Claim Settlement

This feature provides for restriction of settling and unsettling a claim. After a claim is finalized, a provider settlement may occur which means that a settlement with the provider has been agreed upon. As a consequence, the claim should be prevented from being manually adjusted or further processed.

Claims that are part of a provider settlement are flagged by a settlement reason on the working copy external claims data. The settlement reason can be specified only when the claim is finalized. If a settlement reason is specified, the claim cannot be unfinalized through either the UI or any integration point (Claims In, Claims Reprocessing and Claims Update).

Users who have an access restriction for Claim Settlement can add a settlement reason to finalized claims if at least one settlement reason exists that is linked to that access restriction. Users can remove the settlement reason on finalized claims if they have access to the settlement reason that was used to settle that claim.

Users without access cannot update the settlement reason. Of course, access restrictions for having access to the claims page and having access to a data access group are also evaluated (see example below).

There are no restrictions on viewing claims which are settled. All users can see all details of a claim including settlement information (in the title of the local area).

Table 1. Example

User	Access to Claim Page?	Access to Data Access Group?	Access to Settlement Reason?	User is Allowed to…​
John	yes	yes	yes	John can see the claim and update the settlement reason
Paul	yes	yes	no	Paul can see the claim and the settlement reason, but is not allowed to update the settlement reason.
George	yes	no	yes/no	George can open the page but is unable to retrieve the claim.
Ringo	no	yes/no	yes/no	Ringo cannot open the claims page.

Inference Prevention

Not applicable.

Related Entities

Not applicable.

Related APIs

The following APIs check for settlement reason access

• PUT/PATCH Generic API externalclaimsdata