Introduction

Claims is an enterprise strength healthcare payer back office application. It is designed as a component and holds only limited information and relies on integration with contingent systems to retrieve the information it needs to adjudicate healthcare claims.

The calculation that determines the amount for which the payer is liable depends on two contracts.

• The first is between the payer and the provider and specifies the height of the reimbursement for the health services that are performed by the provider. These are typically fee schedules that lists a large number of services and their corresponding prices.

• The second is between the payer and the member. This contract is the insurance Policy that the member has with the payer. The policy specifies for which costs the payer provides coverage and to what extend the member is liable. For example the policy may state that the member is liable for 10% of the incurred costs for a particular health care service.

Claims automates the execution of the second contract, that is, the one between the member and the payer. The footprint of the core functionality offered by this component is best described by the following sequence of steps:

• It takes repriced healthcare claims,

• It calculates the applicable coverage based on

  • The allowed amount on the claim

  • the member’s insurance and limit accumulation

  • the provider and his/her relation to the member’s insurance

• It produces a representation of the adjudicated claim

• and it produces a financial transaction that could possibly amount to a payable.

Claims adjudicates claims in real-time. New claim submissions are sent in through a standard integration point. As soon as the claim is accepted by the application it is picked up by the embedded calculation workflow. Once the claim is adjudicated and finalized, the application produces an event to notify downstream subscribers and stores a copy of the adjudicated claim, and a separate financial transaction in its internal repository. The down stream consuming systems can then retrieve a copy of the finalized claim and/or of the resulting financial message through a standard integration point.

Within the context of this document a Claim represents a reimbursement request for the incurred cost of a healthcare services rendered by a healthcare professional ( referred to as the provider) to an insured patient (referred to as the member). The receiver of the reimbursement is typically also the party that submitted the claim, and could be either the member or the provider. This reimbursement represents the amount for which the payer is liable and is referred to as the covered amount.