Change Claim

This page is used to edit existing claims that have the status 'change'. The retrieval and display of data in this page is subject to restrictions described in the "User Access" chapter of the Security Guide.

This page can be accessed through the Claims Search Result page on one of the search results. This will open an instance of this page in a dynamic tab for that particular claim.

Display and Specifics

Changing Claims

While changing a claim, field values are not checked for time validity as of the service date. These validations are executed during processing, not while changing the claim.

The Type field on the claim is mandatory and is editable when changing a claim that is in the CHANGE status.

The following claim line fields are mandatory:

claimLine.claimedNumberOfUnits (Qty)
claimLine.startDate (Start Date)
claimLine.sequence (Seq)

The following fields are set by Claims and can never be edited directly:

claim.manual (Manual?)
claim.totalClaimedAmount.amount and claim.totalClaimedAmount.currencyCode (Total Charged)
claim.totalAllowedAmount.amount and claim.totalAllowedAmount.currencyCode (Total Allowed)
claim.totalCoveredAmount.amount and claim.totalCoveredAmount.currencyCode (Total Covered)
claim.classificationScheme (Classification Scheme)
claim.classification (Classification)
claimLine.classification (Classification)
claimLine.classificationAuthorization (Classification Auth)
claimLine.status (Status)
claimLine.coveredAmount.amount and claimLine.coveredAmount.currencyCode (Covered)
claimLine.coveredNumberOfUnits (Covered #)
claimLine.code (Code)
claimLine.manualPricing (Manual Pricing?)
claimLine.manualBenefits (Manual Benefits?)

Claim lines that are replaced are visible (grayed out), but cannot be removed/updated. This section has a button "undo line replacements". Clicking this button will prompt the following message to be shown above the claim code: "GEN-UINT-016: The replaced claim lines have been restored, press save to commit the changes". If the user clicks Save, then

all claim lines that replace another claim line(s) are removed
all messages with a skip tag are removed
all allowed amount skip tags on claim lines are removed
all non-replaced claim lines that have a skip tag are removed
all replaced claim lines are restored and their skip tags are removed
the contents section 2, 3 and 4 are refreshed.

Messages and Pend Reasons

The user can attach a single message to multiple claim lines at once. First the user selects the claim lines to which the message needs to be attached - using the claim line selection check box - and clicks the 'Add Message' button. This opens the list of available messages. Messages that are system specific are not shown in the list. The user picks one of the messages from the list and clicks 'Ok'. The message is now attached to all selected lines.

The user can also delete one or more messages from multiple claim lines at once. First the user selects the claim lines from which the message is to be removed and clicks the 'Delete Message(s)' button. This opens the distinct list of messages that are currently attached to at least one of the selected lines. Messages that are system specific are not shown in the list. The user picks one of the messages from the list and clicks 'Ok'. The message is now removed from all of the selected lines to which it was attached.

It is also possible to attach and remove messages to and from lines through the claim line messages detail dialog. The user is free to add or remove any message, with the exception of System specific messages. System specific messages are system messages that cannot be ignored.

The user can resolve one or more pend reasons from multiple claim lines at once. First the user selects the lines on which the pend reason(s) need(s) to be resolved and clicks the 'Resolve Pend(s)' button. This opens the distinct list of pend reasons that are currently attached to at least one of the selected lines. The user can resolve one or more of these and click OK. The selected pend reasons are now resolved on all of the selected lines to which they are attached.

Displaying and Updating Non-Matched Fields

A field is considered non-matched when the claims in integration point failed to map a reference in the message unto the referential data table in Claims. For example, when no relation record matching the serviced person provided in the claims in message can be found.

By definition, non-matched fields can only be look-up fields. Look up fields generally consist of two parts: a key field (editable) and a description/name field (display only). For non-matched fields no key value is displayed. The description field displays information as specified on the canonical claims in message. The information displayed depends on the field:

For relations and providers, the non-matched formatted name is displayed.
For any other field, the non-matched code is displayed.

When a user opens op a look-up table (LOV) for a non-matched field that represents a relation or a provider, a LOV dialog with an appended header section will open. This header section displays the information that was sent in on the claims in message for that particular relation/provider, with the purpose of aiding the user in selecting the correct relation/provider record in the LOV.

Because modifiers are displayed (and updateable) through a multi value list rather than a LOV, non-matched modifiers are corrected through a detail summary specifically for unmatched modifiers.

Note that non-matched fields are cleaned up once a match has been made.

Process Fields

In case of non-matched process fields, the non-matched code will be shown, followed by the boilerplate text "(not matched)". Non-matched process fields cannot be manually matched as these fields are read-only.

Replaced and Replacing Claim Lines

Claim lines that are replaced cannot be edited or deleted. When a claim line is replaced, section 4 displays an explanatory text that refers to the claim lines that replace that line,for example, 'this line is replaced by line 1 and 2'.

