Multiple Payment Receivers with Adjustment

This use case shows the claim transactions, financial transactions and financial messages that would be created for a claim that includes covered amounts that need to be paid out to several payment receivers and is then adjusted resulting in:

  • previously paid payment receivers not receiving any amount

  • a new payment receiver, and

  • changes in amounts to existing payment receivers.

Although payment receiver is at line level, 'custom logic' is in place to split payments based on there being a value in the 'Insured Entity Amount' claim line dynamic field. One of the lines has a pay to insured entity amount and both covered and withhold amounts.

The adjustment is done after the first version has already been selected for payment.

Summary

  • Version 1

    • Financial message includes;

      • three invoices to pay the covered amount of the claim to each of the payment receivers

      • accounting details for all coverages of the claim

  • Version 2

    • Financial Message includes;

      • four invoices;

        • a credit memo to retrieve back the amount from payment receiver that was replaced

        • an invoice to fully pay the covered amount to the new payment receiver

        • an invoice to pay the copay difference between version 1 and 2 of the claim

        • an invoice with a $0 difference between version 1 and 2 of the claim

      • accounting details for all coverages of the claim

Version 1

Adjudicate Claim

The claim is adjudicated resulting in the following details in Oracle Health Insurance:

  • $25.00 Copay

  • $110.00 Coverage

    Working Copy Claim

Code

Person Code

Provider Code

Total Claimed Amount

Total Covered Amount

CL123

456

789AB

135.00

110.00
Working Copy Claim Lines
Sequence Payment Receiver Insured Entity Amount Allowed Amount Action Amount Label

1

789AB

15.00

75.00

Covered

50.00

Covered

Withhold

25.00

Copay

2

456EF

60.00

Covered

60.00

Covered

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

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

CL123

1

12-Mar-2014

456

789AB

135.00

110.00

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

CL123

N

1

1

75.00

789AB

Covered

Covered

35.00

REL456

Covered

Covered

15.00

Withhold

Copay

25.00

2

60.00

456EF

Covered

Covered

60.00

Financial Transaction

The financial transaction has the following details:

Base Financial Object
Type Claim code Status

CLA

CL123

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

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

1

N

1

Covered

35.00

Y

N

N

789AB

Covered

15.00

Y

N

N

REL456

Copay

25.00

N

N

N

2

Covered

60.00

Y

N

N

456EF

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 with the following details:

  • One invoice for every payment receiver

  • Separate invoice lines for each financial transaction detail that has its invoice indicator set, included in the invoice of the related payment receiver

  • Separate accounting details for each of the financial transaction detais

The message is just for the one claim (because Financial Message Bulking Group is set to the claim code). It will not include any reversal transaction because the previous version was not actually included in a 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 Group

132432

14-Mar-2014

CL123
Financial Message - Invoice ⇒ Invoice Lines
ID Invoice Type Vendor Num Invoice Amount Attribute 1 (CTR Claim Code) Attribute (CTR Version)

89070

Standard

789AB

35.00

CL123

1

89071

Standard

REL456

15.00

CL123

1

89072

Standard

456EF

60.00

CL123

1
Financial Message - Invoice Line
ID Invoice 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

89070

1

ITEM

35.00

CL123

1

N

1

123573

89071

1

ITEM

15.00

CL123

1

N

1

123574

89072

2

ITEM

60.00

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

35.00

CL123

1

N

1

COVERED

8719049

32423432

14-Mar-2014

15.00

CL123

1

N

1

COVERED

8719050

32423432

14-Mar-2014

25.00

CL123

1

N

1

COPAY

8719051

32423432

14-Mar-2014

60.00

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

89071

123573

8719049

CL123

1

1

8719050

CL123

1

2

89072

123574

8719051

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:

  • Version 1 of the CTR Claim (transaction) is labeled as unfinalized

  • A reversal CTR Claim (transaction) for version 1 is created with the allowed and covered amounts reversed

  • 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 the following changes:

  • A lower copay for line 1

  • a change of payment receiver for line 2

the claim is adjusted resulting in a change to the copay for line 1. It now has the following details in Claims:

Claim
Code Person Code Provider Code Total Claimed Amount Total Covered Amount

123

456

789AB

135.00

125.00
Claim Line ⇒ Coverages
Sequence Payment Receiver Insured Entity Amount Claimed Amount ⇒ Action Amount Label

1

789AB

15.00

75.00

Covered

50.00
65.00

Covered

Withhold

25.00
10.00

Copay

2

456EF
DF436

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:

