Approval Limit Restriction
This feature covers restricting the ability of users to adjudicate claims based on the total covered amount in a specific currency. Claim access restrictions are the basis of this feature.
Users may only adjudicate a claim if they have a role that includes a permission for a claim access restriction with a value greater than or equal to the total covered amount in a specific currency of the claim. Note that the claim line covered amounts within a claim can be in different currencies, so to adjudicate these kind of claims users need to have a role that includes multiple permissions (for all claim line covered amount currencies on the claim) for a claim access restriction with a value greater than or equal to the total covered amount in a specific currency.
Approval limits can depend on the claim form, so claim access restrictions claim forms can be defined. An approval limit applies for all claim forms defined for the claim access restriction. When no claim forms are defined for a claim access restriction, the approval limit applies to all claims irrespective of the claim form.
- Example
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Claim access restriction A100 gives rights to adjudicate claims of claim form UB/837I up to a value of 100 $.Access restriction A1000 gives rights to adjudicate claims of claim form UB/837I up to a value of 1000 $.
A100 is granted to Bob. A1000 is granted to Pete. John has no grants.
| Approval Limit | Claim Form | Can Bob Adjudicate? | Can Pete Adjudicate? | Can John Adjudicate? |
|---|---|---|---|---|
10 $ |
UB/837I |
yes |
yes |
no |
100 $ |
UB/837I |
yes |
yes |
no |
101 $ |
UB/837I |
no |
yes |
no |
Adjudication is restricted by default. A user without any granted claim access restrictions, cannot adjudicate any claim.
Attention has to be paid when combining claim access restrictions without claim form with claim form specific claim access restriction. Take for example the following setup of claim access restrictions:
| Access Restriction Code | Approval Limit | Claim Form |
|---|---|---|
GEN_50000 |
50000 $ |
|
UB04_50000 |
50000 $ |
UB04 |
GEN_100000 |
100000 $ |
A user with access grant to GEN_50000 implicitly gets access to right to adjudicate claims of claims form UB04.
The sames applies when granting both GEN_100000 and UB04_50000 to the same role. GEN_100000 gives the ability to adjudicate any claim up to 100000 $. This includes the right to adjudicate a 50000 $ claim for claim form UB04.
In other words: claim access restrictions are cumulative. When granting more claim access restrictions to a role, the role becomes more powerful.
- Inference Prevention
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Not applicable.
- Related Entities
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Not applicable.
Related APIs
The following APIs check for approval limit access
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Claims Submit Operation
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Claims In IP
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Claims Update IP