This pic is awful, but here are what I would group as tables and examples:

   Organizations (hospital, clinic name);
   Providers (dr Smith, dr Johnson);
   Patients (insuranceid#, prob list, pcp);
   Payers (insurance)(coverage, region, policy)
   Procedure (mri) Proc Code (cpt: 72148)
   Associated diagnosis (ICD code: M51.36)
   Vendor (evicore)--third party claims-- different between payers.
   Fax#(xxx-xxx-xxxx) aka claim submission route
   Input: everything other than fax and vendor
   Output: vendor and fax

Also, every single cpt code has several possible diagnosis codes that 'qualify' as in showing
medical necessity.

For example, if my orthodontist recommends braces, my insurance company will want to know 'why'.

Whether my insurance pays or not is totally dependent on proving it's medically necessary.

The diagnosis code my provider chooses makes all the difference.

If I need braces because my bite doesn't line up, and will continue to cause jaw problems and pain as time
progresses, then that is considered necessary. And a predetermined alpha numeric code is submitted to the
insurance company for approval.

However, if my provider recommended braces because I have an over bite and am embarrassed about it, this is
considered cosmetic, and my insurance company will likely not pay.

The guidelines are set by doctors and made nationally available. As are the codes.

I need to be able to plug in my payer, procedure, and diagnosis and output the vendor, fax and likelihood of
codes qualifying for necessity. Having it all in a central location will help organize me.

As currently i must go to every payer website individually to locate policies, vendors, fax numbers, and accepted codes.

If I made a table of each of these independently i could then input the info one time and use it
over and over (until things change, and then I can update in one location and see changes throughout.)

I'm sure it's confusing because I don't explain well and I'm unsure of your medical field knowledge.

I know it's possible. But then again, I don't believe anything is beyond our realm to accomplish--
its just a matter of time. Questions? Comments? Concerns?

Absolutely need a tutorial.

Thanks again!