Generic Claims Resource Behavior

Some scenarios require that the PATCH/POST operation on the claim resource applies several updates in addition to the updates explicitly mentioned in the PATCH request. These additional updates ensure the claim stays consistent. For example, changing the allowed amount on claim line requires immediate recalculation of the provider limit counters.

This behavior is controlled through the boolean header property reprocess that can be specified on a claim PATCH operation unless specifed otherwise. If this property is set to false, the patch only applies updates explicitly included in the PATCH request itself.

If the property is set to true or is left unspecified, the system applies a number of additional updates. Which updates are applied typically depends on which fields are updated and the status of the claim.

Create Claim

Claim Start and End Dates

When a new claim is created the claim startDate is set to the earliest of claimLine startDate that belongs to the claim and the claim endDate is set to the latest date out of all claimLine endDates and claimLine startDates that belong to the claim.

Updates

Claim Line Allowed Amount or Allowed Number of Units

An update to the allowed amount or the allowed number of units on a claim line renders any existing provider limit consumptions inaccurate.

If the claim line allowed amount or allowed number of units is updated, and the claim meets the following conditions:

  • the claim is in the status CHANGE or MANUAL PRICING

  • the claim line is not replaced

  • the claim line is not locked

  • the claim line does not have a fatal message

then the system applies the following additional actions:

  • check the ignored indicator on all provider limit consumption on all lines in the same claim that have a product independent fatal message of origin ENROLLMENT, EXTERNAL, MANUAL, PRE PRICING, PRICING, RESERVATION, NO RECALCULATION or SANITY CHECKS

  • uncheck the ignored indicator on all other provider limit consumption that belongs to a claim line in the same claim

Once the ignored indicators are set, the system applies the following additional actions:

  • checks keep pricing indicator

  • checks the manual pricing indicator

  • uncheck the keep benefits indicator

  • removes all claim line messages with origin PRICING LIMIT

  • recalculates the provider limit consumptions using the edited allowed amount and allowed number of units:

  • re-applies applicable provider limits

  • re-applies applicable provider limit messages

Claim Line Rule Coverages

An update to the claim line rule coverages on a claim line renders all other Claim Line Rule Coverages and consumptions within the same claim inaccurate.

If claim line rule coverages are updated and the following conditions are met:

  • the claim is in the status MANUAL BENEFITS or MANUAL ADJUDICATION

  • the claim line is not replaced

  • the claim line is not locked

then for each claim line on which one or more claim line rule coverages are updated, the system

  • checks the keep benefits indicator

  • checks the manual benefits indicator

  • removes all claim line messages with origin COVERAGE

  • recalculates coverage for that claim line, overriding the system calculated rule coverages with the manually edited rule coverages. Origin COVERAGE messages are reevaluated and attached.

If the manually edited claim line rule coverages can not be made consistent with the benefits input amount, then the system attaches fatal message GEN-UINT-025 to the claim line.

After all claim lines with updated claim line rule coverages are recalculated, the system recalculates coverage for all other lines, except those that are locked, replaced or have a checked keep benefits indicator.

External intervention rules for the manual benefits step are not re-evaluated. The system re-applies the end-benefits derivation rules and recalculates the total covered amount on the claim header.

Claim Line Keep Benefits

Unchecking the keep benefits indicator on a claim line represents a user releasing any manual overrides on that line. This may render all other claim line rule coverages and consumptions within the same claim inaccurate, and therefore triggers a recalculation.

If the claim line keep benefits indicator is updated, and the following conditions are met:

  • the keep benefits indicator is set to false

  • the claim is in the status MANUAL BENEFITS or MANUAL ADJUDICATION.

  • the claim line is not replaced

  • the claim line is not locked

then the system recalculates coverage for all lines including the line on which the keep benefits indicator is now unchecked, but excluding claim lines that are locked, replaced or have a checked keep benefits indicator.

External intervention rules for the manual benefits step are not re-evaluated. The system re-applies the end-benefits derivation rules and recalculates the total covered amount on the claim header.

Checking the keep benefits indicator has no effect, other than the update itself.

Claim Line Keep Pricing

Unchecking the keep pricing indicator on a claim line represents a user releasing any manual overrides on that line. This may render all the results on that claim line inaccurate and therefore triggers repricing for that line.

If the claim line keep pricing indicator is updated, and the following conditions are met:

  • the keep pricing indicator is set to false

  • the claim is in the status CHANGE or MANUAL PRICING

  • the claim line is not replaced

  • the claim line is not locked

then the system reprices the line. The following rules are NOT re-applied:

  • Combination Checks

  • Replacement Rules

  • Pricing External Intervention Rules

  • External Intervention Rules for Manual Pricing

  • Pricing Callout Rules

Messages with origin PRICING NO RECALCULATION are not removed.

Checking the keep pricing indicator has no effect, other than the update itself.

Claim Expires On

If the PATCH payload updates the expiration date on the reservation claim, then the system also updates the expiration date on the provider limit consumptions of all the claim lines that are not locked.

Claim Line Start and End Dates

When the status of claim is Initial, Entry, or Changed and if the start/end date is updated on the claim line(s), then the claim startDate is set to the earliest of claimLine startDate that belongs to the claim and the claim endDate is set to the latest date out of all claimLine endDates and claimLine startDates that belong to the claim.

