Claim with 2 Adjustments
This use case shows the financial transactions and the financial messages that would be created for an invoiced claim that is adjusted twice. The first adjustment increases the amount to be paid and the second reduces it. Each adjustment is done after the previous version has already been included in a financial message.
Summary:
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Version 1
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Financial message includes;
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an invoice to fully pay the covered amount of the claim
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accounting details for all coverages of the claim
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-
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Version 2
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Financial message includes;
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an invoice to pay the difference between version 1 and 2 of the claim
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accounting details to fully reverse all coverages of version 1 of the claim
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accounting details for all coverages of version 2 of the claim
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-
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Version 3
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Financial message includes;
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an invoice (credit memo) to retract the difference between version 2 and 3 of the claim
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accounting details to fully reverse all coverages of version 2 of the claim
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accounting details for all coverages of version 3 of the claim
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Adjudicate Claim
Finalize (First Time)
The claim is finalized for the first time on 12 March 2014. The following are created at the same time:
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First version claim transaction
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A financial transaction with a Base Financial Object
Claim Transaction
Financial Transaction
The financial transaction has the following details:
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 |
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:
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The message is just for the claim (because Financial Message Bulking Group is set to the claim code)
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It will have a single invoice
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It will have a separate invoice line for each financial transaction detail that has its invoice indicator set
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It will have a separate accounting detail for each of the financial transaction detail
Financial Message
The contents of the various parts of the financial message are as follows:
Financial Message - Invoice
ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
---|---|---|---|---|---|
89070 |
Standard |
789AB |
110.00 |
CL123 |
1 |
Financial Message - Invoice Line
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 |
1 |
ITEM |
50 |
CL123 |
1 |
N |
1 |
123573 |
2 |
ITEM |
60 |
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 |
50 |
CL123 |
1 |
N |
1 |
COVERED |
8719049 |
32423432 |
14-Mar-2014 |
25 |
CL123 |
1 |
N |
1 |
COPAY |
8719050 |
32423432 |
14-Mar-2014 |
60 |
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 |
8719049 |
|||
CL123 |
1 |
2 |
89070 |
123573 |
8719050 |
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:
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Version 1 of the CTR Claim (transaction) is labeled as unfinalized
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A reversal CTR Claim (transaction) for version 1 is created with the allowed and covered amounts reversed
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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 in a change to the copay for line 1. It now has the following details in Claims:
- Claim 123
Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
---|---|---|---|---|
123 |
456 |
789AB |
135.00 |
125.00 |
- Claim Line ⇒ Coverages
Sequence | Payment Receiver | Claimed Amount | ⇒ | Action | Amount | Label |
---|---|---|---|---|---|---|
1 |
789AB |
75.00 |
Covered |
50.00 65.00 |
Covered |
|
Withhold |
25.00 10.00 |
Copay |
||||
2 |
789AB |
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:
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A second version claim transaction
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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 |
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 | ⇒ | Action | Label | Amount |
---|---|---|---|---|---|---|---|---|
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CL123 |
Y |
1 |
1 |
-75.00 |
Covered |
Covered |
-50.00 |
|
Withhold |
Copay |
-25.00 |
||||||
2 |
-60.00 |
Covered |
Covered |
-60.00 |
||||
CL123 |
N |
2 |
1 |
75.00 |
Covered |
Covered |
65.00 |
|
Withhold |
Copay |
10.00 |
||||||
2 |
60.00 |
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 |
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 |
---|---|---|---|---|---|---|---|---|---|---|
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1 |
Y |
1 |
Covered |
-50.00 |
Y |
N |
N |
789AB |
||
Copay |
-25.00 |
N |
N |
N |
||||||
2 |
Covered |
-60.00 |
Y |
N |
N |
789AB |
||||
2 |
N |
1 |
Covered |
65.00 |
Y |
N |
N |
789AB |
||
Copay |
10.00 |
N |
N |
N |
||||||
2 |
Covered |
60.00 |
Y |
N |
N |
789AB |
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:
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An invoice with a delta amount calculating the difference between the current and previous financial transaction
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Both the financial transaction details of the current version, and the financial details of the reversal details are included in the 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 Criteria |
---|---|---|
132732 |
22-Mar-2014 |
CL123 |
- Financial Message - Invoice
ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
---|---|---|---|---|---|
89171 |
Standard |
789AB |
15.00 |
CL123 |
2 |
- Financial Message - Invoice Line
ID | Line Number | Line Type | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal) | Attribute 4 (CTR Claim Line Code) |
---|---|---|---|---|---|---|---|
123574 |
1 |
ITEM |
-50 |
CL123 |
1 |
Y |
1 |
123575 |
2 |
ITEM |
-60 |
CL123 |
1 |
Y |
2 |
123676 |
1 |
ITEM |
65 |
CL123 |
2 |
N |
1 |
123677 |
2 |
ITEM |
60 |
CL123 |
2 |
N |
2 |
- Financial Message - Accounting Detail
ID | Ledger ID | Accounting Date | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
---|---|---|---|---|---|---|---|---|
8719051 |
32423432 |
22-Mar-2014 |
-50 |
CL123 |
1 |
Y |
1 |
COVERED |
8719052 |
32423432 |
22-Mar-2014 |
-25 |
CL123 |
1 |
Y |
1 |
COPAY |
8719053 |
32423432 |
22-Mar-2014 |
-60 |
CL123 |
1 |
Y |
2 |
COVERED |
8719154 |
32423432 |
22-Mar-2014 |
65 |
CL123 |
2 |
N |
1 |
COVERED |
8719155 |
32423432 |
22-Mar-2014 |
10 |
CL123 |
2 |
N |
1 |
WITHHOLD |
8719156 |
32423432 |
22-Mar-2014 |
60 |
CL123 |
2 |
N |
2 |
COVERED |
Financial Transaction Process Data
In addition, the following financial transaction process data columns is set.
