Claim Forms and Claim Form Types

Each claim belongs to one single claim form. Claim forms are used to categorize claims within the application. Many configuration rules can differentiate on the claim form. The claim form also specifies which (and how many) procedure codes appear on claim lines of claims that belong to that form. A typical usage in health insurance industry is having separate forms for hospital claims and professional claims.

A claim form has the following attributes:

Claim Form

Table 1. Claim Form
Field Description

Code

The unique code for this claim form

Description

The description for this claim form

Insurance Type

The insurance type for this claim form

Claim Form Type

Optional reference to claim form type

Procedure 1 usage name

The attribute name in dynamic logic

Procedure 1 definition

Flex Code System that defines which codes can be entered

Procedure 1 fatal non match indicator

If checked, a non match leads to a fatal system message. If not, an informative message is applied instead

Procedure 2 usage name

The attribute name in dynamic logic

Procedure 2 definition

Flex Code System that defines which codes can be entered

Procedure 2 fatal non match indicator

If checked, a non match leads to a fatal system message. If not, an informative message is applied instead

Procedure 3 usage name

The attribute name in dynamic logic

Procedure 3 definition

Flex Code System that defines which codes can be entered

Procedure 3 fatal non match indicator

If checked, a non match leads to a fatal system message. If not, an informative message is applied instead.

The context of the fatal non-match indicator is restricted to the automated matching step in the processing flow. This indicator does not make it possible to enter a non-existent procedure code in the claims page, nor to send in a non-existent procedure code through the claims update integration point.

Each claim form belongs to an insurance type. Insurance type specifies a business segment. For example, automobile, health, travel insurance, etc.

Each claim form can belong to a single claim form type. Claim form types are used in a number of configuration rules to reference a set of claim forms.

The practical example for the US health market is that claim forms represent the different formats in which a claim can be submitted, that is, the electronic formats 837P, 837I and 837D and the paper forms UB04, CMS1500 and J400.

The UB04 and the 837I are both institutional claims and are treated the same for adjudication purposes, where it is irrelevant whether the claim was submitted electronically or through the mail. In this example both claim forms would refer to the claim form type "Institutional". Now, when the user sets up a benefit specification that applies only to institutional claims, the system knows to only consider UB04 and 837I claims for that benefit specification.

Claim Form Type

Table 2. Claim Form Type
Field Description

Code

The unique code for this claim form type

Display name

The description of the claim form type that appears in drop down menus

A typical use of the claim form type for the US market is

  • Claim form type: Institutional

    • Claim form: 837I

    • Claim form: UB04

  • Claim form type: Professional

    • Claim form: 837P

    • Claim form: CMS1500

  • Claim form type: Dental

    • Claim form: 837D

    • Claim form: J400