External Intervention
All external intervention rules of the sub type MANUAL BENEFITS are evaluated. If a claim, claim line or bill successfully meets all of the criteria set by the rule, then the rule is 'triggered'.
For each triggered external intervention rule, the specified pend reason is checked: if the reattach indicator is unchecked and the pend reason history indicates that the same pend reason has been previously attached on the same level (claim, bill or line), then the pend reason is not attached and the claim will not pend because of this external intervention rule. Otherwise, the specified pend reason is attached to the claim, claim line or bill, and added to the claim pend reason history.
If no pend reasons are attached as a result of the external intervention rule evaluation, then the claim skips ahead to the "End Benefits Derivation Rules" step. Otherwise, the claim status is set to MANUAL BENEFITS. See the implementation guide on claims flow configuration for more details on how to configure external intervention rules.
Both replaced claim lines and lines with a checked "Locked" and/or "Keep Benefits" indicator are ignored during this step. These lines will not trigger an external intervention rule for manual benefits. It is still possible that the claim pends for manual benefits triggered by other lines, the bill or the claim header.
Apply Manual Benefits
If the claim, claim line or bill has at least one pend reason with a checked 'publish message indicator', then the work flow integration point sends out an event to notify an external work flow management system that a new task is waiting. The event contains all pend reasons that configured to be published. For details, see the chapter on the work flow integration point in the implementation guide on claims flow configuration.
Assigning the task to the applicable claims operator / user is an external responsibility. Once the task has been assigned, the user opens the page for manual benefits and where the following courses of action are available:
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Change system calculated benefit results
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Save changes, triggering a recalculation of the claim that takes into account the edited benefit results
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Submit the claim for further processing.
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Reverting to a status that makes it possible to change the claim, e.g., changing the serviced person.
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Reverting to a status that makes it possible to change the pricing results on the claim lines.
Changing the claim
This option returns the claim to the start of the claims flow, so that the fields on the claim itself can be changed. The claim indicators "Preprocessing Done?" and "Pricing Done?" are unchecked.
The claim status is set to CHANGE and it re-enters the level 2: Receive, Enter and Change Claim flow. Note that the claim, bill and claim line pend reasons remain attached.
Changing pricing results
This option sets the claim back to an earlier status in the flow so that the pricing results can be changed. The claim indicator "Pricing Done?" is unchecked. The claim status is set to MANUAL PRICING and it re-enters the level 2: Pricing flow. Note that the claim, bill and claim line pend reasons remain attached.
The claim pricing results can be edited in the "Manual Pricing" page.
Recalculate and Save
This option executes the following steps:
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Changes to the claim line rule coverages, external claims data and claim line messages are saved
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The claim line rule coverages and consumptions for all lines within the claim are recalculated.
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The recalculated coverages and consumptions are committed.
This functionality is described in more detail in the Manual Benefits page description. The status of the claim remains MANUAL BENEFITS.
Submitting the claim
When a claim is submitted, changes are stored and it is checked whether there is an open work flow task for that claim. This is derived from a technical field on the claim. If so, the work flow integration point sends out a message to inform the work flow distribution system that the task can be closed.
Next, any resolved pend reasons are removed from the claim, bill and claim line. Note that these pend reasons are retained in the pend reason history. It is possible that one or more unresolved pend reasons remain attached to the claim, bill or claim line. If any pend reasons with indicator 'Adjudication Only' set to false remain, the claim’s status remains MANUAL BENEFITS. If at least one of the remaining pend reasons with indicator 'Adjudication Only' set to false has a checked publish message indicator, a new work flow integration point is message sent out. In effect, a claim will not be picked up by the process flow until all pend reasons with indicator 'Adjudication Only' set to false have been resolved.
If no pend reasons with indicator 'Adjudication Only' set to false (no pend reasons at all or only pend reasons with indicator 'Adjudication Only' set to true) remain, the claim continues on its way in the claims flow at the "End benefit derivation rule" step.
Derivation Rules
A derivation rules sets the value of certain fields on a claim, bill or claim line. At this point in the flow, the derivation rules are executed for which the "step" field has the value "end benefits". End benefit derivation rules are evaluated even if a fatal message is attached to the same (or higher) level as specified by the derivation rule.
The end benefit derivation rules are evaluated in the following order: claim line first, bill second, claim (header) last. The rationale behind this sequence is that end benefits derivation rules typically aggregate the results of processing to the the level of claim header. Since benefits are calculated per claim line, the claim derivation rules are triggered last, so that those dynamic fields on the claim line and bill (that are also set by derivation rules) can serve as input. If multiple derivation rules exist for the same level, they are executed in order of the configured sequence (sequence null is evaluated last).
End Benefits Callout Rules
At this step of the flow the application checks if any End Benefits callout rules apply to the claim. If so, the application halts the claim at its current location in the claims flow. The claim’s status is not changed. The callout rules that apply to the claim are then executed sequentially, in order of their specified sequence.
The application executes the End Benefits callout rules for claims independent of the Keep Benefit setting of the claim lines. Note that the claims flow does not cleanup the reults of a previous Benefits step for claim lines with Keep Benefits set to Yes. This means that calling out and resubmitting a claim with such claim lines more than once, can result in claim lines holding details from more than one callout.
If the callout definition specifies a "Response Logic" dynamic logic function, this logic processes the response message. The response message can update dynamic fields and add a message through a pre-defined method. Sending in (fatal) messages will however not impact the status of the claim or claim line that was set in the previous step. If the response of the callout has to set the claim or claim line status, or if it should lead to reprocessing the claim, the response should be send in through a Claims Update IP-SOAP/HTTP request message. This option is only available for callout definitions with an asynchronous messaging pattern.