Multiple Payment Receivers with Adjustment
This use case shows the claim transactions, financial transactions and financial messages that would be created for a claim that includes covered amounts that need to be paid out to several payment receivers and is then adjusted resulting in:
-
previously paid payment receivers not receiving any amount
-
a new payment receiver, and
-
changes in amounts to existing payment receivers.
Although payment receiver is at line level, 'custom logic' is in place to split payments based on there being a value in the 'Insured Entity Amount' claim line dynamic field. One of the lines has a pay to insured entity amount and both covered and withhold amounts.
The adjustment is done after the first version has already been selected for payment.
Summary
-
Version 1
-
Financial message includes;
-
three invoices to pay the covered amount of the claim to each of the payment receivers
-
accounting details for all coverages of the claim
-
-
-
Version 2
-
Financial Message includes;
-
four invoices;
-
a credit memo to retrieve back the amount from payment receiver that was replaced
-
an invoice to fully pay the covered amount to the new payment receiver
-
an invoice to pay the copay difference between version 1 and 2 of the claim
-
an invoice with a $0 difference between version 1 and 2 of the claim
-
-
accounting details for all coverages of the claim
-
-
Version 1
Adjudicate Claim
The claim is adjudicated resulting in the following details in Oracle Health Insurance:
-
$25.00 Copay
-
$110.00 Coverage
Working Copy Claim
Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
---|---|---|---|---|
CL123 |
456 |
789AB |
135.00 |
110.00 |
Working Copy Claim Lines
Sequence | Payment Receiver | Insured Entity Amount | Allowed Amount | Action | Amount | Label |
---|---|---|---|---|---|---|
1 |
789AB |
15.00 |
75.00 |
Covered |
50.00 |
Covered |
Withhold |
25.00 |
Copay |
||||
2 |
456EF |
60.00 |
Covered |
60.00 |
Covered |
Finalize (First Time)
The claim is finalized for the first time on 12 March 2014. The following are created at the same time:
-
First version claim transaction
-
A financial transaction with a Base Financial Object
Claim Transaction
The claim transaction has the following details.
CTR Claim
Claim Transaction Code | Version | Transaction Date | Person Code | Provider Code | Total Allowed Amount | Total Covered Amount | Reversal Ind |
---|---|---|---|---|---|---|---|
CL123 |
1 |
12-Mar-2014 |
456 |
789AB |
135.00 |
110.00 |
N |
CTR Claim Line ⇒ Coverages
Claim Transaction Code | Reversal Ind | Version | Claim Line Transaction Code | Allowed Amount | ⇒ | Payment Receiver | Action | Label | Amount |
---|---|---|---|---|---|---|---|---|---|
CL123 |
N |
1 |
1 |
75.00 |
789AB |
Covered |
Covered |
35.00 |
|
REL456 |
Covered |
Covered |
15.00 |
||||||
Withhold |
Copay |
25.00 |
|||||||
2 |
60.00 |
456EF |
Covered |
Covered |
60.00 |
Financial Transaction
The financial transaction has the following details:
Base Financial Object
Type | Claim code | Status |
---|---|---|
CLA |
CL123 |
IN |
Financial Transaction and Financial Transaction Process Data
Version | Processing Type | Reversal? | Creation Date | Total Amount | ⇒ | Due Date | Financial Message Mandatory | Financial Message Bulking Group | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|---|---|---|---|
1 |
Regular |
N |
12-Mar-2014 |
$110.00 |
25-Mar-2014 |
N |
CL123 |
null |
null |
Financial Transaction Detail and Financial Transaction Detail Process Data
Version | Reversal | Claim Line Code | Component Code | Amount | ⇒ | Invoice Indicator | Invoice Line Grouping | Accounting Detail Grouping | Payment Receiver | |
---|---|---|---|---|---|---|---|---|---|---|
1 |
N |
1 |
Covered |
35.00 |
Y |
N |
N |
789AB |
||
Covered |
15.00 |
Y |
N |
N |
REL456 |
|||||
Copay |
25.00 |
N |
N |
N |
||||||
2 |
Covered |
60.00 |
Y |
N |
N |
456EF |
Create Financial Messages
The financial messages are created on 14 March 2014. The claim is still in status Finalized. A financial message will be created with the following details:
-
One invoice for every payment receiver
-
Separate invoice lines for each financial transaction detail that has its invoice indicator set, included in the invoice of the related payment receiver
-
Separate accounting details for each of the financial transaction detais
The message is just for the one claim (because Financial Message Bulking Group is set to the claim code). It will not include any reversal transaction because the previous version was not actually included in a financial message.
