Manual Benefits

This page allows a claims processor to alter the benefit results calculated by the system. This page can be accessed through the search claim page by clicking on the claim code link on one of the search results. This will open an instance of this page in a dynamic tab for that particular claim. Alternatively, this page can be access directly by the URL provided in the work flow notification message.

Display and Specifics

This page displays only claims that are in the status MANUAL BENEFITS. The user can add, remove or alter external claims data and on non-replaced claim lines:

Change the amount on claim line rule coverages
- Not possible on locked claim lines
Check or uncheck the keep benefits indicator
- Not possible on locked claim lines
Add informative non-ohi specific claim line messages (they will get the origin MANUAL)
Remove informative claim line messages with the origin MANUAL or EXTERNAL

Editing claim line rule coverages

Users cannot remove or create new claim line rule coverages, i.e., they can only change the amount and only to non negative values. Edits to the amount field may affect limit consumption. To show the effects of the edits on the rest of the claim (except for locked claim lines and replaced claim lines), the user can force an ad-hoc recalculation by saving the claim. Saving the claim triggers the following steps:

Edits to external claims data and claim line messages are saved
For each line on which at least one claim line rule coverage was edited:
- Check both the keep benefits and manual benefits indicators
- Remove all claim line messages that originated from limits and (post) cover withhold rules (origin COVERAGE)
- Recalculate the benefit results of the claim line, overriding the system calculated rule coverages with the manually edited rule coverages
- Re-evaluate and create new limit, reservation regime, (post) cover withhold rule messages
For all other lines (except for locked claim lines and replaced claim lines):

KB^*	Action
Y	Retain all results
N	Recalculate the benefits results of the claim line based on the system configuration (meaning that the Benefits step is performed again with the exception of sub-step 'Evaluate External Intervention Rules')

KB^*

Action

Retain all results

Recalculate the benefits results of the claim line based on the system configuration (meaning that the Benefits step is performed again with the exception of sub-step 'Evaluate External Intervention Rules')

^* KB: Keep Benefits Indicator~

After the recalculation, the end-benefits derivation rules* are re-evaluated and the total covered amount is updated accordingly (set to the sum of the claimLine.coveredAmounts of non-replaced claim lines) as long as all the currencies of the claim line covered amounts are equal.

^* Note that the claim line level rules are not evaluated for locked claim lines and replaced claim lines

The keep benefits indicator is visible and editable (except for locked claim lines and replaced claim lines). Unchecking the keep benefits indicator entails that the next recalculation ignores any manual edits on that line and redoes the calculation based solely on the system configuration. When this happens, the system sets the claimLine.indManualBenefits to "false". Manually checking the keep benefits indicator allows a user to 'freeze' a system calculated benefit result without making any edits. When this happens, the manual benefits indicator is not checked. Note that the manual benefits indicator can not be manually set.

When a line is recalculated it takes into account all finalized consumption, all preliminary consumption originating from the same claim and all 'frozen' consumption of lines within the same claim that have a checked KB indicator.

A fatal message appears if the user attempts to save a claim where the benefits input amount of a claim line does not equal the sum (amount) of the claim line coverages of that same claim line. This check also triggers if the user selects one of the options in the dropdown list (Change claim, Price claim, Submit claim) followed by OK.

Code	Sev	Text
GEN-UINT-025	Fatal	The manual changes made to the claim line rule coverage can not be reconciled with the benefits input amount

Code

Sev

Text

GEN-UINT-025

Fatal

The manual changes made to the claim line rule coverage can not be reconciled with the benefits input amount

Additional Fields and Buttons

All detail dialog boxes are display only, with the exception of: claim pend reasons, claim line pend reasons and claim line messages. The pend reason resolved indicator shown in the pend reason detail summary in section 2 and 4 is editable. Also, pend reasons (at the different levels claim and claim line) can be added. The dialog box for claim line message allows the user to add informative and non-ohi specific messages and to remove manually attached informative messages. Section 3 has the following additional columns:

Display label	Entity, field
Pend Reason	Displays the claimLine.claimLinePendReason.code with the lowest value for claimLinePendReason.priority If the lowest priority value is shared by more than one claimLinePendReason, show the claimLinePendReason that comes first based on alphabetical sort on the pend reason code.

