Detail Dialogs

The claim page uses detail pages which are accessible by selecting an icon displayed at the top of the claim. The details pages can be used to 1) view specific details or 2) to perform actions.

If a detail page displays claim line information (e.g. claim line pends), all records specific to a claim line are grouped together and displayed in an embedded list view under a collapsible header.

Some details are combined with tabs in a single page. For example, claim and claim line messages are combined in a single page separated by tabs. One tab displays claim messages the other displays claim line messages. Another example is the benefits results page. This page combines five tabs: applied benefits, coverages, limit consumptions, claim line limits and parameters.

Detail Dialogs

The following detail dialogs are displayed. Actions such as adding a message, resolving a pend or adding a financial hold depends are restricted based on user access.

• Claim

  • Claim Summary Page

• Pend reasons

• Messages

• Benefits

• Pricing

• Financial Hold

• Unfinalize Reasons

Pend Reasons

The pend reason detail page groups claim and claim line pend reasons. Claim pend reasons are ordered on priority, then on code.

Claim Pend Reasons

Field	Object
Code	claimPendReason.pendReason.code
Description	claimPendReason.pendReason.description
Resolved	claimPendReason.indResolved
External Code	claimPendReason.pendReason.externalCode
Non-clean?	claimPendReason.pendReason.indNonClean
Publish?	claimPendReason.pendReason.indPublishMessage
Adjudication Only?	claimPendReason.pendReason.indAdjudicationOnly

Claim Line Pend Reasons

Field	Object
Code	claimLinePendReason.pendReason.code
Description	claimLinePendReason.pendReason.description
Resolved	claimLinePendReason.indResolved
External Code	claimLinePendReason.pendReason.externalCode
Non-clean?	claimLinePendReason.pendReason.indNonClean
Publish?	claimLinePendReason.pendReason.indPublishMessage
Adjudication Only?	claimLinePendReason.pendReason.indAdjudicationOnly

Actions

The user actions depend on the status of the claim

Status Change

The following actions are displayed when the user that has access grant to update a claim(function access)

• It is possible to resolve pends. This action is not available if the user does not have grant on the operation resolve pends.

• It is possible to add pend reasons

Message(s)

The message detail page groups displays two tabs: one for claim messages and one for claim line messages. Messages are sorted on severity (fatal first) and on code. Messages are sorted on severity (fatal first) and on code. Messages configured to be suppressed do not show in the dialog.

Claim Messages

Field	Details
Code	claimMessage.message.code
Message	claimMessage.message.message
Severity	claimMessage.message.severity
Origin	claimMessage.origin
System Specific?	claimMessage.message.indOHISpecific

Claim Line Message

Field	Details
Code	claimLineMessage.message.code
Message	claimLineMessage.message.message
Severity	claimLineMessage.message.severity
Origin	claimLineMessage.origin
System Specific?	claimLineMessage.message.indOHISpecific
Product	claimLineMessage.product

Actions

The user actions depends on the status of the claim.

Status Change

It is possible to add or remove non system specific message. It is possible to edit a message reference in case of a non-matched message. Addition and Removal of messages may be restricted by configuring appropriate grants on Claim message group.

These actions add/edit/remove are only displayed when the user that has access grant to update a claim(function access)

Benefits

The benefits page includes tabs to display the following claim line information:

• Applied Benefits

• Coverages

• Limit Consumptions

• Limit Overrides

• Parameters

Applied Benefits

Field	Details
Code	claimLineBenefitSpecifcation.benefitSpecification.subType + code Type is derived from the regime. The Type is the subtype of the BenefitSpecification
Description	claimLineBenefitSpecification.benefitSpecification.description
Product	claimLineBenefitSpecification.product.code
Regime + description	claimLineBenefitSpecification.coverageRegime.code (or) authorizationRegime.code (or) waitingPeriodRegime.code (or) postBenefitsRegime.code Description is displayed on hover
Product Provider Group	claimLineBenefitSpecification.productProviderGroupStatus claimLineBenefitSpecification.productProviderGroup.code, Description only displayed on hover
Specific Provider Group + description	claimLineBenefitSpecification.specificProviderGroupStatus claimLineBenefitSpecification.specificProviderGroup.code, Description only displayed on hover
Inherited Provider Group	claimLineBenefitSpecification.inheritedProviderGroupStatus
Processed as IN?	claimLineBenefitSpecification.processedAsIn

Coverages

Display claim line coverages.

