Claim Event Rules

From the first time that a claim enters the system up to and including the finalization, the claim goes through a process flow consisting of many steps. The claim status field defines the place in the flow the claim is currently in. It might be of interest to external systems or users to know that a certain claim reaches a certain status in the claims flow. By defining claim event rules, the claim event integration point can be triggered to publish claim events.

This document describes the structure of rules that are used to publish events to external consumers. Essentially an event rule represents a condition. If the claim or claim line meets that condition, then the integration point sends out a claim event message.

Concepts

Claim event rules define when the claim event integration point publishes a message. The following table describes claim event rules:

Claim Event Rule

Field	Description	Mandatory
Code	Identifying code.	yes
Level	The level at which the rule is executed (CLAIM, CLAIMWITHLINES, CLAIMLINE)	yes
Topic	Topic to be sent in the published message. Used to group related events together.	yes
Event	Event to be sent in the published message.	yes
Status	Status that triggers the sending of the message.	no
Claim Type	If defined, a message is published only for claims with matching claim type.	no
Message Group	For CLAIM level rules an event message is published for claims that have a message of this message group attached directly. For CLAIMWITHLINES and CLAIMLINE level rules an event message is published for claim lines that have a message of this message group attached.	no
Claim Line Procedure Group	If defined, a message is published only for claim lines that have a procedure that is, on the start date of the claim line, part of this procedure group. A procedure group can only be set for rules of the level CLAIMWITHLINES and CLAIMLINE.	no
Claim Line Procedure Group 2	If defined, a message is published only for claim lines that have a procedure that is, on the start date of the claim line, part of this procedure group. A procedure group can only be set for rules of the level CLAIMWITHLINES and CLAIMLINE.	no
Claim Line Procedure Group 3	If defined, a message is published only for claim lines that have a procedure that is, on the start date of the claim line, part of this procedure group. A procedure group can only be set for rules of the level CLAIMWITHLINES and CLAIMLINE.	no
Dynamic Logic Condition	If defined, a message is published only when the dynamic logic condition evaluates to true. For CLAIM level rules the input object that is passed to the dynamic logic is a Claim For rules of the level CLAIMLINE or CLAIMWITHLINES the input object that is passed to the dynamic logic is a ClaimLine.	no
Dynamic Logic Function (Claim Fields)	If defined, this dynamic function produces a list of name value pairs that are included in the claim event in the <fields> element at the claim level	no
Dynamic Logic Function (Claim Line Fields)	If defined, this dynamic function produces a list of name value pairs that are included in the claim event in the <fields> element at the claim line level. Therefore, it has no impact for level 'CLAIM'.	no
Reraise event indicator?	Should the claim event rule also fire a second time (this can only be prevented if the claim event history is logged)	yes
Display in UI indicator	Should the claim events fired by this rule be shown in the UI? Note that this requires that events are logged in the first place, so it has no meaning if the log event indicator is set to No.	yes
Enabled indicator?	This claim event rule is only executed when this box is checked	yes

A claim must match all criteria defined in the claim event rule, in order for the claim event integration point to send out an event. E.g., if both a procedure group and message group are specified, the claim lines needs to have both a procedure and a message in those respective groups.

The dynamic logic condition can be used for all situations that cannot be handled with the fixed criteria of a claim event rule. The claim or claim line object is passed to the dynamic logic, depending on the level.

Claim event rule claim forms allow a user to configure different rules for different claim forms. If specified, the claim’s form must match one of the specified forms. If no claim even rule form is specified, then the rule applies to any form.

Claim Event Rule Claim Form

Field	Description	Mandatory
Claim Event Rule	Identifier for this claim event rule.	yes
Claim Form	The claim form the claim event rule applies to	yes

Level of Execution

This field has one of three possible values.

CLAIM level rules are executed once per claim. A claim that meets the configured conditions will cause a single claim event to be sent out for that claim.

Likewise, CLAIM LINE level rules are executed per claim line. A line that meets the configured conditions will cause a single event to be sent out per line, which could mean multiple per claim. Note that locked claim lines and replaced claim lines are ignored.

CLAIMWITHLINES level rules are executed per claim line. If at least one of the lines in the claim meets the configured conditions, a single event is sent out for that claim. Note that locked claim lines and replaced claim lines are ignored.