Detail Dialogs

The claims pages use detail summaries that link to dialogs. To make the best possible use of the available page real estate, the main claim page displays only a limited selection of key information per topic. Claim processors can see all information on a topic, or create/update/delete items in the the corresponding dialog.

Some dialogs allow for edits. The creation, update and deletion of records in these dialog boxes are committed only when the claim is saved as a whole, i.e., by clicking the save or submit button on the claim header.

Non-editable dialog boxes show an 'OK' button on the left side of the box. Editable dialog boxes also show a 'CANCEL' button next to the 'OK' button. Clicking this button has the effect of undoing all changes made in the dialog box itself.

Claim/Claim Line Messages

Displays the attributes in a table based layout. This dialog allows inserts, updates and deletes of claim/claim line messages. The following fields are displayed in table columns:

Field	Type	Remark
Severity	Label	claimLineMessage.message.severity
Priority	Label	claimLineMessage.message.priority
Origin	Label	claimLineMessage.origin
System specific?	Check box, display only	claimLineMessage.message.indSystemSpecific
Code	LOV	claimLineMessage.message.code
Product	Label	claimLineMessage.product
Text	Label	claimLineMessage.message.message (for non matched messages claimLineMessage.code is displayed)

Messages that are configured to be suppressed in the UI do not appear in this dialog. As a result, it is not possible to remove these messages through the UI either. It is possible to select these messages in the LOV when entering a new message.

It is not possible to add or remove messages that are OHI specific. What kind of messages can be added or removed depends on the status of the claim, and is described in the section for that specific claim page.

The message text is shown with the substitution parameter values. Message product is not displayed in Claim messages; only claim line messages can have a reference to a product. The claim line messages detail dialog also displays (read-only) fatal claim messages.

Claim/Claim Line Diagnoses

Displays the attributes in a table based layout. This dialog box allows for inserts, updates and deletes of claim/claim line diagnoses. The following fields are displayed in table columns:

Field	Type	Remark
Sequence	Up/down icons	claimDiagnosis.sequence
Type	LOV	claimDiagnosis.diagnosisType.code
+ type description	Label	claimDiagnosis.diagnosisType.description
Diagnosis code	LOV	claimDiagnosis.diagnosis.code
+ diagnosis description	Label	claimDiagnosis.diagnosis.description
+ diagnosis definition code	Label	claimDiagnosis.diagnosis.flexCodeDefinition.code

The inline overflow area has no fixed fields. It is used to display any configured dynamic fields.

Claim Internal/External Remarks

Displays an editable text area.

Claim Status, Event, Pend Reason and Callout History

The dialog consists of four sections: a master showing the claim status history with details showing the pend reason history, the claim event history and the claim callout history. All sections are display only and show the attributes in a table based layout. The claim event history only shows records with a checked display in UI indicator; possible details (claim line event history) are shown in a single field by comma separating the claim line codes, like displaying modifiers elsewhere. Claim event history records are sorted on level and then event. The claim callout history also only shows records with a checked display in UI indicator.

The following fields are displayed in table columns:

Claim status history

Field	Type	Entity, field
Date time	Label	claimStatusHistory.dateTime
Status	Label	claimStatusHistory.status

Pend reason history

Field	Type	Entity, field
Priority	Label	claimPendReasonHistory.pendReason.priority
Code	Label	claimPendReasonHistory.pendReason.code
Description	Label	claimPendReasonHistory.pendReason.description
Claim Line Code	Label	claimPendReasonHistory.claimLineCode
Resolved By	Label	claimPendReasonHistory.resolvedBy

Claim event history

Field	Type	Entity, field
Level	Label	claimEventHistory.level
Topic	Label	claimEventHistory.topic
Event	Label	claimEventHistory.event
Claim line codes	Label	claimLineEventHistory.claimLineCode

Claim callout history

Field	Type	Entity, field
Definition	Label	claimCalloutHistory.definitionCode
Description	Label	claimCalloutHistory.definitionDescr
Request Sent	Label	claimCalloutHistory.requestSentDatetime
Response Received	Label	claimCalloutHistory.responseReceivedDatetime

