Subsequently Denied Claim
This scenario shows the claim transactions, financial transactions and financial messages, for a claim that is initially approved and included in a financial message and then adjusted and fully denied (with fatal claim line messages).
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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Version 2
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Financial message includes;
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an invoice to fully reverse the covered amount of version 1 of the claim
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accounting details to fully reverse all coverages of version 1 of the claim
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Version 1
Adjudicate Claim
The claim is adjudicated resulting in the following details in Claims:
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Both claim lines being fully covered
- Working Copy Claim
Code |
Person Code |
Provider Code |
Total Claimed Amount |
Total Covered Amount |
CL389 |
456 |
789AB |
$110.00 |
$110.00 |
- Working Copy Claim Lines ⇒ Claim Line Coverages
| Sequence | Claimed Amount | Status | ⇒ | Action | Amount | Label |
|---|---|---|---|---|---|---|
1 |
$50.00 |
Approved |
Covered |
50.00 |
Covered |
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2 |
$60.00 |
Approved |
Covered |
60.00 |
Covered |
Finalize (First Time)
The claim is finalized for the first time on 12 March 2014. The following are created as part of the finalization step:
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A first version claim transaction
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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 |
|---|---|---|---|---|---|---|---|
CL389 |
1 |
20-Mar-2014 |
456 |
789AB |
110.00 |
110.00 |
N |
- CTR Claim Line ⇒ Coverages
| Version | Sequence | Claimed Amount | ⇒ | Action | Label | Amount |
|---|---|---|---|---|---|---|
1 |
1 |
50.00 |
Covered |
Covered |
50.00 |
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2 |
60.00 |
Covered |
Covered |
60.00 |
Financial Transaction
The financial transaction has the following details:
- Base Financial Object
| Type | Claim code | Status |
|---|---|---|
CLA |
CL389 |
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 |
CL389 |
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 |
50.00 |
Y |
N |
N |
789AB |
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2 |
Covered |
60.00 |
Y |
N |
N |
789AB |
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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A single invoice
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Separate invoice lines for each financial transaction detail that has its invoice indicator set
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Separate accounting details for each of the financial transaction detail
The message is just for the one claim (because Financial Message Bulking Group is set to the claim code).
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 |
14-Mar-2014 |
CL389 |
- Financial Message - Invoice
| ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
|---|---|---|---|---|---|
89170 |
Standard |
789AB |
110.00 |
CL389 |
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) |
|---|---|---|---|---|---|---|---|
123672 |
1 |
ITEM |
50 |
CL389 |
1 |
N |
1 |
123673 |
2 |
ITEM |
60 |
CL389 |
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) |
|---|---|---|---|---|---|---|---|---|
8719148 |
32423432 |
14-Mar-2014 |
50 |
CL389 |
1 |
N |
1 |
COVERED |
8719150 |
32423432 |
14-Mar-2014 |
60 |
CL389 |
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 |
|---|---|---|---|---|---|---|
CL389 |
1 |
N |
14-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 | Version Code | _Claim Line Transaction _ | ⇒ | Invoice ID | Invoice Line ID | Accounting Detail ID |
|---|---|---|---|---|---|---|
CL389 |
1 |
1 |
89170 |
123672 |
8719148 |
|
CL389 |
1 |
2 |
89170 |
123673 |
8719150 |
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 (in the Finalize Step).
Adjust Claim
The claim is adjusted resulting in the claim being denied. It now has the following details in Claims:
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Both claim lines are denied
As a result these claim lines do not have any claim line coverages.
- Claim 12389
| Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
|---|---|---|---|---|
CL389 |
456 |
789AB |
110.00 |
0 |
- Claim Line ⇒ Coverages
| Sequence | Claimed Amount | Status | ⇒ | Action | Amount | Label |
|---|---|---|---|---|---|---|
1 |
50.00 |
Approved |
Covered |
50.00 |
Covered |
|
2 |
60.00 |
Approved |
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
- Claim Transaction 12389
Code |
Version |
Transaction Date |
Person Code |
Provider Code |
Total Claimed Amount |
Total Approved Amount |
Reversal Indicator |
CL389 |
1 |
12-Mar-2014 |
456 |
789AB |
110.00 |
110.00 |
N |
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- CTR Claim Line ⇒ Coverages
| Claim Transaction Code | Reversal Indicator | Version | Sequence | Claimed Amount | ⇒ | Action | Label | Amount |
|---|---|---|---|---|---|---|---|---|
CL389 |
N |
1 |
1 |
50.00 |
Covered |
Covered |
50.00 |
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2 |
60.00 |
Covered |
Covered |
60.00 |
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Financial Transaction
Both the reversal financial transaction which is created when unfinalizing the claim and the transaction resulting from finalizing the claim are shown as 'new' 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 |
CL389 |
132532 |
M |
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- 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 |
50.00 |
Y |
N |
N |
789AB |
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2 |
Covered |
60.00 |
Y |
N |
N |
789AB |
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| Version 2 does not have any financial transaction details because it has been fully denied. |
Create Financial Message
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 to completely reverse the previously paid amount
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Accounting details to completely reverse the previous version
Financial Message
The contents of the various parts of the financial message are as follows:
- Financial Message Table
| Job ID | Message Date | Message Bulking Criteria |
|---|---|---|
132932 |
22-Mar-2014 |
CL389 |
- Financial Message - Invoice
| ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
|---|---|---|---|---|---|
89771 |
Credit |
789AB |
-110.00 |
CL389 |
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) |
|---|---|---|---|---|---|---|---|
123974 |
1 |
ITEM |
-50 |
CL389 |
1 |
Y |
1 |
123975 |
2 |
ITEM |
-60 |
CL389 |
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) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
|---|---|---|---|---|---|---|---|---|
8719951 |
32423432 |
22-Mar-2014 |
-50 |
CL389 |
1 |
Y |
1 |
COVERED |
8719953 |
32423432 |
22-Mar-2014 |
-60 |
CL389 |
1 |
Y |
2 |
COVERED |
Financial Transaction Process Data
| Strictly speaking version 2 does not get included in a message. |
However as it is the cause for the version 1 reversal it, both it and the reversal are considered to be included in the financial message
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 |
|---|---|---|---|---|---|---|
CL389 |
1 |
N |
14-Mar-2014 |
132432 |
M |
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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 |
|---|---|---|---|---|---|---|---|
CL389 |
N |
1 |
1 |
89170 |
123672 |
8719148 |
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CL389 |
N |
1 |
2 |
89170 |
123673 |
8719150 |
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