Claim Transaction Code | Version Code | Reversal | ⇒ | Financial Message Datetime | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|
|
|
N |
|
|
|
|
CL123 |
1 |
Y |
22-Mar-2014 |
132732 |
M |
|
CL123 |
2 |
N |
22-Mar-2014 |
132732 |
M |
Financial Transaction Detail Process Data
The following financial message transaction detail process data columns are set.
Claim Transaction Code | Reversal | Version Code | Claim Line Transaction | ⇒ | Invoice ID | Invoice Line ID | Accounting Detail ID |
---|---|---|---|---|---|---|---|
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|
CL123 |
Y |
1 |
1 |
89171 |
123674 |
8719151 |
|
CL123 |
Y |
1 |
1 |
8719152 |
|||
CL123 |
Y |
1 |
2 |
89171 |
123675 |
8719153 |
|
CL123 |
N |
2 |
1 |
89171 |
123676 |
8719154 |
|
CL123 |
N |
2 |
1 |
8719155 |
|||
CL123 |
N |
2 |
2 |
89171 |
123677 |
8719156 |
Unfinalize Claim
The claim is unfinalized on the 25th of March 2014. This results in a the version 2 claim transaction being labeled as unfinalized. The following records are created:
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A reversal CTR claim transaction, with the allowed and covered amount reversed
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A reversal financial transaction, with allowed and covered amounts reversed, associated with the base financial object created earlier
These reversals are shown below.
Adjust Claim
The claim is unfinalized on 25 march 2014. The claim is adjusted resulting in a $20 coinsurance for claim line two. The working copy claim now has the following details:
Working Copy Claim
Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
---|---|---|---|---|
CL123 |
456 |
789AB |
135.00 |
105.00 |
Claim Line -→ Coverages
Sequence | Payment Receiver | Allowed Amount | Action | Amount | Label |
---|---|---|---|---|---|
1 |
789AB |
75.00 |
Covered |
65.00 |
Covered |
Withhold |
10.00 |
Copay |
|||
2 |
789AB |
60.00 |
Covered |
60.00 |
Covered |
Withhold |
20.00 |
Coinsurance |
Finalize (Third Time)
The claim is finalized for the third time on 27 March 2014, creating a third claim transaction:
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A third version claim transaction
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A third version financial transaction
CTR Claim Transaction
- Claim Transaction
Claim Transaction Code | Version | Transaction Date | Person Code | Provider Code | Total Allowed Amount | Total Covered Amount | Reversal Indicator |
---|---|---|---|---|---|---|---|
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|
CL123 |
3 |
27-Mar-2014 |
456 |
789AB |
135.00 |
105.00 |
N |
- Claim Line Transaction ⇒ Coverages
Claim Transaction Code | Reversal Indicator | Version | Claim Line Transaction Code | Allowed Amount | ⇒ | Action | Label | Amount |
---|---|---|---|---|---|---|---|---|
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CL123 |
Y |
2 |
1 |
-75.00 |
Covered |
Covered |
-65.00 |
|
Withhold |
Copay |
-10.00 |
||||||
2 |
-60.00 |
Covered |
Covered |
-60.00 |
||||
CL123 |
N |
3 |
1 |
75.00 |
Covered |
Covered |
65.00 |
|
Withhold |
Copay |
10.00 |
||||||
2 |
60.00 |
Covered |
Covered |
40.00 |
||||
Withhold |
Coinsurance |
20.00 |
Financial transaction
The financial transaction which is created is associated with the base financial object that was created for claim transaction version 1. The following financial transaction is created.