Claim/Claim Line Pend Reasons

Displays the attributes in a table based layout. This dialog box allows a user to add new pend reasons and to toggle the resolved indicator on all existing pend reasons in status CHANGE, MANUAL PRICING, MANUAL PRICING ADJUDICATION, MANUAL BENEFITS and MANUAL ADJUDICATION; in status ENTRY, adding or updating pend reasons is not allowed. The following fields are displayed in table columns:

Field	Type	Entity, field
Resolved	Check box	claimPendReason.indResolved
Priority	Label	claimPendReason.pendReason.priority
Code	LOV	claimPendReason.pendReason.code
Description	Label	claimPendReason.pendReason.description
External Code	Label	claimPendReason.pendReason.externalCode
Non-clean?	Check box, display only	claimPendReason.pendReason.indNonClean
Publish?	Check box, display only	claimPendReason.pendReason.indPublishMessage
Adj. Only?	Check box, display only	claimPendReason.pendReason.indAdjudicationOnly

There are no fields displayed in the inline overflow.

Financial Hold status and history

Displays the financial holds applied to the claim in context. If the user has the Financial holds access rights, it is possible to record and release financial holds on the claim or claim transaction. Otherwise the dialog is display only.

The following fields are displayed:

Field	Object.field
Hold Type	FinancialHold.FinancialHoldType.code
Status	Derived Field
Held By	FinancialHold.User.displayName
Start Date Time	FinancialHold.startDatetime
Released By	FinancialHold.User.displayName
Release Date Time	FinancialHold.releaseDatetime
Expiration Date Time	FinancialHold.expirationDatetime
Auto Release on New Version?	FinancialHold.autoRelease
Hold Comment	FinancialHold.remarks
Release Comment	FinancialHold.releaseRemarks

Hold Comment and Release Comment are shown in the overflow area of the page and can be used to provide extra information on the financial hold.

The status field can have the following values:

• Active

A financial hold is Active when the release date is empty and the expiration date is in the future or empty.

• Released

A financial hold is Released when the release date has a value.

• Expired

A financial hold is expired when the release date is empty and the expiration date is in the past.

A financial hold can be released by clicking the Release Hold checkbox. When the hold is released, the Released By field is set to the user that releases the financial hold and the Release Datetime is set to the current system date and time. The status of the financial hold is changed to Released.

Updates to a financial hold are restricted to Active holds. Only the following fields can be updated:

• Hold Comment

• Release Comment

• Expiration Date Time; The expiration date time cannot be set to a date and time in the past.

• Auto Release on New Version?

Sub Lines

Displays the attributes in a table based layout. This dialog box allows for creates, updates and deletes of claim sub lines. The following fields are displayed in table columns:

Field	Type	Entity, field
Sequence	Number field	claimSubLine.sequence
Qty	Number field	claimSubLine.numberOfClaimedUnits
Procedure	LOV	claimSubLine.procedure
+ description	Label	claimSubLine.procedure
+ definition code	Label	claimSubLine.procedure

The inline overflow area has no fixed fields. It is used to display any configured dynamic fields.

Applied benefit rules

Shows the applied benefit specifications, the product benefit specification parameters, the claim line coverages and limit consumptions, all displayed in separate tables (note that this is not a master-detail display). All four tables are display only.

Field	Type	Remark
Product	Label	claimLineBenefitSpecification. product.code
Type	Label	Derived from the regime.If a BenefitSpecification is specified the Type should be the subtype of the BenefitSpecification, otherwise it should be "Cover" if the Claim Line Benefit Specification is for a Coverage Regime, "Auth" if the Claim Line Benefit Specification is for a Authorization Regime "Wait" if the Claim Line Benefit Specification is for a Waiting Period Regime "Post" if the Claim Line Benefit Specification is for a Post Benefit Regime
Benefit Specification	Label, URL*	claimLineBenefitSpecifcation. benefitSpecification.code
+ description	Label	claimLineBenefitSpecification. benefitSpecification.description
Regime	Label, URL*	claimLineBenefitSpecification. coverageRegime.code (or) authorizationRegime.code (or) waitingPeriodRegime.code (or) postBenefitsRegime.code (or) reservationRegime.code
+ description	Label	claimLineBenefitSpecification. coverageRegime.description (or) authorizationRegime.description (or) waitingPeriodRegime.description (or) postBenefitsRegime.description (or) reservationRegime.description

