Change a Claim

This document provides an overview of the way a claim can be changed.

Changing Claim Attributes

While changing a claim, field values are not checked for time validity as of the service date. These validations are executed during processing, not while changing the claim.

The Type field on the claim (Provider or Restitution) is mandatory and is editable when changing a claim that is in the CHANGE status.

Changing Claim Line Attributes

The following claim line fields are mandatory:

• claimLine.claimedNumberOfUnits (Qty)

• claimLine.startDate (Start Date)

• claimLine.sequence (Seq)

The following fields are set by Claims and can never be edited directly:

• claim.manual (Manual?)

• claim.totalClaimedAmount.amount and claim.totalClaimedAmount.currencyCode (Total Charged)

• claim.totalAllowedAmount.amount and claim.totalAllowedAmount.currencyCode (Total Allowed)

• claim.totalCoveredAmount.amount and claim.totalCoveredAmount.currencyCode (Total Covered)

• claim.classificationScheme (Classification Scheme)

• claim.classification (Classification)

• claimLine.classification (Classification)

• claimLine.classificationAuthorization (Classification Auth)

• claimLine.status (Status)

• claimLine.coveredAmount.amount and claimLine.coveredAmount.currencyCode (Covered)

• claimLine.coveredNumberOfUnits (Covered #)

• claimLine.code (Code)

• claimLine.manualPricing (Manual Pricing?)

• claimLine.manualBenefits (Manual Benefits?)

Replacing Claim Lines

Replacement Rules create new claim lines that replace existing claim lines on one claim.

Replacements can also be 'undone', meaning:

• all claim lines that replace another claim line(s) are removed

• all messages with a skip tag are removed

• all allowed amount skip tags on claim lines are removed

• all non-replaced claim lines that have a skip tag are removed

• all replaced claim lines are restored and their skip tags are removed

Non-Matched Fields

A field is considered non-matched when the claims in integration point failed to map a reference in the message unto the referential data table in Claims. For example, when no relation record matching the serviced person provided in the claims in message can be found.

By definition, non-matched fields can only be look-up fields. Look up fields generally consist of two parts: a key field (editable) and a description/name field (display only). For non-matched fields no key value is displayed. The description field displays information as specified on the canonical claims in message. The information displayed depends on the field:

• For relations and providers, the non-matched formatted name is displayed.

• For any other field, the non-matched code is displayed.

When a user opens a look-up table (LOV) for a non-matched field that represents a relation or a provider, a LOV dialog with an appended header section will open. This header section displays the information that was sent in on the claims in message for that particular relation/provider, with the purpose of aiding the user in selecting the correct relation/provider record in the LOV.

Note that non-matched fields are cleaned up once a match has been made.

Process Fields

In case of non-matched process fields, the non-matched code will be shown, followed by the boilerplate text "(not matched)". Non-matched process fields cannot be manually matched as these fields are read-only.

Replaced and Replacing Claim Lines

Claim lines that are replaced cannot be edited or deleted. When a claim line is replaced, it displays an explanatory text that refers to the claim lines that replace that line,for example, 'this line is replaced by line 1 and 2'.

Claim lines that replace other lines display as normal. They can be edited, but not deleted: removing a replacing line can only be accomplished by undoing all (un)bundling for the whole claim. When a claim line is a replacement line, it displays an explanatory text that refers to the claim lines that it replaces,for example, 'this line is replaces line 4 and 5'.

It is not possible to bundle (many replaced by one) or unbundle (one replaced by many) through this page (nor any other page). It is possible to undo all bundling/unbundling for an entire claim (by means of a button on the page). This has the effect that all replacement lines are discarded and all replaced lines are restored as 'normal' claim lines. This is accomplished by clicking the button Undo (Redo) Claim Line Replacements.

Locked Claim Lines

Locked claim lines (including all details except claim line pend reasons and informative claim line messages of origins External and Manual) cannot be edited or deleted. Locked lines can be unlocked by selecting them in the claim lines section and clicking on the Unlock Line(s) button. After clicking on the button a warning dialog is displayed, where the user has to confirm that he/she wants to unlock the selected claim lines. After confirming, the selected claim lines are unlocked and they become editable. The statuses on the unlocked claim lines are cleared.

The Unlock Line(s) button is only displayed for users that have an access restriction (with read and update grants) of type 'Claim Line Unlocking'. Refer to the "User Access" chapter of the Security Guide for more information.

Attributes on Multiple Levels

The following fields can be specified on either the claim or claim line:

• serviced person or object

• service provider

• location

• referral provider

• diagnoses

• service specialties

• authorization code

• emergency indicator

• payment receiver

• location type

The following logic applies:

• If the claim line field is unspecified, then it shows the value of its counterpart on the claim header level. If this field is also empty, no value is shown.

• If the claim line field is specified, then that value is shown.

Note that the above logic does not apply to non-matched values; only matched values are inherited from higher levels to lower levels.

In context of these rules, the list of diagnosis codes is treated as a single field value. In other words, the user interface will not merge the set of diagnoses on the claim header with the diagnoses on the claim line; if the line specifies a list of diagnoses, those are the diagnoses shown for that line; if the line does not specify diagnoses, then the list on the claim header is shown for that line. Note that the display of the diagnoses values extends to the dynamic field values that may be specified on the intersection entities: claim diagnosis and claim line diagnoses.