Display label

Entity, field

Pend Reason

Displays the claimLine.claimLinePendReason.code with the lowest value for claimLinePendReason.priority

If the lowest priority value is shared by more than one claimLinePendReason, show the claimLinePendReason that comes first based on alphabetical sort on the pend reason code.

Section 3 displays the claim line rule coverages, directly below the claim line table:

Display label	Entity, field
Coverage Amount (Amount and Currency)	claimLineRuleCoverage.amount.amount and claimLineRuleCoverage.amount.displayCode (read-only)
Claim Line Rule Coverage	The value is composed of several fields: claimLineRuleCoverage.numberOfUnits (e.g., "10") claimLineRuleCoverage.action (e.g. "W") claimLineRuleCoverage.displayName (e.g. "Deductible") and is displayed using natural language, e.g., "Over 10 unit(s) withheld as Deductible"

Display label

Entity, field

Coverage Amount (Amount and Currency)

claimLineRuleCoverage.amount.amount and claimLineRuleCoverage.amount.displayCode (read-only)

Claim Line Rule Coverage

The value is composed of several fields:

claimLineRuleCoverage.numberOfUnits (e.g., "10")
claimLineRuleCoverage.action (e.g. "W")
claimLineRuleCoverage.displayName (e.g. "Deductible")

and is displayed using natural language, e.g., "Over 10 unit(s) withheld as Deductible"

Header Buttons

The following buttons display on the top right of the local area:

Field	Remark
View Claim Transaction (drop menu)	Provides access to claim transactions of the current claim. The drop menu contains one line for each claim transaction in the claims transaction repository that originated from this claim. Each entry shows the version number and transaction date. The most recent version is the default value. Versions are ordered by version number, most recent at the first entry.
Change (button)	Performs all steps of the save button. Sets the claim to status CHANGE. Closes this page and opens (in the same tab) the Enter Change Claim page.
Manual Pricing (button)	Performs all steps of the save button. Sets the claim to status MANUAL PRICING. Closes this page and opens (in the same tab) the Manual Pricing page.
Submit (button)	Performs all steps of the save button. The claim continues processing. If all pend reasons are resolved, this page closes and the View Claim page opens (in the same tab). A claim may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.
Refresh (button)	Button that forces a re-query of the displayed claim. Used to track a claims status progress real time.
Save (button)	Saves any changes made to the claim (user is able to edit external claims data and claim line messages in this page). Also triggers the recalculation of the claim as described above.
Cancel (button)	Rolls back any unsaved changes.

Field

Remark

View Claim Transaction

(drop menu)

Provides access to claim transactions of the current claim. The drop menu contains one line for each claim transaction in the claims transaction repository that originated from this claim.

Each entry shows the version number and transaction date. The most recent version is the default value. Versions are ordered by version number, most recent at the first entry.

Change (button)

Performs all steps of the save button. Sets the claim to status CHANGE. Closes this page and opens (in the same tab) the Enter Change Claim page.

Manual Pricing (button)

Performs all steps of the save button. Sets the claim to status MANUAL PRICING. Closes this page and opens (in the same tab) the Manual Pricing page.

Submit (button)

Performs all steps of the save button. The claim continues processing.

If all pend reasons are resolved, this page closes and the View Claim page opens (in the same tab).

A claim may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.

Refresh

(button)

Button that forces a re-query of the displayed claim. Used to track a claims status progress real time.

Save

(button)

Saves any changes made to the claim (user is able to edit external claims data and claim line messages in this page).

Also triggers the recalculation of the claim as described above.

Cancel

(button)

Rolls back any unsaved changes.

The buttons 'Change' and 'Manual Pricing' set the claim back to an earlier part of the claims flow. The pend reasons on the claim and claim lines will remain attached; the application still considers the claim to be in a pended state. Resolved pend reasons are removed as soon as the claim is resubmitted for processing.