  • A second version claim transaction

  • 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

12-Mar-2014

456

789AB

135.00

110.00

N

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 ⇒ Payment Receiver Action Label Amount

CL123

N

1

1

75.00

789AB

Covered

Covered

35.00

REL456

Covered

Covered

15.00

Withhold

Copay

25.00

2

60.00

456EF

Covered

Covered

60.00

CL123

Y

1

1

-75.00

789AB

Covered

Covered

-35.00

REL456

Covered

Covered

-15.00

Withhold

Copay

-25.00

2

-60.00

456EF

Covered

Covered

-60.00

CL123

N

2

1

75.00

789AB

Covered

Covered

50.00

REL456

Covered

Covered

15.00

Withhold

Copay

10.00

2

60.00

DF436

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

N

12-Mar-2014

$110.00

25-Mar-2014

N

CL123

132432

M

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

1

N

1

Covered

35.00

Y

N

N

789AB

Covered

15.00

Y

N

N

REL456

Copay

25.00

N

N

N

2

Covered

60.00

Y

N

N

456EF

1

Y

1

Covered

-35.00

Y

N

N

789AB

Covered

-15.00

Y

N

N

REL456

Copay

-25.00

N

N

N

2

Covered

-60.00

Y

N

N

456EF

2

N

1

Covered

50.00

Y

N

N

789AB

Covered

15.00

Y

N

N

REL456

Copay

10.00

N

N

N

2

Covered

60.00

Y

N

N

DF436

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:

  • One invoice for every payment receiver (4 total), of which;

  • 2 invoices with a delta amount calculating the difference between the current and previous financial transaction

  • A full credit memo for the total amount to be received back from the payment receiver that was replaced

  • A full invoice for the new payment receiver

  • Separate invoice lines for each financial transaction detail that has its invoice indicator set, included in the invoice of the related payment receiver

  • Separate accounting details for each of the financial transaction detais

Financial Message

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

Financial Message
Job ID Message Date Message Bulking Group

132532

22-Mar-2014

CL123
Financial Message - Invoice
ID Invoice Type Vendor Num Invoice Amount Attribute 1 (CTR Claim Code) Attribute 2 (CTR Version)

89075

Standard

789AB

15.00

CL123

2

89076

Standard

REL456

0.00

CL123

2

89077

Credit

456EF

-60.00

CL123

2

89078

Standard

DF436

60.00

CL123

2
Financial Message - Invoice Line
ID Invoice 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)

123582

89075

1

ITEM

-35.00

CL123

1

Y

1

123583

89076

1

ITEM

-15.00

CL123

1

Y

1

123584

89077

2

ITEM

-60.00

CL123

1

Y

2

123585

89075

1

ITEM

50.00

CL123

1

Y

1

123586

89076

1

ITEM

15.00

CL123

1

Y

1

123587

89078

2

ITEM

60.00

CL123

1

Y

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)

8719052

32423432

22-Mar-2014

-35.00

CL123

1

Y

1

COVERED

8719053

32423432

22-Mar-2014

-15.00

CL123

1

Y

1

COVERED

8719054

32423432

22-Mar-2014

-25.00

CL123

1

Y

1

COPAY

8719055

32423432

22-Mar-2014

-60.00

CL123

1

Y

2

COVERED

8719056

32423432

22-Mar-2014

50.00

CL123

2

N

1

COVERED

8719057

32423432

22-Mar-2014

15.00

CL123

2

N

1

COVERED

8719058

32423432

22-Mar-2014

10.00

CL123

2

N

1

COPAY

8719059

32423432

22-Mar-2014

60.00

CL123

2

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

CL123

1

Y

22-Mar-2014

132532

M

CL123

2

N

22-Mar-2014

132532

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 Reversal Version Code Claim Line Transaction ⇒ Invoice ID Invoice Line ID Accounting Detail ID

CL123

N

1

1

89070

123572

8719048

CL123

N

1

1

89071

123573

8719049

CL123

N

1

1

8719050

CL123

N

1

2

89072

123574

8719051

CL123

Y

1

1

89075

123582

8719052

CL123

Y

1

1

89076

123583

8719053

CL123

Y

1

1

8719054

CL123

Y

1

2

89077

123584

8719055

CL123

N

2

1

89075

123585

8719056

CL123

N

2

1

89076

123586

8719057

CL123

N

2

1

8719058

CL123

N

2

2

89078

123587

8719059