Generic Claims Resource Behavior

Claims resource needs additional business functionality in case of updates/patches applied to it. This documents details the characteristics of the claims generic resource when it is updated using either PUT or PATCH.

Following is the description of additional functionality in case of each HTTP Method

GET: No Change

POST: No Change

DELETE: No Change

PUT/PATCH: Please find the details below.

Updating allowed amount and/or allowed number of units

When updating the allowed amount and/or the allowed number of units for both claim and reservation, the new values will normally be no longer in sync with the provider limit consumptions.

If the claim is in the status Change then the re-calculation is restricted to the effects on the claim line at hand. For each line on which at least one of allowed amount and allowed number of units was edited:

  • Check both the keep pricing and manual pricing indicators

  • Uncheck the keep benefits indicator

  • Remove all claim line messages that originated from provider limits (origin PRICING LIMIT)

  • Recalculate the provider limit consumptions of the claim line based on the edited allowed amount and/or allowed number of units:

  • It is possible that existing provider limit consumption has to be updated

  • It is possible that existing provider limit consumption (plus counter period/counter) has to be deleted

  • It is possible that new provider limit consumption (plus counter period/counter) has to be created

  • Reevaluate and create new provider limit category messages and/or reservation regime messages

Updating expires on

When expiration date on the reservation claim is updated, the expiration date on the provider limit consumptions of all the claim lines that are not locked is updated to the new date.

Add pend reasons on claim/claim line

Pend reasons are added on the claim/claim line level (based on the payload) and the pend reason history is added to the most recent status history.

Delete Claim Line

If the lines are deleted, the consumption taken by the line are not deleted, but transferred to the claim header level.