Description of the Company:

“Health is Wealth” is a supplemental health insurance company that pays claims after its policyholders’ primary insurance benefits through their employer or another policy have been exhausted. The company currently processes claims manually and have a total of 10 employees involve in claims processing. The following narrative partially describes its claims processing system.

Scenario:
The Policy holders must submit their Claims to the claims processing department. The Claims should include an Explanation of Benefits (EOB) and proof of policy payment that their primary health policy claims has been paid.
Claims are initially sorted by the claims screening clerk. This clerk returns all claims that do not include the EOB. For claims returned, a Pending Claim is created, dated, and sorted by date. Once in each week, the claims screening clerk retrieve the Pending Claim file and remove all claim files that are more than 45 days old and sends a letter to the policy holders notifying them that their case has been closed. Claims that include EOB are then sorted according to type of claim. Claims that include an EOB Reference Number are matched with an EOB form, which is pulled from the Open Claims file. At the end of each day, all these claims are forwarded to the preprocessing clerks.
The preprocessing clerks screen the EOB for missing data. They complete the form if possible by looking at their copy of the insurance policy form. Otherwise, a copy of the claim is returned to the policy holder with a letter requesting the missing data. The original EOB is placed in the Open Claims file, and a Pending Claim is sent to the claims screening clerk. Completed claims are assigned a claim number, and the claim is microfilmed and filed for archival purposes.
The proof checker verifies if the Proof of Policy Payment was included or is on file in the Primary Payment file. If it is not available, the policyholder is sent a letter requesting the proof. The EOB is placed in the Pending Proof file. The proof checker will remove claims which are in the Pending Proof file for more than 14 days and he/she will sent a notice to the policy holder whose claims have been removed.
If proof of policy payment is available, the proof checker will forward the claims to final processing clerk who pulls the policy holder’s policy record from the Policy file, records policy and action codes on the EOB, and re-files the policy. At the end of the day, all preprocessed claims are forwarded to Information Systems department


Produce the following for the above mentioned scenario:
a. Context diagram
b. Level 0 DFD of the system
c. Level 1 DFD of one of the processes identified in your Level 0 DFD.

d. Structured English

السلام عليكم

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