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    Decision Table Examples: Medical Insurance: Example 1

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    Adarsh Bansal
    The document provides 4 examples of decision tables for medical insurance reimbursement. Example 1 has 4 rules regarding deductible status and visit type. Example 2 adds preferred provider status for 8 rules. Example 3 includes lab visits for 6 rules. Example 4 incorporates participating physicians for 12 rules, and notes some conditions are mutually exclusive.

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    Decision Table Examples: Medical Insurance: Example 1

    Uploaded by

    Adarsh Bansal
    316 views3 pages
    The document provides 4 examples of decision tables for medical insurance reimbursement. Example 1 has 4 rules regarding deductible status and visit type. Example 2 adds preferred provider status for 8 rules. Example 3 includes lab visits for 6 rules. Example 4 incorporates participating physicians for 12 rules, and notes some conditions are mutually exclusive.

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    The document provides 4 examples of decision tables for medical insurance reimbursement. Example 1 has 4 rules regarding deductible status and visit type. Example 2 adds preferred provider status for 8 rules. Example 3 includes lab visits for 6 rules. Example 4 incorporates participating physicians for 12 rules, and notes some conditions are mutually exclusive.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    316 views3 pages

    Decision Table Examples: Medical Insurance: Example 1

    Uploaded by

    Adarsh Bansal
    The document provides 4 examples of decision tables for medical insurance reimbursement. Example 1 has 4 rules regarding deductible status and visit type. Example 2 adds preferred provider status for 8 rules. Example 3 includes lab visits for 6 rules. Example 4 incorporates participating physicians for 12 rules, and notes some conditions are mutually exclusive.

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    Decision Table Examples:

    Medical Insurance
    Example 1
    No charges are reimbursed to the patient until the
    deductible has been met. After the deductible has been
    met, reimburse 50% for Doctor's Office visits or 80% for
    Hospital visits.

    There will be 4 rules. The first condition (Is the deductible met?) has two
    possible outcomes, yes or no. The second condition (type of visit) has
    two possible outcomes, Doctor's office visit (D) or Hospital visit (H).
    Two times two is four.

    Conditions 1 2 3 4
    1. Deductible met? Y Y NN
    2. Type of visit DHDH
    Actions
    1. Reimburse 50% X
    2. Reimburse 80% X
    3. No reimbursement X X

    Example 2
    No charges are reimbursed to the patient until the
    deductible has been met. After the deductible has been
    met, the amount to be reimbursed depends on whether
    or not the doctor or hospital is a "Preferred Provider." For
    preferred providers Doctor's office visits are reimbursed
    at 65% and Hospital visits are reimbursed at 95%. For
    other providers reimburse 50% for Doctor's Office visits
    or 80% for Hospital visits.

    There will be 8 rules. The first condition (Is the deductible met?) has two
    possible outcomes, yes or no. The second condition (Is it a Preferred
    Provider?) has two possible outcomes, yes or no. The third condition
    (type of visit) has two possible outcomes, Doctor's office visit (D) or
    Hospital visit (H). Two times two times two is 8.

    Conditions 1 2 3 4 5 6 7 8
    1. Deductible met? Y Y Y Y NNNN
    2. Preferred Provider? Y Y N N Y Y N N
    3. Type of visit DHDHDHDH
    Actions
    1. Reimburse 65% X
    2. Reimburse 95% X
    3. Reimburse 50% X
    4. Reimburse 80% X
    5. No reimbursement X X X X

    Example 3
    No charges are reimbursed to the patient until the
    deductible has been met. Doctor's office visits are
    reimbursed at 50%, Hospital visits are reimbursed at
    80% and Lab visits are reimbursed at 70%.

    There will be 6 rules. The first condition (Is the deductible met?) has two
    possible outcomes, yes or no. The second condition (type of visit) has
    three possible outcomes, Doctor's office visit (D) or Hospital visit (H) or
    Lab visit (L). Two times three is 6.

    Conditions 1 2 3 4 5 6
    1. Deductible met? Y Y Y NNN
    2. Type of visit DHL DHL
    Actions
    1. Reimburse 50% X
    2. Reimburse 80% X
    3. Reimburse 70% X
    4. No reimbursement X X X

    Example 4
    No charges are reimbursed to the patient until the
    deductible has been met. Hospital visits are reimbursed
    at 80% and Lab visits are reimbursed at 70%. Doctor's
    office visits are reimbursed at 90% for "Participating
    Physicians" or 50% for others. The question of whether
    the Doctor is a Particpating Physician is only applicable
    for Doctor's office visits; it is not applicable for Hospital
    visits or Lab work.

    There will be 12 rules. The first condition (Is the deductible met?) has
    two possible outcomes, yes or no. The second condition (type of visit)
    has three possible outcomes, Doctor's office visit (D) or Hospital visit
    (H) or Lab visit (L). There are two possible outcomes to the question of
    whether in the case of a Doctor's Office visit the Doctor is a
    Participating Physician, yes or no. Two times three times two is 12.

    Conditions 1 2 3 4 5 6 7 8 9 10 11 12
    1. Deductible met? Y Y Y Y Y Y NNNN N N

    2. Type of visit DDHHL L DDHH L L


    3. Participating Physician? Y N Y N Y N Y N Y N Y N
    Actions
    1. Reimburse 50% X
    2. Reimburse 70% X
    3. Reimburse 80% X
    4. Reimburse 90% X
    5. No reimbursement X X X X
    6. Impossible or N/A X X X X

    Note that the "Y" under Participating Physican specifically


    means that this event for which the patient wants
    reimbursement was a Doctor's Office visit to a
    Participating Physician; "N" would then mean that it was
    not a Doctor's Office visit to a Participating Physician.

    Notice that Hospital visits or Lab visits that are also


    marked Yes for Participating Physician are listed as
    Impossible. These conditions are mutually exclusive. By
    definition a Hospital visit cannot be a Doctor's Office visit
    to a Participating Physician. By definition a Lab visit
    cannot be a Doctor's Office visit to a Participating
    Physician.

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