Functional requirements of Medical Billing System with non-functional

Functional Requirements

1. Patient Management
   • Patient Registration: Capture and manage patient information, including personal details, insurance information, and medical history.
   • Patient Profiles: Maintain up-to-date patient profiles with contact information, medical records, and insurance details.
2. Appointment and Service Tracking
   • Appointment Scheduling: Track and manage patient appointments, including appointment dates, times, and types of services provided.
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   • Service Documentation: Document the services provided during each visit, including procedures, diagnostics, and treatments.
3. Charge Capture
   • Service Codes: Support the entry and management of service codes (e.g., CPT, ICD-10) to accurately reflect medical services rendered.
   • Charge Entry: Allow for the entry of charges for services rendered, including modifiers and units of service.
4. Insurance Verification
   • Eligibility Checks: Verify patient insurance eligibility and coverage before services are rendered.
   • Authorization Management: Manage pre-authorizations and referrals required for specific treatments or procedures.
5. Claim Management
   • Claim Creation: Generate claims based on patient services and charges, including required coding and documentation.
   • Claim Submission: Submit claims electronically or via paper to insurance carriers and other payers.
   • Claim Tracking: Track the status of submitted claims, including pending, approved, denied, and rejected claims.
6. Billing and Payments
   • Patient Billing: Generate and send patient bills for services rendered, including itemized charges and payment instructions.
   • Payment Processing: Process payments from patients and insurance companies, including handling copayments, deductibles, and adjustments.
   • Payment Posting: Post payments and adjustments to patient accounts, and reconcile payments with claims.
7. Account Management
   • Patient Statements: Generate and manage patient statements, including balance due and payment history.
   • Outstanding Balances: Track and manage outstanding balances, including overdue accounts and collection efforts.
8. Reporting and Analytics
   • Financial Reports: Generate financial reports, including revenue reports, accounts receivable aging, and payment summaries.
   • Claims Reports: Provide reports on claims status, denials, and rejections to facilitate follow-up and appeals.
   • Performance Analytics: Analyze billing performance metrics, including claim approval rates and revenue cycles.
9. Compliance and Auditing
   • Regulatory Compliance: Ensure compliance with healthcare billing regulations and standards (e.g., HIPAA, CMS guidelines).
   • Audit Trails: Maintain audit trails of all billing activities, including changes, submissions, and payment transactions.
10. Integration
    • Electronic Health Records (EHR): Integrate with EHR systems to access patient data and streamline billing processes.
    • Practice Management Systems: Integrate with practice management systems for appointment scheduling and service documentation.
    • Payment Gateways: Integrate with payment gateways for online payment processing.
11. User Management
    • Role-Based Access: Implement role-based access control to manage user permissions for billing, claims, and reporting.
    • User Profiles: Manage user profiles and authentication settings, including password management and multi-factor authentication.

Non-Functional Requirements

1. Performance
   • Response Time: Ensure fast response times for billing operations, claim processing, and report generation (e.g., under 2 seconds for most operations).
   • Scalability: The system should handle increasing volumes of billing transactions and claims without performance degradation.
2. Reliability
   • Uptime: Ensure high system availability with minimal downtime (e.g., 99.9% uptime).
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   • Error Handling: Implement robust error handling and recovery mechanisms to manage system failures and ensure data integrity.
3. Security
   • Data Protection: Protect sensitive patient and billing data through encryption and secure storage.
   • Authentication and Authorization: Use secure authentication methods and role-based access control to manage user access and permissions.
   • Compliance: Ensure compliance with data protection regulations and standards (e.g., HIPAA).
4. Usability
   • User Interface: Design an intuitive and user-friendly interface for managing billing tasks, claims, and patient information.
   • Accessibility: Ensure the system is accessible to users with disabilities, following accessibility standards (e.g., WCAG).
5. Maintainability
   • Code Quality: Write high-quality, well-documented code to facilitate system maintenance and updates.
   • Documentation: Provide comprehensive documentation for users, administrators, and developers, including user guides, technical manuals, and troubleshooting guides.
6. Availability
   • Backup and Recovery: Implement regular data backups and establish procedures for data recovery in case of system failures or data loss.
   • Failover: Ensure the system has failover capabilities to switch to backup systems or servers if necessary.
7. Portability
   • Cross-Platform Compatibility: Ensure the system is compatible with various devices and operating systems used by users, including desktops, tablets, and mobile devices.
8. Supportability
   • Technical Support: Provide mechanisms for obtaining technical support and resolving issues, including help desks, online resources, and customer service.
   • Error Reporting: Include functionality for reporting issues or bugs and tracking their resolution.