Claim Page

The claim page displays single claim in OHI Claims Adjudication. The retrieval and display of data in this page is subject to restrictions described in the implementation guide for user access. Function access with 'Retrieve' grant is need at the minimum to view claims page. This page can be accessed through the claim search page by clicking one of the search results or directly with the associated URL. Depending on the status of the claim different actions are presented to the user.

This page it is divided into the following sections:

• Claim Code, Status, Processing Details

      Displays a small set of claim related information (e.g. status, code) and a set
  of icons which allows the user to get more detailed information. It also lists
  avaibale actions on the claim such as submit, save, cancel and many more
  depending on the status of the claim.

• Claim Summary

  Summarizes processing details such as messages, pends, holds and skip tags

• Claim Header Data

  Displays claim header attributes

• Claim Lines

      Lists available actions on the claim line
  *   **Claim Line Data**

  Displays a list of claim lines

• Claim Line Processing

  Displays claim line processing fields and results

• Claim History

      Displays information about the claim history, including statuses, pends,
  call-outs and events

Claim Code, Status and Processing Details

The claim section shows the breadcrumbs, page title, and labels and a set of links to the following providing additional detail not displayed on the claim page:

• Pend reasons

• Messages (matched)

• Benefits, including details:

  • Applied benefits

  • Coverages

  • Limit consumptions

  • Limit overrides

  • Parameters

• Pricing, including details:

  • Contract references (matched)

  • Provider limit consumptions

  • Applied provider pricing clauses

• Financial holds

• Unfinalize reasons

In the top right corner action buttons are displayed. The buttons are displayed depending on the status of the claim and access restrictions. The outmost right button ('More') presents a dropdown menu.

The following actions are displayed for claims in a given status to the user.

Field/Link	Remark	Status	Access Restrictions Grants
Edit	Brings the claims object to edit state	Change, Entry	Function access to update claim**
Cancel	Discards any unsaved changes and re-queries the claim when claim is in edit state. Brought to view status when user cancels in edit state. Clicking cancel in entry state will bring the user back to the claim search page if the object is not yet saved, else it will bring to the view object state.	Change, Entry
Save	Performs all steps of the save button applicable for the claim status	Only when the object claim is in the edit state	Function access to update claim
Delete	Deletes the claim. User is asked for confirmation with a dialog box. Confirmation will commit the delete.	Change, Entry Only when the claim has no transactions.	Function access to delete claim
Benefits only	Performs all steps of the save button in the Change status. Sets the 'Preprocessing Done' indicator and 'Pricing Done' indicator to 'Yes' and saves the claim and submits it for processing It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop up message. In case the claim has outstanding pend reasons (at claim and claim line level and are not adjudication only) it may only be submitted for 'benefits only' when at least one change is made or when at least one outstanding pend on the claim or claim line (not adjudication only) reason is resolved. When the claim cannot be submit because of the above mentioned reasons, the message 'The claim may only be accepted, when at least one change is made or when at least one pend reason is resolved' is shown to the user when user clicks on button.	Change	Function access to update claim and Operation 'Submit Claims' in status 'Change'
Submit	Performs all steps of the save button applicable for the claim status and allow the claim to be picked up for processing. In case the claim has outstanding pend reasons (at claim and claim line level and are not adjudication only) it may only be submitted when at least one change is made or when at least one outstanding pend on the claim or claim line (not adjudication only) reason is resolved. When the claim cannot be submit because of the above mentioned reasons, the message 'The claim may only be accepted, when at least one change is made or when at least one pend reason is resolved' is shown to the user when user clicks on button.	Change	Function access to update claim and Operation 'Submit Claim' in status 'Change'
Change	Sets the claim back to the status change and immediately displays the claim in edit state.	Manual adjudication, Manual pricing adjudication, Manual pricing, Manual benefits	Operation Back to Change
Unfinalize	The unfinalize link allows the user to select one or more unfinalize reasons and set the claim back to the Change status. This link is only displayed if the claim is unsettled (no settlement reason on the external claims data). Opens the Unfinalize Claim dialog, requiring the user to pick at least one unfinalize reason*. Note that only unfinalize reasons (type 'Claim Unfinalization') for which the user has access to are available.	Finalized, Pricing unfinalized	Operation Unfinalize Claim
Add Message	Add message to the claim	Change	Function access to update claim
Add Pend Rason	Add pend reason to the claim	Change	Function access to update claims
Add Financial Hold	Add financial hold to the claim	All Statuses	Financial Hold

^** Appropriate resource access must also be granted.

Note - Access to submit claims in 'all status' ensures that a user has access for a specific status too.

Other access grants that apply to claims page include - Brand claim access, Data access group claim & authorization access and Payer claim access. For details on access restrictions refer chapter Data Access Restrictions in the User Access guide.

Claim Summary

The claim summary section displays claim header information used to steer or report on claims processing. Messages, unresolved pends, active financial holds, skip tags and settlement reason are displayed.

Next to the pend reasons, a link 'Resolve' is shown for claims in the status Change, Manual Pricing, Manual Pricing Adjudication, Manual Benefits, Manual Adjudication. Clicking on the link displays a confirmation pop up with the message 'Resolve Pend?', once the user confirms, the pend is resolved and the link is disabled (until the page is fetched again). This action is subjected to access grants on pend reason resolution, operation resolve pends and claim statuses.

