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

N

N

2. Type of visit

D

H

D

H

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

N

N

N

N

2. Preferred Provider?

Y

Y

N

N

Y

Y

N

N

3. Type of visit

D

H

D

H

D

H

D

H

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

N

N

N

2. Type of visit

D

H

L

D

H

L

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

N

N

N

N

N

N

2. Type of visit

D

D

H

H

L

L

D

D

H

H

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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