Mixed Claim

This scenario shows the financial transactions and the financial messages that would be created for a claim that includes lines that:

  • are approved and invoiced,

  • are approved and not invoiced, (for example, an encounter line)

  • are denied, and

  • have only all withhold coverages

Summary

  • Version 1

    • Financial message includes;

      • an invoice to pay the covered line that is not an encounter

      • accounting details for all coverages of the claim (regardless of encounter indicator)

Version 1

Adjudicate Claim

The claim is adjudicated resulting in the following details in Claims

  • $25 Copay on Claim line 1

  • $60 Covered on Claim line 2. This claim line is marked as an encounter claim

  • Claim line 3 is denied

  • $100 Deductible on Claim line 4

    Working Copy Claim

Code

Person Code

Provider Code

Total Claimed Amount

Total Covered Amount

CL987

456

789AB

280.00

110.00
Working Copy Claim Lines ⇒ Claim Line Coverages
Sequence Payment Receiver Allowed Amount Encounter Status ⇒ Action Amount Label

1

789AB

75.00

N

Approved

Covered

50.00

Covered

Withhold

25.00

Copay

2

789AB

60.00

Y

Approved

Covered

60.00

Covered

3

789AB

45.00

N

Denied

4

789AB

100.00

N

Approved

Withhold

100.00

Deductible

Finalize (First Time)

The claim is finalized for the first time on 12 March 2014. The following are created at the same time:

  • First version claim transaction

  • A financial transaction with a Base Financial Object

  • Financial transaction details for claim line 1, 2 and 4

Claim Transaction

The claim transaction has the following details.

CTR Claim
Claim Transaction Code Version Transaction Date Person Code Provider Code Total Allowed Amount Total Covered Amount Reversal Ind

CL987

1

12-MAR-2014

456

789AB

280.00

110.00

N
CTR Claim Line ⇒ Coverages
Claim Transaction Code Reversal Ind Version Claim Line Transaction Code Allowed Amount ⇒ Action Label Amount

CL987

N

1

1

75.00

Covered

Covered

50.00

Withhold

Copay

25.00

2

60.00

Covered

Covered

60.00

3

45.00

4

100.00

Withhold

Deductible

100.00

Financial Transaction

The financial transaction has the following details:

Base Financial Object
Type Claim code Status

CLA

CL987

IN
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

CL987

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

1

N

1

Covered

50.00

Y

N

N

789AB

Copay

25.00

N

N

N

2

Covered

60.00

N

N

N

789AB

4

Deductible

110.00

N

N

N

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:

  • The message is just for the claim (because Financial Message Bulking Group is set to the claim code)

  • It will have a single invoice

  • It will have a separate invoice line for each financial transaction detail that has its invoice indicator set

  • It will have a separate accounting detail for each of the financial transaction details

Financial Message

The contents of the various parts of the financial message are as follows:

Financial Message
Job ID Message Date Message Bulking Group

132432

14-Mar-2014

CL987
Financial Message - Invoice
ID Invoice Type Vendor Num Invoice Amount Attribute 1 (CTR Claim Code) Attribute 2 (CTR Version)

89070

Standard

789AB

50.00

CL987

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

CL987

1

N

1
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

CL987

1

N

1

COVERED

8719049

32423432

14-Mar-2014

25

CL987

1

N

1

COPAY

8719050

32423432

14-Mar-2014

60

CL987

1

N

2

COVERED

8719051

32423432

14-Mar-2014

100

CL987

1

N

4

DEDUCTIBLE

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

CL987

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

CL987

1

1

89070

123572

8719048

CL987

1

1

8719049

CL987

1

2

8719050

CL987

1

4

8719051