Initially Denied Claim
This scenario shows the claim transactions and financial messages that would be created for an invoiced claim that is initially fully denied (with a claim level fatal message) and then approved. The adjustment (to approve the claim after it was denied) is done after the first version has already been selected for payment.
Summary
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Version 1
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No financial message is required because there are no claim line coverages
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No financial message is required because there are no claim line coverages* Version 2
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Financial message includes;
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an invoice to fully pay the covered amount of version 2 of the claim
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accounting details for all coverages of version 2 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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A fatal message attached to the claim header
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No claim line coverages
- Working Copy Claim
Code |
Person Code |
Provider Code |
Total Claimed Amount |
Total Covered Amount |
CL373 |
456 |
789AB |
110.00 |
0 |
- Working Copy Claim Lines ⇒ Coverages
| Sequence | Payment Receiver | Claimed Amount | Status | ⇒ | Action | Amount | Label |
|---|---|---|---|---|---|---|---|
1 |
789AB |
50.00 |
Denied |
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2 |
789AB |
60.00 |
Denied |
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 Claimed Amount | Total Covered Amount | Reversal Ind |
|---|---|---|---|---|---|---|---|
CL373 |
1 |
12-Mar-2014 |
456 |
789AB |
110.00 |
0 |
N |
- CTR Claim Line ⇒ Coverages
| Claim Transaction Code | Reversal Ind | Version | Claim Line Transaction Code | Allowed Amount | ⇒ | Action | Label | Amount |
|---|---|---|---|---|---|---|---|---|
CL373 |
N |
1 |
1 |
50.00 |
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2 |
60.00 |
Financial Transaction
The financial transaction has the following details:
- Base Financial Object
| Type | Claim Code | Status |
|---|---|---|
CLA |
CL373 |
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 |
0 |
25-Mar-2014 |
N |
CL373 |
null |
null |
- Financial Transaction Detail and Financial Transaction Detail Process Data
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No financial transaction details or financial transaction detail process data record are created.
Create Financial Message
The financial messages are created on 14 March 2014. The claim has not been unfinalized. No financial message will be created because there are no financial transaction details for this transaction. However, the Financial Message Handled Datetime and Financial Message Result are updated to indicate that the transaction has completed financial processing and is therefore ready for reporting of results of adjudication to the provider and insured.
Financial Transaction Process Data
The following financial transaction process data columns are set. These fields provide information back on the financial transaction to make visible that no financial message was created for financial transaction:
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The Financial Message Result is set to 'No Message Required' (N)
| Claim Transaction Code | Version Code | Reversal | Financial Message Handled Datetime | Financial Message ID | Financial Message Result | |
|---|---|---|---|---|---|---|
CL373 |
1 |
N |
14-Mar-2014 |
null |
N |
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
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A reversal Financial Transaction for version 1 is created. It is associated with the base financial object that was 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 approved and fully covered. It now has the following details in Claims:
- Claim
| Code | Person Code | Provider Code | Total Claimed Amount | Total Covered Amount |
|---|---|---|---|---|
CL373 |
456 |
789AB |
110.00 |
0 |
- Claim Line ⇒ Coverages
| Sequence | Payment Receiver | Claimed Amount | Status | ⇒ | Action | Amount | Label |
|---|---|---|---|---|---|---|---|
1 |
789AB |
50.00 |
Denied |
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2 |
789AB |
60.00 |
Denied |
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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 |
|---|---|---|---|---|---|---|---|
CL373 |
1 |
12-Mar-2014 |
456 |
789AB |
110.00 |
0 |
N |
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- CTR Claim Line ⇒ Coverages
| Claim Transaction Code | Reversal Ind | Version | Claim Line Transaction Code | Claimed Amount | ⇒ | Action | Label | Amount |
|---|---|---|---|---|---|---|---|---|
CL373 |
N |
1 |
1 |
50.00 |
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2 |
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 |
$0 |
25-Mar-2014 |
N |
CL373 |
null |
N |
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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 |
|---|---|---|---|---|---|---|---|---|---|---|
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Create Financial Message
The financial messages are created on 22-Mar-2014. The claim has not been unfinalized. A financial message will be created with the following details:
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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). 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 |
|---|---|---|
132532 |
22-Mar-2014 |
CL373 |
- Financial Message - Invoice
| ID | Invoice Type | Vendor Num | Invoice Amount | Attribute 1 (CTR Claim Code) | Attribute 2 (CTR Version) |
|---|---|---|---|---|---|
89170 |
Standard |
789AB |
$110.00 |
CL373 |
2 |
- 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 |
$50.00 |
CL373 |
2 |
N |
1 |
123673 |
2 |
ITEM |
$60.00 |
CL373 |
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 Indicator) | Attribute 4 (CTR Claim Line Code) | Attribute 5 (Component Code) |
|---|---|---|---|---|---|---|---|---|
8719148 |
32423432 |
22-Mar-2014 |
$50.00 |
CL373 |
2 |
N |
1 |
COVERED |
8719150 |
32423432 |
22-Mar-2014 |
$60.00 |
CL373 |
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 |
|---|---|---|---|---|---|---|
CL373 |
1 |
N |
14-Mar-2014 |
N |
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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 |
|---|---|---|---|---|---|---|
CL373 |
2 |
1 |
89170 |
123672 |
8719148 |
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CL373 |
2 |
2 |
89170 |
123673 |
8719150 |