Resolve Pend Reasons
During processing, a claim may be pended. This implies requirement of manual intervention. When a claim pends, one or more pend reasons are attached to the claim on different levels: claim, bill(s) or claim line(s).
Those attached pend reasons need resolution before the claim processing can proceed. Oracle Health Insurance HTTP API supports this pend resolution in various ways with different granularity:
-
A specific pend reason is resolved on all the levels.
-
A specific pend reason is resolved on a specific level.
This comes with two options:
-
As an operation on the claim, but impacting all the individual claim lines. This reduces the number of operations to be called in cases where individual lines are pend with the same pend reason.
-
As an operation on a specific claim or claim line. This is the most fine grained option.
The different scenarios are described in the next sections. Certain aspects always apply:
-
Pend reasons can be protected by access restrictions. HTTP API operations will always enforce those access restrictions.
-
HTTP status 403 is returned if the current user does not have the access rights. Error CLA-IP-CLAI-023 Unresolved pend reasons exist and you don’t have the privileges to resolve them is returned in the response.
-
If any rights are missing, no change is made to the claim or any of its details.
-
-
The bill level is not supported by HTTP API operations.
-
Pend resolution operations are discoverable: when pend resolution is applicable on the claim or claim line level, additional links will be added to the resource representation.
Resolve a specific Pend Reason on Claim and all Claim Lines
When unresolved pend reasons exist for a claim or any of its claim lines, a resolve link is added to the claim resource for each distinct pend reason:
... claim properties ...
"links": [
{
"href": "http://<host>:<port>/api/generic/claims/<id>",
"rel": "self"
},
{
"href": "http://<host>:<port>/api/claims/<claim id>/resolvepend/<pend reason id 1>",
"rel": "claim:resolvepend"
"httpMethod": "POST"
},
{
"href": "http://<host>:<port>/api/claims/<claim id>/resolvepend/<pend reason id 2>",
"rel": "claim:resolvepend"
"httpMethod": "POST"
}
]
}
Clients can trigger the pend resolution by following the link. The pend reason will be resolved on both the claim and claim lines level.
Success
HTTP 303 SEE OTHER after the operation completes successfully, request will be redirected to claims API.
Resolve a specific Pend Reason on all Claim Lines
In cases where claim lines are pended, multiple claim lines may have the same pend reason. Those can be resolved in one go for a single level as well. For pend reasons that exist on the claim line level, an additional link is added:
... claim properties ...
"links": [
{
"href": "http://<host>:<port>/api/generic/claims/<id>",
"rel": "self"
},
{
"href": "http://<host>:<port>/api/claims/<claim id>/resolvepend/<pend reason id 1>",
"rel": "claim:resolvepend"
"httpMethod": "POST"
},
{
"href": "http://<host>:<port>/api/claims/<claim id>/resolvepend/<pend reason id 2>",
"rel": "claim:resolvepend"
"httpMethod": "POST"
},
{
"href": "http://<host>:<port>/api/claims/<claim id>/resolveclaimlinepend/<pend reason id 2>",
"rel": "claim:resolveclaimlinepend"
"httpMethod": "POST"
}
]
}
The pend reason with pend reason id 2 exists on both the claim and claim line level. If the client follows the second link, the pend reason is resolved both on the claim and claim line level. If the client follows the third link (with resolveclaimlinepend), the pend reason is resolved only on the claim line level.
Resolve a specific Pend Reason on Claim Level
This operation is available on the claimpendreasons resource. When a claim pend reason is not resolved yet, a resolve link is added:
{
... claim pend reason properties
"resolved": false,
"links": [
{
"href": "http://<host>:<port>/api/generic/claimpendreasons/<id>",
"rel": "self"
},
{
"href": "http://<host>:<port>/api/claimpendreasons/<id>/resolve",
"rel": "claimpendreason:resolve"
"httpMethod": "POST"
}
]
}
Success
HTTP 303 SEE OTHER after the operation completes successfully, request will be redirected to claimpendreasons API.