Clean Up Benefits Results
If the claim line has been processed before, the old results may need to be discarded before a new calculation takes place.
Claims lines that are processed a second time still have (old) calculation results attached. This step cleans up the results of claim lines that are to be recalculated. The Locked and Keep Benefits indicators allow for specific lines to be excluded from recalculation.
Lines that have been replaced, for example through a replacement rule or the claim update integration point, are ignored when selecting and calculating benefits. These lines are included in the 'clean up benefits results' step, because the lines might not have been replaced in the previous adjudication, and therefore might still have old benefit calculation results attached.
The clean up benefits results flow is schematically depicted by the following figure.
Level 3: Clean Up Benefits Results
The first step is to remove any preliminary consumption on the claim header. This is preliminary consumption that originally belonged to a deleted claim line.
The next step is to check per line whether that line’s benefit results remain untouched or whether they are going to be recalculated. A line is recalculated if the Locked indicator and the Keep Benefits indicator on the claim line are unchecked.
Lines That are Not Re-Calculated
The benefits results on non-replaced claim lines with a checked Locked and/or Keep Benefits indicator are kept. If only final consumption exists, it needs to be copied, for full detail see Consumption.
Lines That are Re-Calculated
For each claim line, the results from an earlier benefits calculation are removed:
-
Claim, bill and claim line benefits messages (that is, messages with origin BENEFITS or COVERAGE)
-
Note that claim and bill messages are only removed if at least one non-replaced and non-locked claim line has an unchecked 'Keep Benefits' indicator
-
-
The covered amount (including the currency) of the claim line is cleared (set to null)
-
The covered number of units of the claim line is cleared (set to null)
-
The coverages attached to the claim line are removed
-
The claim line benefit specifications attached to the claim line are removed
-
The indicator "Manual benefits applied" on the claim line is unchecked
-
The preliminary authorization consumptions are removed[1]
-
The related authorization counter periods are also removed if no non-reversed consumptions remain under the periods (how consumptions count towards counter periods is described in "Authorizations" chapter of the Operations Guide); the related authorization counters are also removed if no consumptions remain at all under those counters
-
-
The preliminary regime consumptions are removed[1]
-
The related regime counters are also removed if no consumptions exist any more under those counters
-
-
The preliminary limit consumptions are removed[1]
-
The related limit counter periods are also removed if no non-reversed consumptions remain under the periods (how consumptions count towards counter periods is described in the "Adjudication Limits" page of the Benefit Rules chapter of the Configuration Guide); the related limit counters are also removed if no consumptions remain at all under those counters.
-
For each claim line, cases from an earlier benefits calculation are reset:
-
If the claim line was a primary line, the case detail is removed. Note that when a adjudication case detail is deleted, the case is also removed if no case details exist any more under that case.
-
If the claim line was an ancillary line, the case detail is removed. Note that when a adjudication case detail is deleted, the case is also removed if no case details exist any more under that case.
-
If another case was closed due to the creation of the case, the end date of the other case is reset.
Consider the following scenarios to clarify the implication of the last bullet.
| Scenario | Result |
|---|---|
The claim line has ended the other case on 31-12-2010. The end date of the other case was previously empty. |
Reset the end date to null |
The claim line has ended the other case on 31-12-2010. The end date of the other case was previously 31-12-2011. |
Reset the end date to 31-12-2011 |
The claim line has ended the other case on 31-12-2010. The end date of the other case was previously empty but another claim lines has set the end date to 31-12-2009 in the mean time. |
End date remains 31-12-2009 |