Claim Forms and Claim Form Types

Each claim belongs to one single claim form. Claim forms are used to categorize claims within the application. Many configuration rules can differentiate on the claim form. The claim form also specifies which (and how many) procedure codes appear on claim lines of claims that belong to that form. A typical usage in health insurance industry is having separate forms for hospital claims and professional claims.

A claim form has the following attributes:

Claim Form

Field	Description
Code	The unique code for this claim form
Description	The description for this claim form
Line of Business	The line of business for this claim form
Claim Form Type	Optional reference to claim form type
Procedure 1 display name	The column header in the claim line section in the claims pages
Procedure 1 usage name	The attribute name in dynamic logic
Procedure 1 definition	Flex Code System that defines which codes can be entered
Procedure 1 fatal non match indicator	If checked, a non match leads to a fatal system message If not, an informative message is applied instead
Procedure 2 display name	The column header in the claim line section in the claims pages
Procedure 2 usage name	The attribute name in dynamic logic
Procedure 2 definition	Flex Code System that defines which codes can be entered
Procedure 2 fatal non match indicator	If checked, a non match leads to a fatal system message If not, an informative message is applied instead
Procedure 3 display name	The column header in the claim line section in the claims pages
Procedure 3 usage name	The attribute name in dynamic logic
Procedure 3 definition	Flex Code System that defines which codes can be entered
Procedure 3 fatal non match indicator	If checked, a non match leads to a fatal system message If not, an informative message is applied instead

The context of the fatal non-match indicator is restricted to the automated matching step in the processing flow. This indicator does not make it possible to enter an non-existent procedure code in the claims page, nor to send in a non-existent procedure code through the claims update integration point.

Each claim form belongs to a line of business; the line of business specifies the business segment, for example Automobile Insurance, Health Insurance, Travel Insurance etc.

Each claim form can belong to a single claim form type. Claim form types are used in a number of configuration rules to reference a set of claim forms.

The practical example for the US health market is that claim forms represent the different formats in which a claim can be submitted, i.e., the electronic formats 837P, 837I and 837D and the paper forms UB04, CMS1500 and J400.

The UB04 and the 837I are both institutional claims and are treated the same for adjudication purposes, where it is irrelevant whether the claim was submitted electronically or through the mail. In this example both claim forms would refer to the claim form type "Institutional". Now, when the user sets up a benefit specification that applies only to institutional claims, the system knows to only consider UB04 and 837I claims for that benefit specification.

Claim Form Type

Field	Description
Code	The unique code for this claim form type
Display name	The description of the claim form type that appears in drop down menus

A typical use of the claim form type for the US market is

• Claim form type: Institutional

  • Claim form: 837I

  • Claim form: UB04

• Claim form type: Professional

  • Claim form: 837P

  • Claim form: CMS1500

• Claim form type: Dental

  • Claim form: 837D

  • Claim form: J400