Legal Case Management - Technical Specification
Core legal case processing and membership management
Purpose
The Legal Case Management module is the central hub of the Case Clinical MedLegal Platform. Each legal case represents a patient's medical treatment related to a legal matter (personal injury, workers' compensation, etc.). Legal cases are tied to Pacific Crest Healthcare IPA memberships, generate Member Registration Numbers (MRNs), and serve as the parent entity for all medical services, claims, and financial transactions.
Key Concepts
| Term | Definition |
|---|---|
| Legal Case | A patient's medical treatment case related to a legal matter |
| MRN | Member Registration Number - Unique identifier for the membership |
| Membership | Pacific Crest Healthcare IPA membership tied to each legal case |
| Case Status | Current state of the legal case (Active, Closed, Pending, etc.) |
| Accident Type | Category of incident (Auto, Work Injury, Slip & Fall, etc.) |
| Date of Loss | Date when the accident/incident occurred |
| Case Account | Financial account associated with the legal case |
| Authorization | Approval for medical services under the case |
| Settlement | Final resolution and payment of the legal case |
User Roles
| Role | Description | Permissions |
|---|---|---|
| Case Manager | Primary case management and oversight | Full CRUD on cases |
| Attorney | Legal representation for the case | Read, Update (limited) |
| Case Coordinator | Assists with case administration | Create, Read, Update |
| Financial Analyst | Reviews case financials | Read only |
| Medical Director | Oversees medical aspects | Read, Approve authorizations |
| Claims Processor | Processes claims against cases | Read, Link claims |
| System Administrator | System-level management | All permissions |
Field Documentation - Legal Case Entity
| Field Name | Type | Required | Description | Validation Rules | Related Entity |
|---|---|---|---|---|---|
| ID | String | Yes | Unique case identifier (CUID) | Auto-generated, immutable | Primary Key |
| Case Number | String | Yes | Human-readable case number | Format: CASE-YYYY-XXXXX | - |
| Patient | Patient | Yes | Patient associated with case | Must exist | Patient |
| Firm | Firm | Yes | Law firm handling the case | Active firm required | Firm |
| Attorney | Attorney | Yes | Primary attorney on case | Active attorney required | Attorney |
| Paralegal | User | No | Assigned paralegal | Valid user with paralegal role | User |
| Accident Type | String | Yes | Type of incident | Enum: Auto, Work Comp, Slip Fall, Medical Malpractice, Other | - |
| Date of Loss | DateTime | Yes | Date of accident/incident | Cannot be future date | - |
| Date of Retention | DateTime | Yes | Date firm retained | Must be after date of loss | - |
| Case Status | String | Yes | Current case status | Enum: Active, Closed, Pending, Suspended, Settlement | - |
| Liability Status | String | No | Liability determination | Enum: Pending, Accepted, Disputed, Unknown | - |
| Police Report Number | String | No | Police report reference | Alphanumeric | - |
| Insurance Claim Number | String | No | Insurance claim reference | Alphanumeric | - |
| Opposing Insurance | String | No | Opposing party's insurance | Free text | - |
| Opposing Counsel | String | No | Opposing attorney info | Free text | - |
| Jurisdiction | String | No | Legal jurisdiction | State/County format | - |
| Court Case Number | String | No | Court filing number | Alphanumeric | - |
| Statute of Limitations | DateTime | No | Legal deadline | Must be future date if active | - |
| MRN | String | Yes | Member Registration Number | Auto-generated, unique | Membership |
| Membership ID | String | Yes | Pacific Crest membership | Auto-generated on case creation | Membership |
| Membership Start Date | DateTime | Yes | Membership effective date | Defaults to case creation | Membership |
| Membership End Date | DateTime | No | Membership termination | Must be after start date | Membership |
| Case Value Estimate | Decimal | No | Estimated case value | Positive number, 2 decimals | - |
| Settlement Amount | Decimal | No | Final settlement value | Positive number, 2 decimals | - |
| Settlement Date | DateTime | No | Date of settlement | Required if status is Settlement | - |
| Medical Lien Amount | Decimal | No | Total medical liens | Calculated field | - |
| Attorney Fee Percentage | Decimal | No | Attorney fee rate | Between 0 and 100 | - |
| Referral Source | String | No | How case was referred | Free text | - |
| Case Notes | Text | No | General case notes | Max 5000 chars | - |
| Created At | DateTime | Yes | Record creation timestamp | Auto-generated | - |
| Updated At | DateTime | Yes | Last modification timestamp | Auto-updated | - |
| Created By | User | Yes | User who created case | Valid user ID | User |