^* Clicking the benefit specification code will open the Benefit Specification page in context of that benefit specification. Clicking the regime code will open the coverage regime, authorization regime , waiting period regime or post benefits regime page, in context of that regime.^

The overflow area contains the following fields, under the condition that the type is a "Cover" specification

Field	Type	Remark
Product Provider Group Status	Label	claimLineBenefitSpecification. productProviderGroupStatus
Product Provider Group + description	Label	claimLineBenefitSpecification. productProviderGroup.code productProviderGroup.description
Specific Provider Group Status	Label	claimLineBenefitSpecification. specificProviderGroupStatus
Specific Provider Group + description	Label	claimLineBenefitSpecification. specificProviderGroup.code specificProviderGroup.description
Inherited Provider Group Status	Label	claimLineBenefitSpecification. inheritedProviderGroupStatus
Processed as IN?	Label	claimLineBenefitSpecification. processedAsIn

Field	Type	Entity, field
Parameter + value + currency (if applicable)	Label	productBenefitSpecificationParameter, policyProductParameter and policyProduct.factor (only if this has a value)

This table shows details of the product benefit specification that is referenced by the claim line benefit specification. It is sorted as follows: first product benefit specification values are shown (sorted on cover withhold category code), then product benefit specification limits are shown (sorted on limit code).

A product benefit specification value is shown as a concatenation of the cover withhold category code with either the amount (including the currency display code) or the percentage (including a percentage sign) - analogous to the way these are shown elsewhere. If a policy product parameter exists that has the same alias code as the product benefit specification value, the amount (including currency) or the percentage specified on the policy product parameter (which value is displayed depends on the type of the value specified on the product benefit specification value) is displayed instead of the amount or percentage specified on the product benefit specification value. Note that only product benefit specification values that are valid on the claim line service date are displayed.

A product benefit specification limit is shown as a concatenation of the limit with either the amount (including the currency display code), the number of units (including the denomination of units) or number of service days (including a day label) - analogous to the way these are shown elsewhere. If the product benefit specification limit counts towards a specific cover withhold category that cover withhold category and the 'when reached' action are also displayed (see mockup). If a policy product parameter exists that has the same alias code as the product benefit specification limit, the amount (including currency), the number of units or the number of service days specified on the policy product parameter (which value is displayed depends on the type of the limit) is displayed instead of the amount, the number of units or the number of service days specified on the product benefit specification limit. Note that only product benefit specification limits that are valid on the claim line service date are displayed.

A product benefit specification reinsurance is shown as a concatenation of the alias code, the percentage and the percentage sign. The percentage is take from the policy product parameter that has a matching alias code. Note that both the product benefit specification reinsurance and the policy product parameter have to be valid on the benefits input date. Note that if there is no matching policy product parameter, then no percentage is shown, i.e., only the alias code is shown.

If a prorating factor is available on the policy product, it is shown in this section as the string 'Prorating factor is' concatenated with the policy product factor. Note that the label 'Prorating factor is', is configurable as boilerplate text.

Field	Type	Entity, field
Amount	Label	claimLineCoverage.amount.amount and claimLineCoverage.amount.displayCode
Action	Label	claimLineCoverage.action
Display Name	Label	claimLineCoverage.displayName
Coverage Label	Label	claimLineCoverage.coverageLabel.code
Applied Product	Label	claimLineCoverage.product.code
Number Of Units	Label	claimLineCoverage.numberOfUnits

Field	Type	Entity, field
Amount	Label	limitConsumption.amount.amount and limitConsumption.amount.displayCode
Number	Label	limitConsumption.numberOfUnits
Service Days	Label	No field (show label: 1 Day)
Display Name	Label	limitConsumption.displayName
Limit	Label	limitConsumption.limitCounter.limit.code

Note that reversed limit consumptions are not displayed.

Applied reimbursement method and pricing rules

Shows the applied provider pricing clauses in the order of execution during claims processing and the provider limit consumptions (displayed in separate tables). The tables are display only.

