"Data entry & Report" Project . Due in 2 days.

Claim

PK Claim ID

Statement of Actual Services EPSDT Title XIX Request for Preauthorization Preauthorization Number FK1 Patient ID Other Fee Diagnosis Code List Qualifier Remarks Patient Signature Patient Signature Date Subscriber Signature Subscriber Signature Date Place of Treatment Enclosures Orthodontics Treatment Date Appliance Placed Months of Treatment Prothesis Replacement Date Prior Placement Treatment For Accident Date Auto Accident State Treating Dentist Signature Treating Dentist Signature Date FK3 Treating Dentist NPI FK2 Billing Dentist NPI

Insurance Plan

PK Insurance Plan ID

Plan Name Street Address City State Zip Code

Subscriber

PK Subscriber ID

First Name Middle Initial Last Name Suffix Street Address City State ZIP Code Primary Coverage Birth Date Gender Plan Group Number Employer Name Coverage Type FK1 Insurance Plan ID

offers

PATIENT

PK PATIENT ID

FIRST NAME MIDDLE INITIAL LAST NAME SUFFIX STREET ADDRESS CITY STATE ZIP CODE BIRTH DATE GENDER ACCOUNT NUMBER

Service

PK Service ID

FK1 Claim ID Procedure Date Area of Oral Cavity Tooth System Tooth Surface FK2 Procedure Code Diagnosis Code Pointer Quantity Description Fee

Service Tooth

PK,FK1 Service ID PK,FK2 Tooth ID

is performed on

Tooth

PK Tooth ID

Tooth Number Tooth Letter Tooth Description

is referenced by

contains

generates

Claim Subscriber

PK,FK1 Subscriber ID PK,FK2 Claim ID

Primary Subscriber Patient Subscriber Relationship

lists is listed on

Missing Tooth

PK,FK1 Claim ID PK,FK2 Tooth ID

identifies

is referenced by

Claim Diagnosis

PK,FK1 Claim ID PK,FK2 Diagnosis Code

Primary Diagnosis

Diagnosis

PK Diagnosis Code

Description

lists

is referenced by

Procedure

PK Procedure Code

Procedure Description

is referenced by

Dentist

PK NPI

First Name Last Name Street Address City State ZIP Code License Number TIN Phone Number Additional Provider ID Specialty Code

treats

bills for