Financial Message
The contents of the various parts of the financial message are as follows:
Financial Message
Job ID | Message Date | Message Bulking Group |
---|---|---|
132432 |
14-Mar-2014 |
CL123 |
Financial Message - Invoice ⇒ Invoice Lines
ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute (CTR Version) |
---|---|---|---|---|---|
89070 |
Standard |
789AB |
35.00 |
CL123 |
1 |
89071 |
Standard |
REL456 |
15.00 |
CL123 |
1 |
89072 |
Standard |
456EF |
60.00 |
CL123 |
1 |
Financial Message - Invoice Line
ID | Invoice ID | Line Number | Line Type | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal Indicator) | Attribute 4 (CTR Claim Line Code) |
---|---|---|---|---|---|---|---|---|
123572 |
89070 |
1 |
ITEM |
35.00 |
CL123 |
1 |
N |
1 |
123573 |
89071 |
1 |
ITEM |
15.00 |
CL123 |
1 |
N |
1 |
123574 |
89072 |
2 |
ITEM |
60.00 |
CL123 |
1 |
N |
2 |
Financial Message - Accounting Detail
ID | Ledger ID | Accounting Date | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal Indicator) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
---|---|---|---|---|---|---|---|---|
8719048 |
32423432 |
14-Mar-2014 |
35.00 |
CL123 |
1 |
N |
1 |
COVERED |
8719049 |
32423432 |
14-Mar-2014 |
15.00 |
CL123 |
1 |
N |
1 |
COVERED |
8719050 |
32423432 |
14-Mar-2014 |
25.00 |
CL123 |
1 |
N |
1 |
COPAY |
8719051 |
32423432 |
14-Mar-2014 |
60.00 |
CL123 |
1 |
N |
2 |
COVERED |
Financial Transaction Process Data
In addition, the following financial transaction process data columns are set. These fields provide information back on the financial transaction to make visible which message the transaction is included in.
Claim Transaction Code | Version Code | Reversal | ⇒ | Financial Message Handled Datetime | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|
CL123 |
1 |
N |
14-Mar-2014 |
132432 |
M |
Financial Transaction Detail Process Data
The following financial message transaction detail process data columns are set. These fields provide information back on the financial transaction detail to make visible which invoice line and accounting detail the transaction detail has been included in.
Claim Transaction Code | Version Code | Claim Line Transaction | ⇒ | Invoice ID | Invoice Line ID | Accounting Detail ID |
---|---|---|---|---|---|---|
CL123 |
1 |
1 |
89070 |
123572 |
8719048 |
|
CL123 |
1 |
1 |
89071 |
123573 |
8719049 |
|
CL123 |
1 |
1 |
8719050 |
|||
CL123 |
1 |
2 |
89072 |
123574 |
8719051 |
Version 2
Unfinalize Claim
The claim is unfinalized on 16 March 2014 making the working copy of it available for changing and readjudication. When unfinalizing the following occurs:
-
Version 1 of the CTR Claim (transaction) is labeled as unfinalized
-
A reversal CTR Claim (transaction) for version 1 is created with the allowed and covered amounts reversed
-
A reversal Financial Transaction for version 1 is created with allowed and covered amounts reversed. It will be associated with the base financial object created when the claim was first finalized.
These reversals are shown below.