Claim lines that replace other lines display as normal. They can be edited, but not deleted: removing a replacing line can only be accomplished by undoing all (un)bundling for the whole claim. When a claim line is a replacement line, section 4 displays an explanatory text that refers to the claim lines that it replaces,for example, 'this line is replaces line 4 and 5'.

It is not possible to bundle (many replaced by one) or unbundle (one replaced by many) through this page (nor any other page). It is possible to undo all bundling/unbundling for an entire claim (by means of a button on the page). This has the effect that all replacement lines are discarded and all replaced lines are restored as 'normal' claim lines. This is accomplished by clicking the button Undo (Redo) Claim Line Replacements.

Locked Claim Lines

Locked claim lines (including all details except claim line pend reasons and informative claim line messages of origins External and Manual) cannot be edited or deleted. Locked lines can be unlocked by selecting them in the claim lines section and clicking on the Unlock Line(s) button. After clicking on the button a warning dialog is displayed, where the user has to confirm that he/she wants to unlock the selected claim lines. After confirming, the selected claim lines are unlocked and they become editable. The statuses on the unlocked claim lines are cleared.

The Unlock Line(s) button is only displayed for users that have an access restriction (with read and update grants) of type 'Claim Line Unlocking'. Refer to the "User Access" chapter of the Security Guide for more information.

Attributes on Multiple Levels

The following fields can be specified on either the claim or claim line:

serviced person or object
service provider
location
referral provider
diagnoses
service specialties
authorization code
emergency indicator
payment receiver
location type

The following logic applies:

If the claim line field is unspecified, then it shows the value of its counterpart on the claim header level. If this field is also empty, no value is shown.
If the claim line field is specified, then that value is shown.

Note that the above logic does not apply to non-matched values; only matched values are inherited from higher levels to lower levels.

In context of these rules, the list of diagnosis codes is treated as a single field value. In other words, the user interface will not merge the set of diagnoses on the claim header with the diagnoses on the claim line; if the line specifies a list of diagnoses, those are the diagnoses shown for that line; if the line does not specify diagnoses, then the list on the claim header is shown for that line. Note that the display of the diagnoses values extends to the dynamic field values that may be specified on the intersection entities: claim diagnosis and claim line diagnoses.

Because the emergency indicator can never be unspecified (it is either true or false) the value 'false' is treated as unspecified. This means that a line shows the value true when the claim header has the value true.

The Claim Lines section has the following additional display-only column which is only displayed if the claim has the status CHANGE:

Display label	Entity, Field
Pend Reason	Displays the claimLine.claimLinePendReason.code with the lowest value for claimLinePendReason.priority If the lowest priority value is shared by more than one claimLinePendReason, show the claimLinePendReason that comes first based on alphabetical sort on the pend reason code.

Display label

Entity, Field

Pend Reason

Displays the claimLine.claimLinePendReason.code with the lowest value for claimLinePendReason.priority

If the lowest priority value is shared by more than one claimLinePendReason, show the claimLinePendReason that comes first based on alphabetical sort on the pend reason code.

Page Specific Rules

Only claims that have the status 'change' can be accessed through this page.
The following claim fields are updated accordingly, upon saving changes:
- Total Claimed (Charged) Amount
  - This field is set to the sum of the claimLine.claimedAmounts (only non-replaced claim lines) as long as all the currencies of the claim line claimed amounts are equal; the currency for the total claimed amount is set as well
  - If the currencies are not equal the field is not set; if it was already set it is nullified (including the currency)
- Total Allowed Amount
  - This field is set to the sum of the claimLine.allowedAmounts (only non-replaced claim lines) as long as all the currencies of the claim line allowed amounts are equal; the currency for the total allowed amount is set as well
  - If the currencies are not equal the field is not set; if it was already set it is nullified (including the currency)
- Start Date
- End Date
The message field in a claim message or claim line message can only be updated if no message is specified (that is, if the message is non-matched).
The diagnosis code field in a claim diagnosis or claim line diagnosis can only be updated if no diagnosis is specified (if the diagnosis is non-matched).
The specified modifier field in a claim line modifier can only be updated if no modifier is specified (if the modifier is non-matched).
The user is allowed to add informative and fatal messages with the exception of system specific messages. Added messages are attached as MANUAL messages.
The user is allowed to delete informative and fatal messages with the exception of system specific messages, and messages that display only because they are actually attached to the claim header
When doing a cascade delete from a higher level (when deleting a claim line or claim), all claim line messages are deleted, regardless the origin.

Updating Allowed Amount or Allowed Number of Units

When updating the allowed amount and/or the allowed number of units for both claim and reservation, the new values will normally be no longer in sync with the provider limit consumptions.