Note: reprocess claim level start and end dates are reset irrecpective of reprocess property configuration.

Adding and Removing Claim Details

Adding Pend Reason

If the PATCH payload adds a pend reason to the claim or claim line, then the system also creates a corresponding entry in the pend reason history.

Adding a Fatal Claim Message

If the PATCH payload adds a fatal claim message to a claim that has status MANUAL BENEFITS, MANUAL ADJUDICATION or MANUAL PRICING ADJUDICATION then the system applies a several updates to the claim lines.

The following list of actions is applied only to claims in status MANUAL BENEFITS and MANUAL ADJUDICATION:

  • uncheck the keep benefits indicator

  • uncheck the manual benefits indicator

  • set the claim line covered amount to 0

  • set the claim line covered number of units to 0

  • remove all claim line rule coverages

  • remove all claim line coverages

  • remove all claim line benefit specifications

  • remove all claim line messages with origin BENEFITS or COVERAGE

  • remove all preliminary authorization consumptions

  • remove authorization counter periods for which no non-reversed consumption remains

  • remove authorization counters for which no consumptions remain at all

  • remove preliminary regime consumptions

  • remove regime counters if no non-reversed consumption remains

  • remove preliminary limit consumptions

  • remove limit counter periods if no non-reversed consumptions remain

  • remove limit counters if no consumption remains

  • remove medical case details

The values of the Keep Pricing and Manual Pricing indicators on the claim lines are kept as they are.

The ignored indicator on the preliminary provider limit consumptions of all the claim lines is checked.

The claim line pricing results remain as they are:

  • claim line allowed amount

  • claim line allowed number of units

  • claim line provider pricing clauses

  • claim line messages with origin PRICING, PRICING LIMIT or PRICING NO RECALCULATION

  • preliminary provider limit consumptions (the ignored indicator checked)

The claim total covered amount is not null, the system sets it to 0.

Unless the claim external pricing indicator is checked, the system re-applies the end-pricing derivation rules.

The system reapplies the end-benefits derivation rules.

Adding a Fatal Claim Line Message

If the PATCH payload adds a fatal claim line message to a claim that has status MANUAL BENEFITS, MANUAL ADJUDICATION or MANUAL PRICING ADJUDICATION then the system applies a several updates to the claim lines:

The following list if actions is applied to claims in status MANUAL BENEFITS or MANUAL ADJUDICATION:

  • uncheck the keep benefits indicator

  • uncheck the manual benefits indicator

  • set the claim line covered amount to 0

  • set the claim line covered number of units to 0

  • remove all claim line rule coverages

  • remove all claim line coverages

  • remove all claim line benefit specifications

  • remove all claim line messages with origin BENEFITS or COVERAGE

  • remove all preliminary authorization consumptions

  • remove authorization counter periods for which no non-reversed consumption remains

  • remove authorization counters for which no consumptions remain at all

  • remove preliminary regime consumptions

  • remove regime counters if no non-reversed consumption remains

  • remove preliminary limit consumptions

  • remove limit counter periods if no non-reversed consumptions remain

  • remove limit counters if no consumption remains

  • remove medical case details

The values of the Keep Pricing and Manual Pricing indicators on the claim line are kept as they are.

The ignored indicator on the preliminary provider limit consumptions of the claim line is checked.

The claim line pricing results remain as they are:

  • claim line allowed amount

  • claim line allowed number of units

  • claim line provider pricing clauses

  • claim line messages with origin PRICING, PRICING LIMIT or PRICING NO RECALCULATION

  • preliminary provider limit consumptions (the ignored indicator checked)

After the claim line is updated, the system reprices and recalculates the other lines.

Table 1. Adding a Fatal Claim Line Message
Line Reprice? Recalculate coverage?

Locked lines

No

No

Replaced lines

No

No

Keep Benefits?

No

No

Keep Pricing?

No

Yes

Externally Priced?

No

Yes

All other lines

Yes

Yes

If the claim has status MANUAL PRICING ADJUDICATION then coverage is not recalculated. The claim is repriced only.

For those claim lines that are repriced, the following rules are NOT re-applied:

  • Combination Checks

  • Replacement Rules

  • Pricing External Intervention Rules

  • External Intervention Rules for Manual Pricing

  • Pricing Callout Rules

Messages with origin PRICING NO RECALCULATION are not removed. The system re-applies the pre Benefits Process Field Derivation Rules for process field Benefits Input Amount.

Unless the claim external pricing indicator is checked, the system re-applies the end-pricing derivation rules. The system recalculates the total allowed amount on the claim header.

The system reapplies the end-benefits derivation rules. For those lines for which coverage is recalculated the external intervention rules for the manual benefits step are not re-evaluated.

The system re-applies the end-benefits derivation rules and recalculates the total covered amount on the claim header.

Adding a Claim Line

If the PATCH payload adds a new claim line, then the claim startDate is set to the earliest of all the claimLines startDate that belongs to the claim and the claim endDate is set to the latest date out of all claimLine endDates and claimLine startDates that belong to the claim.

Removing a Claim Line

If the PATCH payload removes a claim line, the system transfers any existing consumption under that line to the claim header level.

In addition, they system also re calculates the claim startDate and end date. The claim start date is set it to the earliest of all the claimLines startDate that belongs to the claim and the claim endDate is set to the latest date out of all claimLine endDates and claimLine startDates that belong to the claim by the system.