Adjust Claim
The claim is adjusted resulting the following changes:
-
A lower copay for line 1
-
a change of payment receiver for line 2
the claim is adjusted resulting in a change to the copay for line 1. It now has the following details in Claims:
Claim
Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
---|---|---|---|---|
123 |
456 |
789AB |
135.00 |
125.00 |
Claim Line ⇒ Coverages
Sequence | Payment Receiver | Insured Entity Amount | Claimed Amount | ⇒ | Action | Amount | Label |
---|---|---|---|---|---|---|---|
1 |
789AB |
15.00 |
75.00 |
Covered |
50.00 |
Covered |
|
Withhold |
25.00 |
Copay |
|||||
2 |
456EF |
60.00 |
Covered |
60.00 |
Covered |
Finalize (Second Time)
The claim is finalized for the second time on 20 March 2014. The following are created:
-
A second version claim transaction
-
A second version financial transaction
CTR Claim Transaction
CTR Claim (Transaction)
Claim Transaction Code | Version | Transaction Date | Person Code | Provider Code | Total Allowed Amount | Total Covered Amount | Reversal Indicator |
---|---|---|---|---|---|---|---|
CL123 |
1 |
12-Mar-2014 |
456 |
789AB |
135.00 |
110.00 |
N |
CL123 |
1 |
16-Mar-2014 |
456 |
789AB |
-135.00 |
-110.00 |
Y |
CL123 |
2 |
20-Mar-2014 |
456 |
789AB |
135.00 |
125.00 |
N |
CTR Claim Line ⇒ Coverages
Claim Transaction Code | Reversal Indicator | Version | Claim Line Transaction Code | Allowed Amount | ⇒ | Payment Receiver | Action | Label | Amount |
---|---|---|---|---|---|---|---|---|---|
CL123 |
N |
1 |
1 |
75.00 |
789AB |
Covered |
Covered |
35.00 |
|
REL456 |
Covered |
Covered |
15.00 |
||||||
Withhold |
Copay |
25.00 |
|||||||
2 |
60.00 |
456EF |
Covered |
Covered |
60.00 |
||||
CL123 |
Y |
1 |
1 |
-75.00 |
789AB |
Covered |
Covered |
-35.00 |
|
REL456 |
Covered |
Covered |
-15.00 |
||||||
Withhold |
Copay |
-25.00 |
|||||||
2 |
-60.00 |
456EF |
Covered |
Covered |
-60.00 |
||||
CL123 |
N |
2 |
1 |
75.00 |
789AB |
Covered |
Covered |
50.00 |
|
REL456 |
Covered |
Covered |
15.00 |
||||||
Withhold |
Copay |
10.00 |
|||||||
2 |
60.00 |
DF436 |
Covered |
Covered |
60.00 |
Financial Transaction
The reversal financial transaction which is created when unfinalizing the claim is depicted below.
Financial Transaction and Financial Transaction Process Data
Version | Processing Type | Reversal? | Creation Date | Total Amount | ⇒ | Due Date | Financial Message Mandatory | Financial Message Bulking Group | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|---|---|---|---|
1 |
Regular |
N |
12-Mar-2014 |
$110.00 |
25-Mar-2014 |
N |
CL123 |
132432 |
M |
|
1 |
Regular |
Y |
16-Mar-2014 |
-$110.00 |
25-Mar-2014 |
N |
CL123 |
null |
null |
|
2 |
Regular |
N |
20-Mar-2014 |
$125.00 |
25-Mar-2014 |
N |
CL123 |
null |
null |
Financial Transaction Detail and Financial Transaction Detail Process Data
Version | Reversal | Claim Line Code | Component Code | Amount | ⇒ | Invoice Indicator | Invoice Line Grouping | Accounting Detail Grouping | Payment Receiver | |
---|---|---|---|---|---|---|---|---|---|---|
1 |
N |
1 |
Covered |
35.00 |
Y |
N |
N |
789AB |
||
Covered |
15.00 |
Y |
N |
N |
REL456 |
|||||
Copay |
25.00 |
N |
N |
N |
||||||
2 |
Covered |
60.00 |
Y |
N |
N |
456EF |
||||
1 |
Y |
1 |
Covered |
-35.00 |
Y |
N |
N |
789AB |
||
Covered |
-15.00 |
Y |
N |
N |
REL456 |
|||||
Copay |
-25.00 |
N |
N |
N |
||||||
2 |
Covered |
-60.00 |
Y |
N |
N |
456EF |
||||
2 |
N |
1 |
Covered |
50.00 |
Y |
N |
N |
789AB |
||
Covered |
15.00 |
Y |
N |
N |
REL456 |
|||||
Copay |
10.00 |
N |
N |
N |
||||||
2 |
Covered |
60.00 |
Y |
N |
N |
DF436 |
Create Financial Messages
The financial messages are created on 22 March 2014. The working copy claim has not been unfinalized. A financial message is created with the following details:
-
One invoice for every payment receiver (4 total), of which;
-