For amounts, this typically happens in a situation where the allowed amount and/or allowed number of units are determined by an external party, but the callouts need to be done internally.

This functionality is similar to changing the allowed amount and/or allowed number of units in the Manual Pricing page, but then restricted to the effects on the claim line at hand. It is identical to changing the allowed amount and/or allowed number of units through the Claims Update IP.

For each line on which at least one of allowed amount and allowed number of units was edited:

Check both the keep pricing and manual pricing indicators
Uncheck the keep benefits indicator
Remove all claim line messages that originated from provider limits (origin PRICING LIMIT)
Recalculate the provider limit consumptions of the claim line based on the edited allowed amount and/or allowed number of units:
- It is possible that existing provider limit consumption has to be updated
- It is possible that existing provider limit consumption (plus counter period/counter) has to be deleted
- It is possible that new provider limit consumption (plus counter period/counter) has to be created
Reevaluate and create new provider limit category messages and/or reservation regime messages

Note that the currency of an existing allowed amount cannot be changed.

Updating Expires On

When expiration date on the reservation claim is updated, the expiration date on the provider limit consumptions of all the claim lines that are not locked is updated to the new date.

Updating Price Principal Procedure Indicators

Price principal procedure indicators will typically be set either through Claims In or through the process field derivation rule. It is, however, also possible to update one or more of these indicators through either the UI or the Claims Update IP; the functionality of these updates is analogous.

The layout of the price principal procedure indicators for example, the View Claims page is described in the Local Area. But where in all other pages only information is shown, can in the Change page updates take place on the price principal procedure indicators.

If one or more of the price principal procedure indicators is changed, then after the change is saved the indicator to keep principal procedures is set to Y and a clickable hyperlink 'Release Override' will appear (instead of the label 'Override' in the other pages). This has the effect that the process field derivation rule for the price principal procedure indicators is skipped.

If that link is clicked (possibly in combination with other updates), then after the change is saved the indicator to keep principal procedures is set to N and the hyperlink 'Release Override' will disappear. This has the effect that the process field derivation rule for the price principal procedure indicators is not skipped.

Header Buttons

The following buttons display on the top right of the page:

Field	Remark
Refresh (icon)	Forces a re-query of the displayed claim. Used to track a claims status progress real time.
Delete (icon)	Deletes the claim. User is asked for confirmation with a dialog box. Confirmation will commit the delete. Claims for which a claims transaction exists cannot be deleted. This is a cascade delete of all entities referring to this claim.
Submit (button)	Performs all steps of the save button. Sets the 'Pricing Done' indicator to 'No' and saves the claim in the 'Initial' status, that is, the claim can no longer be altered and will be picked up for processing. It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop-up message. The Change Claim dynamic tab is closed and a new View Claim dynamic tab opens for the same claim. In case the claim has outstanding pend reasons, it may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.
Benefits Only (button)	Performs all steps of the save button. Sets the 'Preprocessing Done' indicator and 'Pricing Done' indicator to 'Yes' and saves the claim in the 'Initial' status, that is, the claim can no longer be altered and will be picked up for processing. It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop-up message. The Change Claim dynamic tab is closed and a new View Claim dynamic tab opens for the same claim. In case the claim has outstanding pend reasons, it may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.
Save (button)	Saves the claim without changing the status, and performs the steps described under 'Updating allowed amount and/or allowed number of units' and 'Updating price principal procedure indicators' above.
Cancel (button)	Discards any unsaved changes and re queries the claim.

Field

Remark

Refresh

(icon)

Forces a re-query of the displayed claim. Used to track a claims status progress real time.

Delete

(icon)

Deletes the claim. User is asked for confirmation with a dialog box. Confirmation will commit the delete. Claims for which a claims transaction exists cannot be deleted.

This is a cascade delete of all entities referring to this claim.

Submit

(button)

Performs all steps of the save button. Sets the 'Pricing Done' indicator to 'No' and saves the claim in the 'Initial' status, that is, the claim can no longer be altered and will be picked up for processing.

It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop-up message.

The Change Claim dynamic tab is closed and a new View Claim dynamic tab opens for the same claim.

In case the claim has outstanding pend reasons, it may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.

Benefits Only

(button)

Performs all steps of the save button. Sets the 'Preprocessing Done' indicator and 'Pricing Done' indicator to 'Yes' and saves the claim in the 'Initial' status, that is, the claim can no longer be altered and will be picked up for processing.

It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop-up message.

The Change Claim dynamic tab is closed and a new View Claim dynamic tab opens for the same claim.

In case the claim has outstanding pend reasons, it may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.

Save

(button)

Saves the claim without changing the status, and performs the steps described under 'Updating allowed amount and/or allowed number of units' and 'Updating price principal procedure indicators' above.

Cancel

(button)

Discards any unsaved changes and re queries the claim.