- Financial Transaction and Financial Transaction Detail 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 |
---|---|---|---|---|---|---|---|---|---|---|
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2 |
Regular |
Y |
24-Mar-2014 |
-$125.00 |
25-Mar-2014 |
N |
CL123 |
NULL |
NULL |
|
3 |
Regular |
N |
25-Mar-2014 |
$105.00 |
25-Mar-2014 |
N |
CL123 |
NULL |
NULL |
- Financial Transaction Detail and Financial Transaction Process Data
Version | Reversal? | Claim Line Code | Component Code | Amount | ⇒ | Invoice Indicator | Invoice Line Grouping | Accounting Detail Grouping | Payment Receiver | |
---|---|---|---|---|---|---|---|---|---|---|
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3 |
N |
1 |
Covered |
65.00 |
Y |
N |
N |
789AB |
||
Copay |
10.00 |
N |
N |
N |
||||||
2 |
Covered |
40.00 |
Y |
N |
N |
789AB |
||||
Coinsurance |
20.00 |
N |
N |
N |
Create Financial Messages
The financial messages are created on 29-Mar-2014. The claim has not been unfinalized. A financial message will be created with the following details:
-
An invoice with a negative calculated delta amount displaying the difference between the current and previous financial transaction
Financial Message
Financial Message - Invoice
ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
---|---|---|---|---|---|
89271 |
Standard |
789AB |
-20.00 |
CL123 |
3 |
Financial Message - Invoice Line
ID | Line Number | Line Type | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal) | Attribute 4 (CTR Claim Line Code) |
---|---|---|---|---|---|---|---|
123772 |
1 |
ITEM |
-65 |
CL123 |
2 |
Y |
1 |
123773 |
2 |
ITEM |
-60 |
CL123 |
2 |
Y |
2 |
123774 |
1 |
ITEM |
65 |
CL123 |
3 |
N |
1 |
123775 |
2 |
ITEM |
40 |
CL123 |
3 |
N |
2 |
Financial Message - Accounting Detail
ID | Ledger ID | Accounting Date | Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) | Attribute 3 (Reversal) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
---|---|---|---|---|---|---|---|---|
8719261 |
32423432 |
29-Mar-2014 |
-65 |
CL123 |
2 |
Y |
1 |
COVERED |
8719262 |
32423432 |
29-Mar-2014 |
-25 |
CL123 |
2 |
Y |
1 |
COPAY |
8719263 |
32423432 |
29-Mar-2014 |
-60 |
CL123 |
2 |
Y |
2 |
COVERED |
8719264 |
32423432 |
29-Mar-2014 |
65 |
CL123 |
3 |
N |
1 |
COVERED |
8719265 |
32423432 |
29-Mar-2014 |
25 |
CL123 |
3 |
N |
1 |
COPAY |
8719266 |
32423432 |
29-Mar-2014 |
40 |
CL123 |
3 |
N |
2 |
COVERED |
8719267 |
32423432 |
29-Mar-2014 |
20 |
CL123 |
3 |
N |
2 |
COINSURANCE |
Financial Transaction Process Data
In addition, the following financial transaction processdata columns are set.
Claim Transaction Code | Version Code | Reversal | ⇒ | Financial Message Datetime | Financial Message ID | Financial Message Result |
---|---|---|---|---|---|---|
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|
CL123 |
2 |
Y |
29-Mar-2014 |
132932 |
M |
|
CL123 |
3 |
N |
29-Mar-2014 |
132932 |
M |
Financial Transaction Detail Process Data
The following financial message transaction detail process data columns are set.
Claim Transaction Code | Reversal | Version Code | Claim Line Transaction | Component Code | ⇒ | Invoice ID | Invoice Line ID | Accounting Detail ID |
---|---|---|---|---|---|---|---|---|
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CL123 |
Y |
2 |
1 |
89271 |
123772 |
8719261 |
||
CL123 |
Y |
2 |
1 |
8719262 |
||||
CL123 |
Y |
2 |
2 |
89271 |
123773 |
8719263 |
||
CL123 |
N |
3 |
1 |
89271 |
123774 |
8719264 |
||
CL123 |
N |
3 |
2 |
8719265 |
||||
CL123 |
N |
3 |
1 |
89271 |
123775 |
8719266 |