Reconciliation

While uploading pay instruction files, you need to specify the reconciliation type using which you want to create the reconciliation. A reconciliation type indicates the algorithm which validates the pay instruction file and creates a pay instruction for each record in the file. Two algorithm types named C1-PAYINSUPL and C1-RECONPROC are shipped with the product. You need to maintain separate reconciliation types for different file formats. If you want to use a reconciliation type while uploading a pay instruction file in the CSV format, you need to create an algorithm using the C1-PAYINSUPL algorithm type and attach it to the reconciliation type. However, if you want to use a reconciliation type while uploading a pay instruction file in the EDI 820 format, you need to create an algorithm using the C1-RECONPROC algorithm type and attach it to the reconciliation type.

Once a file is successfully validated, the reconciliation is created for the file in the Draft status. The reconciliation is immediately transitioned to the Send Notification status and the algorithms attached to the Send Notification status are executed. Once the To Do is created, the status of the reconciliation is changed to Pending. A pay instruction is created for each record in the file and its status is set to either Pending or Error depending on whether it is successfully validated or not.

You need to then specify the payment ID against which you want to reconcile the billed items for which you have received the pay instructions. Once you specify the payment information and submit the pay instructions for reconciliation, the payment amount is distributed against the reconciliation contract of the accounts for which you have received the pay instruction. The status of the reconciliation is changed to Pending Reconciliation.

On reconciling the pay instructions, the system finds the bill segment against which the pay instruction must be reconciled using the account identifier, policy number, plan number, member identifier, and coverage period combination. Once the bill segment is identified, the transfer adjustment is created against the bill segment and offset adjustment is created against the respective reconciliation contract. If all pay instructions in the file are successfully reconciled, the status of the reconciliation is changed to Completed. However, if one or more pay instruction in the file could not be successfully reconciled, the status of the reconciliation is changed to Open. If a file contains a pay instruction for previous coverage period, then system checks whether there is any open pay instruction for that coverage period in the system and accordingly tries to reconcile the pay instruction. However, if an open pay instruction for that coverage period does not exist in the system, the system tries to reconcile the pay instruction against the billed item.

You may manually reconcile the pay instructions which are in the Pending Reconciliation status. Alternatively, you can execute the Reconciliation Periodic Monitor (C1-RCNM) batch at regular interval to reconcile the pay instructions.

If you cancel the payment tender, the payment and reconciliation associated with the payment are automatically canceled. The status of the reconciliation is changed to Pending Cancelation. And, the status of all pay instructions in the reconciliation is changed to Canceled. If required, you can manually cancel a reconciliation. However, you can cancel a reconciliation when it is in the Open or Completed status. On canceling a reconciliation, the status of the reconciliation is changed to Pending Cancelation and the status of all pay instructions in the reconciliation is changed to Canceled.

You need to configure the Reconciliation Cancellation Periodic Monitor (C1-RCNMD) batch to execute at the regular intervals. It monitors whether there are reconciliations in the Pending Cancelation status. If there is a reconciliation in the Pending Cancelation status, the status of the reconciliation is changed to Canceled.

The system enables you to create a copy of reconciliation when it is in the Canceled status. If the number of pay instructions in the reconciliation does not exceed the value specified in the Defer Processing Count option type of the C1-RECDUPBH feature configuration, a copy of the reconciliation and pay instructions is created in the real time (i.e. immediately). The status of the reconciliation is set to Pending. And, the status of the pay instruction is set to either Pending or Error depending on whether it is successfully validated or not.

However, if the number of pay instructions in the reconciliation exceeds the value specified in the Defer Processing Count option type of the C1-RECDUPBH feature configuration, a batch job is automatically created using the Duplicate Reconciliation (C1-RECDU) batch. A message appears indicating the batch job ID. This batch job creates a copy of the reconciliation and pay instructions. The status of the reconciliation is set to Pending. And, the status of the pay instruction is set to either Pending or Error depending on whether it is successfully validated or not.

If the policy number, plan number, and member identifier are specified in a pay instruction, then the pay instruction is reconciled at the main subscriber level. If the policy number and plan number are specified in a pay instruction, then the pay instruction is reconciled at the plan level. However, if the policy number is only specified in a pay instruction, then the pay instruction is reconciled at the policy level.

While generating a discrepancy report, you need to specify the discrepancy report type using which you want to create the discrepancy report. Once you review and finalize the discrepancy report, its status is changed to Completed. At a time, you can only have one discrepancy report for the file or account in the Pending status. Until, you finalize a discrepancy report, you cannot create another discrepancy report for the file or account. Also, note that you can create a discrepancy report for a file only when its corresponding reconciliation is in the Open status.

Related Topics

Parent Topic: Oracle Revenue Management and Billing Insurance Business Processes