Because the emergency indicator can never be unspecified (it is either true or false) the value 'false' is treated as unspecified. This means that a line shows the value true when the claim header has the value true.

The Claim Lines section has the following additional display-only column which is only displayed if the claim has the status CHANGE:

Table 1. Attributes on Multiple Levels

Display label	Entity, Field
Pend Reason	Displays the claimLine.claimLinePendReason.code with the lowest value for claimLinePendReason.priority If the lowest priority value is shared by more than one claimLinePendReason, show the claimLinePendReason that comes first based on alphabetical sort on the pend reason code.

Automatically updated claims fields

• Total Claimed (Charged) Amount

  • This field is set to the sum of the claimLine.claimedAmounts (only non-replaced claim lines) as long as all the currencies of the claim line claimed amounts are equal; the currency for the total claimed amount is set as well

  • If the currencies are not equal the field is not set; if it was already set it is nullified (including the currency)

• Total Allowed Amount

  • This field is set to the sum of the claimLine.allowedAmounts (only non-replaced claim lines) as long as all the currencies of the claim line allowed amounts are equal; the currency for the total allowed amount is set as well

  • If the currencies are not equal the field is not set; if it was already set it is nullified (including the currency)

• Start Date

• End Date

  • The message field in a claim message or claim line message can only be updated if no message is specified (that is, if the message is non-matched).

  • The diagnosis code field in a claim diagnosis or claim line diagnosis can only be updated if no diagnosis is specified (if the diagnosis is non-matched).

  • The specified modifier field in a claim line modifier can only be updated if no modifier is specified (if the modifier is non-matched).

  • The user is allowed to add informative and fatal messages with the exception of system specific messages. Added messages are attached as MANUAL messages.

  • The user is allowed to delete informative and fatal messages with the exception of system specific messages, and messages that display only because they are actually attached to the claim header

  • When doing a cascade delete from a higher level (when deleting a claim line or claim), all claim line messages are deleted, regardless the origin.

Updating Allowed Amount or Allowed Number of Units

When updating the allowed amount and/or the allowed number of units for both claim and reservation, the new values will normally be no longer in sync with the provider limit consumptions.

For amounts, this typically happens in a situation where the allowed amount and/or allowed number of units are determined by an external party, but the callouts need to be done internally.

This functionality is similar to changing the allowed amount and/or allowed number of units in the Manual Pricing page, but then restricted to the effects on the claim line at hand. It is identical to changing the allowed amount and/or allowed number of units through the Claims Update IP.

For each line on which at least one of allowed amount and allowed number of units was edited:

• Check both the keep pricing and manual pricing indicators

• Uncheck the keep benefits indicator

• Remove all claim line messages that originated from provider limits (origin PRICING LIMIT)

• Recalculate the provider limit consumptions of the claim line based on the edited allowed amount and/or allowed number of units:

  • It is possible that existing provider limit consumption has to be updated

  • It is possible that existing provider limit consumption (plus counter period/counter) has to be deleted

  • It is possible that new provider limit consumption (plus counter period/counter) has to be created

• Reevaluate and create new provider limit category messages and/or reservation regime messages

Note that the currency of an existing allowed amount cannot be changed.

Updating Expires On

When expiration date on the reservation claim is updated, the expiration date on the provider limit consumptions of all the claim lines that are not locked is updated to the new date.

Updating Price Principal Procedure Indicators

Price principal procedure indicators will typically be set either through Claims In or through the process field derivation rule. It is, however, also possible to update one or more of these indicators through either the UI or the Claims Update IP; the functionality of these updates is analogous.

But where in all other pages only information is shown, can in the Change page updates take place on the price principal procedure indicators.

If one or more of the price principal procedure indicators is changed, then after the change is saved the indicator to keep principal procedures is set to Y and a clickable hyperlink 'Release Override' will appear (instead of the label 'Override' in the other pages). This has the effect that the process field derivation rule for the price principal procedure indicators is skipped.

If that link is clicked (possibly in combination with other updates), then after the change is saved the indicator to keep principal procedures is set to N and the hyperlink 'Release Override' will disappear. This has the effect that the process field derivation rule for the price principal procedure indicators is not skipped.

Header Buttons

The following buttons display on the top right of the page:

Save

Saves the claim without changing the status, and performs the steps described under 'Updating allowed amount and/or allowed number of units' and 'Updating price principal procedure indicators' above.

Submit

Performs all steps listed in Save. Sets the 'Pricing Done' indicator to 'No' and saves the claim in the 'Initial' status, that is, the claim can no longer be altered and will be picked up for processing.

It is checked whether the claim has at least one claim line; if not, then the claim status remains unchanged and the user is warned with a pop-up message.

In case the claim has outstanding pend reasons, it may only be submitted, when at least one change is made or when at least one outstanding pend reason is resolved.

Benefits Only

Performs all steps listed under Submit. The only difference is that it sets the 'Preprocessing Done' indicator and 'Pricing Done' indicator to 'Yes'

Delete

Deletes the claim. User is asked for confirmation with a dialog box. Confirmation will commit the delete. Claims for which a claims transaction exists cannot be deleted.

This is a cascade delete of all entities referring to this claim.