2. Enterprise Analysis

2.1. Mission Statement.

“The mission of the Center for Child Development is to provide effective psychiatric counseling to our clients without regard to the severity of their condition, or their ability to pay. We will exploit all available private and public means of obtaining the resources to accomplish this task, with the fruits of these efforts going to aid our clients and not towards meeting corporate profit margins. The bottom line for all of our employees to remember is that our patients come first.”

2.2. Key Tasks. To accomplish our mission we must develop a list of essential tasks that if completed, will result in our ultimately accomplishing our mission.

2.2.1. Pinpoint the nature of a clients neuroses or psychoses and develop a specific plan of treatment for each patient. If necessary, obtain treatment resources from outside the organization.

2.2.2. Develop specific plans of treatment that include testing and evaluation, therapy, periodic evaluations, changes in treatment, and realistic expectations about the effects of treatment.

2.2.3. Develop treatment plans regardless of a client’s ability to pay.

2.2.4. Maximize every applicable private and public source of revenue to bring our clients the care and counseling they need.

2.2.5. Adjust to the evolving public assistance programs available to our clients to ensure our clients realize the resources they provide.

2.3. Application Perspective. This application will make a direct impact on our ability to maximize the resources provided by Medicaid by ensuring that claims are processed and submitted in a timely manner. Additional benefits include reducing the number of disputed claims due to errors or missing information, and a running balance of how much the Government has paid, what we believe they owe, and claims that were denied for payment. Most importantly, it allows us to quickly compile and submit claims for each day services are provide.

Figure 3.1

Demonstrates all of the major entities with which the application must interact. Although the application may not directly interact with an external entity, it may have to accomplish tasks that facilitate the process. An example is preparing reports to file with Medicaid.

3. System Analysis

Figure 3.2

Displays the stepping stones required to developing an effective application

3.1. Analysis of the system required three major efforts. Initially we had to review the manual process currently used to file claims. By doing this, we are able to identify all of the processes that the application will accomplish and all the entities with which it will interact. This effort will provide us with a map of what the application will do. Next, we must add the details of each process so we have sufficient information one we begin to design the application. The finishing task during our analysis is to review each entity and process and remove those that are irrelevant or repeated. The final product is a detailed road map of every step we must take in developing the actual code for this application.

3.2. Context Diagram. Figure 3.1 displays the Context Diagram used to identify external entities that will interact with, or effect the application. This is the first step in identifying all of the features this application will require. The main external entities are the clients we serve each day through counseling and therapy and the Medicaid Office that reviews and pays our claims. Every process that interacts with something outside the application must interact with on of these two external entities. If any additional external entities are exposed, it is imperative that we identify them immediately and make any required updates.

Figure 3.3

Show the major activities conducted by this application. Listing the processes beneath them provides the details required to start the design process.

3.3. Entity Relationship Diagrams. The next step in our analysis process is to identify all of the major entities, both internal and external that effect our application. Boxes are drawn to depict the entities and the relationships they hold between each other are listed in the space between them. The major entities include the clients, CCD, claims, Medicaid, and files used to hold claims in accordance with their Medicaid status. Figure 3.2 depicts these relationships.

3.4. DFD’s. The next step in the process is to take the stepping stones in the Entity Relationship Diagram, and arrange them in a logical sequence we feel will allow the application to accomplish its purpose. We start by identifying the processes that support each major Activity. From this point, we see the three major activities are managing client information, managing client visits, and managing claims made to Medicaid. Figure 3.3 shows these activities and the processes that support them.

3.5. Now that we have identified all of the entities and processes required for our application to accomplish its tasks, we have to fill in some details that the designer and programmers will need. It will act like the mortar between the bricks when building a house. Figures 3.4 through 3.6 depict how the data will flow in each activity of the application.

3.5.1. Figure 3.4 outlines the process that takes place when new or current clients make appointments or call with administrative changes.

Figure 3.4

Depicts The processes that occur when a patient makes an appointment or merely calls with administrative information updates.

3.5.2. Figure 3.5 lists the process taken when a visit is scheduled.

Figure 3.5

Depicts the steps taken if a visit is scheduled or a payment is made on the account clients

Figure 3.6

Note how a claim is reconciled until it is paid or denied

3.6. Data Dictionary. This tool is used to identify entities, processes, and attributes as they relate to the application being developed.

Entity	Alias	Definition	Relationship	Owner
A

Amount paid	AmtPd	Amount of money paid by client. Insurance or Medicaid	Visit Form Filed
Amount Requested	AmtReq	Amount of reimbursement requested for services provided	Medicaid Form Field
Appointment Type	AptTyp	Type of appointment scheduled, regular, Intake etc.	Visit form field
B


Billing Date	BlDte	Date claim is submitted to Medicaid	Medicaid Form Field
Balance Due	BalDue	Amount owed by Insurance or Medicaid	Visit form field
C
Claim	Clm	A request payment for expenses
Center for Child Development	CCD	The organization for which this application is being developed	Sponsor	CCD
Client	Medicaid ID Number	The recipient of services for whom we charge the government for our services.	Filing claims against their public assistance from the government is the purpose
Completed by	CompBy	Name of staff member completing the form	Medicaid Form Field
Counseling	Cnsl	The service we provide for which we incur an expense	Description of the service provided when a claim is submitted.
D

Dates of Visit	DteOfVst	This is the Date of each historical visit to the clinic	Client Form Field
Date	Dte	Date of a scheduled visit	Visit form field
Diagnosese	Diagn	120 Possible entries that describe the affliction treated during a claimed visit	Medicaid Form Field
Dispute	Dspte	A process by which Medicaid clarifies the information provided in a claim to determine if it is payable or not
E

Expense	Fee	Charges for services provided
F

Family Identifier	FmlID	Used to Identify a family that is deemed eligible for services	Client Form Field	Medicaid
Fees Per Week	FeePrWk	Amount of money charged to the account of a client for services provided in a given week.	Client Form Field
First name	FrstNme	The Client’s First name
Fiscal year	FscYr	Current Fiscal Year	Used to support which funds pay a claim by Medicaid
Form	MdcFrm	A document used to provide information to Medicaid that substantiates a claim to reimbursed for expenses	A product of this application that must meet Medicaid guidelines
G

H

I

Initial Determination	IntlDtrmn	Medicaid’s initial evaluation of a claim for payment
J

K

L

Last name	LstNme	The Client’s last name	Client Form Field
Line Identifier	LneID	Used by Medicaid to ID specific clients, their eligibility, and payment history	Client and Medicaid Form Field	Medicaid
M

Medicaid	MdcAd	A government program that reimburses service providers for assisting eligible clients
Medicaid Eligible	MdcAdElg	Determination of eligibility for benefits by Medicaid administration	Visit Form Field
Middle Initial	MI	Client’s Middle Initial
N

O

P

The Center for Child Development

“Engineering a MEDICAID Claim Processing System” by Edward D. (Fast Eddie) Clark

Figure 3.1

Figure 3.3

Figure 3.4

Figure 3.5

Figure 3.6

Entity