Applied Provider Pricing Clauses

Field	Type	Remark
Order	Label	claimLineProviderPricingClause.sequence
Type	Label, URL*	The type of the reimbursement method / pricing rule to which the provider pricing clause refers.
Description	Label	The description of the provider pricing clause.
Quantifier	Label	The quantifier of the provider pricing clause, showing either the percentage, maximum amount, maximum number of units or maximum service days (including the value type).
Code of Reimbursement Method / Pricing Rule	Label, URL*	The code of the reimbursement method / pricing rule to which the provider pricing clause refers.
Mark	Label	claimLineProviderPricingClause.mark
Difference (Amount and Currency)	Label	claimLineProviderPricingClause.amount.amount and claimLineProviderPricingClause.amount.displayCode Note that this amount is zero (as opposed to null) for e.g. a message rule. After internal calculation, the sum of the amounts of all the Claim line provider pricing clauses adds up to the allowed amount of the claim line; when the allowed amount is changed manually, the claim line provider pricing clauses are kept until a recalculation so the numbers need not add up anymore.

^* Clicking the type will open the Provider Pricing Clause page in context of that provider pricing clause. Clicking the code of the reimbursement method / pricing rule will open one of the specific pages for reimbursement methods or pricing rules, in context of the reimbursement method or rule; for a fee schedule, the page will be opened in context of the fee schedule line.^

Provider Limit Consumptions

Field	Type	Entity, field
Consumption Amount (Amount and Currency)	Label	providerLimitConsumption.amount.amount and providerLimitConsumption.amount.displayCode
Number	Label	providerLimitConsumption.numberOfUnits
Service Days	Label	No field (show label: 1 Day)
Limit Code	Label	providerLimitConsumption.providerLimitCounter. providerLimitRule.code

Note that reversed limit consumptions are not displayed.

Unfinalize Reasons

Shows claim unfinalize reasons, display only (except in the Change Claim page where the Source Reference field and the dynamic fields are editable). Dynamic fields appear in the inline overflow area.

Field	Type	Entity, field
Code	Label	claimUnfinalizeReason.unfinalizeReason.code
Description	Label	claimUnfinalizeReason.unfinalizeReason.description
Source Reference	Label	claimUnfinalizeReason.sourceReference

Claim Line Parameters

Displays the claim line parameters. This dialog box allows a user to add, update and delete parameters. The following fields are displayed in table columns:

Field	Type	Entity, field
Parameter Value (Value and Type)	Number field and Dropdown	claimLineParameter.amount.amount and claimLineParameter.amount.displayCode OR claimLineParameter.percentage
Category	LOV	claimLineParameter.coverWithholdCategory.code
Product	LOV	claimLineParameter.product.code
+ description	Label	claimLineParameter.product.description

There are no fields displayed in the inline overflow (except for configured dynamic fields). Sorting is on coverWithholdCategory.code, product.code (nulls first).

Claim Line Limits

Displays the claim line limits. This dialog box allows a user to add, update and delete claim line limits. The following fields are displayed in table columns:

Field	Type	Entity, field
Limit	LOV	claimLineLimit.limit.code
Category	LOV	claimLineLimit.coverWithholdCategory.code
Aggregation Level	Character Field	claimLineLimit.aggregationLevel
Maximum (Value and Type)	Number field and Dropdown/Label	claimLineLimit.maximumAmount.amount and claimLineLimit.maximumAmount.displayCode OR claimLineLimit.maximumNumber OR claimLineLimit.maximumServiceDays
Action Reached	Dropdown	claimLineLimit.actionReached
Product	LOV	claimLineLimit.product.code
+ description	Label	claimLineLimit.product.description

There are no fields displayed in the inline overflow (except for configured dynamic fields). Sorting is on limit.code, type, product.code (nulls first).

Claim Line Contract References

Displays the claim line contract references. This dialog box allows a user to add, update and delete claim line contract references. The following fields are displayed in table columns:

Field	Type	Entity, field
Code	LOV	contractReference.code
+ description	Label	contractReference.description

There are no fields displayed in the inline overflow. Sorting is on code.

External Claims Data

For a description of the dialog for external claims data, see the paragraph on Local area.