Link to release an active financial hold is placed next to the financial hold. This link is only shown if the user has access grant on 'Financial Hold' Once the hold is released, the link is disabled until the page is refreshed again.

Skip tags are shown with their display name and action. Link 'Change' is available next to the skip tag details to update the skip tags actions. This link is available only when the claim is in the status 'Change'. The link 'Change' is only shown when user has access grant to 'Update Skip Tags' and 'Change Claim'.

For a settled claim, the settlement reason code and description are shown.

Claim Line Data

The claim line element is used to display the claim line header information.

The claim line section displays claim lines and claim line processing results. At the top of this section different actions are displayed depending on the claim status, a filter to only show pended claim lines and claim line sorting. The following sorting options are available:

• Claim line code

• Sequence

• Start date

• Procedure code

• Status

The number of claim lines displayed by default is limited. If a claim has more lines, a pagination option becomes available for the user to display subsequent claim lines. It is possible to select multiple lines across page or on the page using - select all visible lines or select all lines options.

A switch is displayed to filter claim lines to only display claim lines with claim line pends. This switch is only shown when there are lines with pends.

The following actions are displayed in the status 'CHANGE', to the user that has access grant to update a claim (function access) and to submit it in the status 'Change'. The actions are further subjected to addition access grants as specified:

Field/Link	Remark	Access Restriction Grants
Add	Claim Line - Takes the user to claim line 'create' object page Message - Add message to one or more claim lines. Pend Reasons - Add pend reasons to claim line
Remove	Claim Line - Removes the selected line Message - Removes the selected message from one or more claim lines
Resolve Pend	Resolve pend on one or more claim lines.	Operation Resolve Pends.
Undo Line Replacement	Undo claim line replacement if one or more lines have been replaced. Redo line replacement if undo action has been performed. Either Undo or Redo is displayed. If no lines have been replaced, neither buttons are displayed.	Operation Undo Line Replacement
Unlock Lines	Locked lines can be unlocked by selecting them in the claim lines section and clicking on the Unlock Line(s) button.	Operation Unlock Lines

The claim line section displays the claim line level information. On click the user is taken to the claim line details page. The top row of the claim line displays colored boxes with information about the status, unresolved pends, fatal messages or replacement information.

Claim lines that are replaced or locked are visible, but cannot be removed/updated. When a replaced/locked line is selected for any actions - delete, add message, a message pop up is shown with a message 'Lines cannot be updated as they are locked or replaced'. The claim line detail pages are shown in the view only mode for a such lines.

Claim Line Processing

The claim line processing section displays claim line information used to steer or report on claim line processing. Selecting a claim line refreshes this section to display information specific to that line. Similar to the claim header a summary is provided in a colored box to display claim line messages, claim line pend reasons and replacement information. Claim line pends can be resolved in the same manner as claim pends.

Below the summary section reporting is displayed for pricing and benefits processing. Pricing information is limited to display provider limit consumptions. Benefit information is limited to the display of claim line coverages and member limit consumptions. Both the pricing and the benefits section have a 'Show more' link that will direct the user to the associated detail page with the selected claim displayed in context.

Claim History

Claim history details are displayed in a separate drawer accessible though a floating div at the right side of screen. It includes details about the claim status history, pend history, status event history and callout history. Filter options are provided to display specific details only:

• Display claim status

• Display pend reason

• Display claim callout history

• Display claim event history

Filter Options

Filter switches allow the user to hide records based on type or process cycle. Types status, pend reason, callout and events can be filtered. By default only the display claim status history switch is enabled. Enabling a switch includes related types from the list. Disabling switch 'status' removes any status record that does not have to display an associated pend reason, callout or event. Finally, a switch allows the user to display the last claims cycle only or the full claims history. This switch is disabled by default which means only the last cycle is displayed, which means only status history records up to the previous PRICING FINALIZED or FINALIZED record (if any) are displayed.

History Detail Timeline

History claim status details are displayed in a timeline in descending order based on creation date time displaying the most current claim status first. Applicable callout, pend reason and event history details are included under each associated claim line status. For example, if a claim is pended in manual adjudication, the associated pend reason is displayed directly underneath the MANUAL ADJUDICATION status record.

The claim event history and claim callout 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. Claim event history records are sorted on level and then event. Pend reasons are sorted on priority.

The following details are included in the history timeline:

CLAIM STATUS HISTORY

Field	Label	Origin
Status	Title	claimStatusHistory.status
Date time	Title	claimStatusHistory.dateTime

PEND REASON HISTORY

Field	Label	Origin
Description	Title	claimPendReasonHistory.pendReason.description
Code	Row	claimPendReasonHistory.pendReason.code
Priority	Row	claimPendReasonHistory.pendReason.priority
Claim Line Code	Row	claimPendReasonHistory.claimLineCode
Resolved By	Row	claimPendReasonHistory.resolvedBy

CLAIM EVENT HISTORY

Field	Label	Origin
Topic	Title	claimEventHistory.topic
Event	Row	claimEventHistory.event
Level	Row	claimEventHistory.level
Claim line codes	Row	claimEventHistory.event

CLAIM CALLOUT HISTORY

Field	Label	Origin
Description	Title	claimCalloutHistory.definitionDescr
Definition	Row	claimCalloutHistory.definitionCode
Request Sent	Row	claimCalloutHistory.requestSentDatetime
Response Received	Row	claimCalloutHistory.responseReceivedDatetime