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 |