External Claims Data

The data model of external claims data is for a small part fixed and for a larger part configurable. First the fixed model is explained and then the configuration is described, with a couple of examples to show how it works.

Each claim record and each claim transaction record can have an external claims data record. Note that external claim data records are created automatically in such a way that (1) non version specific external claim data can be added at any time to claims, and (2) version specific external claim data can be added to claim transactions during creation of them and at any time after they have been created.

Table 1. External Claims Data
Field Description

Claim Code

The unique code of the claim to which the external claim data is attached (required).

Claim Version

The version of the CTR claim transaction to which this external claim data is attached (optional).

Settlement Reason

The settlement reason that was used to settle the claim. If specified, the claim cannot be unfinalized through any process. This is a non version specific field, meaning that it is only applicable to working copy claims and not to CTR claim transactions.

Ind Exempt From Purging

If checked, the claim to which this external claims data belongs to will not be purged by the claims purging database process (refer to the Operations Guide for more information on purging). This is a non version specific field, meaning that it is only applicable to working copy claims and not to CTR claim transactions.

External claim data records that do not have a claim version only point to the claim and not to a CTR claim transaction. They can be considered to apply to all versions.

External claim data records can be extended with dynamic records and fields as described in the Developer Guide on Extensibility. Note that it is possible to make a reference from a flex code field usage to a dynamic logic function, specifying the composition of an URL. The field that has this reference, will then appear in the UI as a deeplink to the URL that is being composed.

Scenarios

Scenario A: Configure External Claims data for Payable

In this use case the setup data needed to configure the External claims data for information about the payments of a claim version is illustrated.

First a record definition 'PAYMENTS' is created, consisting of the fields

  • check number

  • check amount

  • check date

Then external claims data is connected to the record definition 'PAYMENTS'.

Now let’s assume that for version 1 of claim '1234' $100 has been paid and that the claim has been unfinalized and reprocessed. As a result of the new version an additional $20 has been paid. In the external claim data the following information can be sent in through generic HTTP API.

Table 2. Scenario A: Configure External Claims Data for Payable
Claim code Version Type Check Number Check Amount Check date

1234

1

PAYMENTS

9213.4566

$100.00

2010-25-09

1234

2

PAYMENTS

9213.4898

$20.00

2010-21-10

Scenario B: Configure External Claims Data for Letters

In this use case the setup data needed to configure the External claims data for information about the letters regarding a claim or a claim version is illustrated.

First a record definition 'LETTERS' is created, consisting of the fields:

  • letter code

  • letter reference

  • date sent

Then external claims data is connected to the record definition 'LETTERS'.

Let’s suppose two letters have been sent out for this claim. One for a Coordination of benefits investigation and one for a missing authorization. In that case the following information can be registered through generic HTTP API.

Table 3. Scenario B: Configure External Claims Data for Letters
Claim code Version Type Letter Code Reference Date Sent

1234

LETTERS

CoB Investigation

1A3/AXDD

2010-25-09

1234

LETTERS

Auth Missing

5C8/BYFG

2010-21-10

Note that if the Coordination of benefits investigation letter would have been sent referencing a specific claims transaction, then the version would have been filled in the first example record. In others words, it is possible that external claims data can exist for the same record definition and the same claim, but one time referring to the claim in general and the other time referring to a specific version.