2 invoices with a delta amount calculating the difference between the current and previous financial transaction
-
A full credit memo for the total amount to be received back from the payment receiver that was replaced
-
A full invoice for the new payment receiver
-
Separate invoice lines for each financial transaction detail that has its invoice indicator set, included in the invoice of the related payment receiver
-
Separate accounting details for each of the financial transaction detais
Financial Message
The contents of the various parts of the financial message are as follows:
Financial Message
Job ID | Message Date | Message Bulking Group |
---|---|---|
132532 |
22-Mar-2014 |
CL123 |
Financial Message - Invoice
ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
---|---|---|---|---|---|
89075 |
Standard |
789AB |
15.00 |
CL123 |
2 |
89076 |
Standard |
REL456 |
0.00 |
CL123 |
2 |
89077 |
Credit |
456EF |
-60.00 |
CL123 |
2 |
89078 |
Standard |
DF436 |
60.00 |
CL123 |
2 |
Financial Message - Invoice Line
ID | Invoice ID | Line Number | Line Type | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal Indicator) | Attribute 4 (CTR Claim Line Code) |
---|---|---|---|---|---|---|---|---|
123582 |
89075 |
1 |
ITEM |
-35.00 |
CL123 |
1 |
Y |
1 |
123583 |
89076 |
1 |
ITEM |
-15.00 |
CL123 |
1 |
Y |
1 |
123584 |
89077 |
2 |
ITEM |
-60.00 |
CL123 |
1 |
Y |
2 |
123585 |
89075 |
1 |
ITEM |
50.00 |
CL123 |
1 |
Y |
1 |
123586 |
89076 |
1 |
ITEM |
15.00 |
CL123 |
1 |
Y |
1 |
123587 |
89078 |
2 |
ITEM |
60.00 |
CL123 |
1 |
Y |
2 |
Financial Message - Accounting Detail
ID | Ledger ID | Accounting Date | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal Indicator) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
---|---|---|---|---|---|---|---|---|
8719052 |
32423432 |
22-Mar-2014 |
-35.00 |
CL123 |
1 |
Y |
1 |
COVERED |
8719053 |
32423432 |
22-Mar-2014 |
-15.00 |
CL123 |
1 |
Y |
1 |
COVERED |
8719054 |
32423432 |
22-Mar-2014 |
-25.00 |
CL123 |
1 |
Y |
1 |
COPAY |
8719055 |
32423432 |
22-Mar-2014 |
-60.00 |
CL123 |
1 |
Y |
2 |
COVERED |
8719056 |
32423432 |
22-Mar-2014 |
50.00 |
CL123 |
2 |
N |
1 |
COVERED |
8719057 |
32423432 |
22-Mar-2014 |
15.00 |
CL123 |
2 |
N |
1 |
COVERED |
8719058 |
32423432 |
22-Mar-2014 |
10.00 |
CL123 |
2 |
N |
1 |
COPAY |
8719059 |
32423432 |
22-Mar-2014 |
60.00 |
CL123 |
2 |
N |
2 |
COVERED |
Financial Transaction Process Data
In addition, the following financial transaction process data columns are set. These fields provide information back on the financial transaction to make visible which message the transaction is included in.
Claim Transaction Code | Version Code | Reversal | ⇒ | Financial Message Handled Datetime | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|
CL123 |
1 |
N |
14-Mar-2014 |
132432 |
M |
|
CL123 |
1 |
Y |
22-Mar-2014 |
132532 |
M |
|
CL123 |
2 |
N |
22-Mar-2014 |
132532 |
M |
Financial Transaction Detail Process Data
The following financial message transaction detail process data columns are set. These fields provide information back on the financial transaction detail to make visible which invoice line and accounting detail the transaction detail has been included in.
Claim Transaction Code | Reversal | Version Code | Claim Line Transaction | ⇒ | Invoice ID | Invoice Line ID | Accounting Detail ID |
---|---|---|---|---|---|---|---|
CL123 |
N |
1 |
1 |
89070 |
123572 |
8719048 |
|
CL123 |
N |
1 |
1 |
89071 |
123573 |
8719049 |
|
CL123 |
N |
1 |
1 |
8719050 |
|||
CL123 |
N |
1 |
2 |
89072 |
123574 |
8719051 |
|
CL123 |
Y |
1 |
1 |
89075 |
123582 |
8719052 |
|
CL123 |
Y |
1 |
1 |
89076 |
123583 |
8719053 |
|
CL123 |
Y |
1 |
1 |
8719054 |
|||
CL123 |
Y |
1 |
2 |
89077 |
123584 |
8719055 |
|
CL123 |
N |
2 |
1 |
89075 |
123585 |
8719056 |
|
CL123 |
N |
2 |
1 |
89076 |
123586 |
8719057 |
|
CL123 |
N |
2 |
1 |
8719058 |
|||
CL123 |
N |
2 |
2 |
89078 |
123587 |
8719059 |