| Updated By | User | Yes | User who last updated | Valid user ID | User |
| Appointments | Appointment[] | No | Related appointments | - | Appointment (1:Many) |
| Authorizations | Authorization[] | No | Service authorizations | - | Authorization (1:Many) |
| Claims | Claim[] | No | Related claims | - | Claim (1:Many) |
| Documents | Document[] | No | Case documents | - | Document (1:Many) |
| Case Account | CaseAccount | No | Financial account | One per case | CaseAccount (1:1) |
| Medical Records | MedicalRecord[] | No | Medical documentation | - | MedicalRecord (1:Many) |
| Liens | Lien[] | No | Medical liens | - | Lien (1:Many) |
Workflows
Legal Case Creation Workflow
-
Patient Selection
- Select existing patient or create new
- Verify patient demographics
- Confirm patient consent
-
Case Information
- Select law firm and attorney
- Enter accident type and date of loss
- Capture insurance information
- Set initial case status
-
Membership Creation
- Auto-generate MRN
- Create Pacific Crest Healthcare IPA membership
- Set membership effective date
- Issue membership card
-
Financial Setup
- Create case account in financial system
- Set up attorney fee structure
- Initialize balance tracking
-
Initial Authorizations
- Create initial evaluation authorization
- Set authorization limits
- Enable appointment scheduling
Case Status Management Workflow
-
Status Transitions
- Active → Can transition to any status
- Pending → Requires activation approval
- Suspended → Temporary hold on services
- Settlement → Initiates settlement workflow
- Closed → Final status, no further changes
-
Status Change Validations
- Check for open authorizations
- Verify no pending claims
- Confirm financial reconciliation
- Document reason for change
Authorization Workflow
-
Authorization Request
- Service type selection
- Provider selection
- Number of visits/units
- Date range specification
-
Auto-Approval Logic
- Office visits (DOS) auto-approved
- Initial evaluations auto-approved
- Other services require review
- Generate authorization number
-
Authorization Tracking
- Track units used vs authorized
- Monitor expiration dates
- Alert on approaching limits
Business Rules
Case Creation Rules
- Patient must exist before case creation
- One active case per accident for a patient
- Firm and attorney must be active
- Date of loss cannot be in the future
- MRN must be unique system-wide
Membership Rules
- Each case gets exactly one membership
- Membership starts on case creation date
- MRN format: PCH-YYYY-XXXXXXX
- Membership remains active until case closure
Financial Rules
- Case account created automatically
- Attorney fees calculated on settlement
- Medical liens tracked against case
- All financial transactions require case ID
Authorization Rules
- All services require authorization
- Office visits auto-approved via backend service
- Authorization numbers are unique
- Authorizations expire after specified period
Integrations
| System | Integration Type | Purpose |
|---|---|---|
| Patient Management | Direct Database | Patient linkage |
| Firm Management | Direct Database | Attorney assignment |
| Authorization System | Backend Service | Auto-approval engine |
| Claims Processing | Direct Database | Claim validation |
| Financial System | Direct Database | Case accounting |
| Business Central | API Sync | Financial synchronization |
| Document Management | File System | Case documentation |
| Appointment Scheduler | Direct Database | Service scheduling |
Common Issues
| Issue | Description | Resolution |
|---|---|---|
| Duplicate MRN | System attempts to create duplicate MRN | Regenerate with new sequence |
| Missing Membership | Case without membership record | Run membership creation job |
| Status Conflicts | Invalid status transitions | Review status history, correct manually |
| Authorization Expired | Services rendered after auth expiration | Retroactive authorization process |
| Settlement Delays | Settlement amount disputes | Hold status until resolved |
Screenshots Needed
- Case Creation Wizard
- Case Dashboard
- Case Status Timeline
- Membership Card View
- Authorization Management
- Case Financial Summary
- Case Document Library
- Settlement Calculator
- Case Search Interface
Performance Considerations
- MRN generation must be atomic (no duplicates)
- Case search should support 50,000+ records
- Status changes should cascade immediately
- Authorization checks must be sub-second
Security Considerations
- Attorney-client privilege protection
- Case access restricted by firm assignment
- Financial data encryption
- Audit trail for all case changes
- Document access control
Notes
- Cases cannot be deleted, only closed
- All case modifications are audited
- MRN is printed on physical membership cards
- Integration with court systems planned for Phase 2