
  • Claim_ID
  • Claim_Status_Code
  • Hospital_ID
  • Insurance_Company_ID
  • Patient_ID
  • Updated_Date
  • Amount_Claimed
  • Amount_Paid
  • Other_Claim_Details
Claim Status
  • Claim_Status_Code
  • Claim_Status_Description(In Dispute, Settled)
Claim Dispute Management
  • Dispute_Area_Code
  • Dispute_Area_Description(None,Consultation,Medication,Treatment)
Patients
  • Patient_ID
  • Gender
  • Date_Of_Birth
  • Patient_Name
  • Patient_Address
  • Other_Patient_Details
Insurance Companies
  • Insurance_Company_ID
  • Insurance_Company_Name
  • Insurance_Company_Other_Details
Staff
  • Staff_ID
  • Staff_Category_Code
  • Gender
  • Staff_Firstname
  • Staff_Lastname
  • Staff_Qualifications
  • Staff_Birth_Date
  • Staff_Other_Details
Claim Processing Module
  • Claim_ID
  • Process_Date
  • Dispute_Area_Code
  • Processor_Staff_ID
  • End_Date
  • Step_Descriptions

Reference: http://www.databaseanswers.org/data_models/health_insurance_claims/index.htm