Fields	Object
Display name	claimLineCoverage.displayName
Amount	claimLineCoverage.amount (currency display code + amount value)
Number of Units	claimLineCoverage.numberOfUnits + unit(s)
Action	claimLineCoverage.action
Coverage Label	claimLineCoverage.coverageLabel.code
Applied Product	claimLineCoverage.product.code

Limit Consumptions

Displays the claim line limit consumptions. Limit consumption reversals are not displayed.

Fields	Object
Limit Code	limitConsumption.limitCounter.limit.code
Amount	limitConsumption.amount (currency display code + amount value)
Number of Units	limitConsumption.numberOfUnits + unit(s)
Service Days	No field (show label: 1 Day)
Display Name	limitConsumption.displayName

Limit Overrides

Displays the claim line limits.

Fields	Object
Limit	claimLineLimit.limit
Cover Withhold Category	claimLineLimit.coverWithholdCategory
Reached Action	claimLineLimit.reachedAction
Maximum Amount	claimLineLimit.maximumAmount (currency display code + amount value)
Maximum No. of Days	claimLineLimit.maximumServiceDays
Maximum No. of Units	claimLineLimit.maximumNumber
Product	claimLineLimit.product

Actions

The user actions depend on the status of the claim

Status Change

• It is possible to add/edit/remove limit overrides when the user that has access grant to update a claim(function access)

Add/Edit Limit Dialog

Parameters

Displays the claim line parameters.

Fields	Details
Category	claimLineParameter.coverWithholdCategory.code
Parameter Value (Value and Type)	claimLineParameter.amount or claimLineParameter.percentage
Product	claimLineParameter.product.code

Actions

The user actions depend on the status of the claim

Status Change

• It is possible to add/edit/remove parameters when the user that has access grant to update a claim(function access)

Pricing

The pricing page includes tabs to display the following claim line information:

• Applied Provider Pricing Clauses

• Provider Limit Consumptions

• Contract References

Applied Provider Pricing Clauses

Display provider pricing clauses.

Fields	Details
Code of Reimbursement Method / Pricing Rule	The code of the reimbursement method / pricing rule to which the provider pricing clause refers.
Type	The type of the reimbursement method / pricing rule to which the provider pricing clause refers.
Mark	claimLineProviderPricingClause.mark
Difference	claimLineProviderPricingClause.amount (currency display code + amount value) 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.
Quantifier	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).
Order	claimLineProviderPricingClause.sequence

Provider Limit Consumptions

Displays the claim line limit consumptions.

Fields	Details
Limit Code	providerLimitConsumption.providerLimitCounter. providerLimitRule.code
Amount	providerLimitConsumption.amount (currency display code + amount value)
Number	providerLimitConsumption.numberOfUnits + unit(s)
Service Days	No field (show label: 1 day)

Contract References

Displays the claim line contract references.

Fields	Object
Code	contractReference.code
Description	contractReference.description

Financial Holds

Financial holds apply to the claim. The dialog is display only. An active hold is a hold where the expiration date and the release date time have not yet expired. Hold type codes are ordered on status (active first) and expiration date (nearest date first). In the dialog all information about the financial hold is displayed.

Field	Details
Code	FinancialHold.FinancialHoldType.code
Status	n/a 'Active' when the release date is empty and the expiration date is in the future or empty 'Released' when the release date has a value 'Expired' when the release date is empty and the expiration date is in the past
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

Add Financial Hold

On clicking 'Add', a detail dialog with the following fields is shown:

• Hold Type

• Expiration Date

• Auto Release on New Version

• Hold Remarks

Selecting 'Add' adds the hold and 'Cancel' closes the dialog.

Release Financial Hold

The action 'Release' is available for the active holds. On selecting 'Release' a detail dialog with the following fields is shown:

• Expiration Date

• Release?

• Release Remarks

Selecting 'Release' releases the hold and 'Cancel' closes the dialog.

Add and Release financial hold actions are only shown to a user that has grant on access restriction type 'Financial Hold'.

Unfinalize Reasons

Displays the unfinalize reasons.

Field	Object
Code	claimUnfinalizeReason.unfinalizeReason.code
Description	claimUnfinalizeReason.unfinalizeReason.description
Source Reference	claimUnfinalizeReason.sourceReference

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