Manual Operations
All operations on a claim or its details like creating, retrieving, updating and deleting but also settling, unsettling and finalizing and unfinalizing are subject to restrictions described in the "User Access" chapter of the Security Guide.
Operations
Settle and Unsettle
- Settle
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A claim can only be settled if
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the claim has status FINALIZED
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the claim is unsettled (no settlement reason on the external claims data)
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the user has one or more access restrictions (with read and update grants) of type 'Claim Settlement' and one or more settlement reasons exist that are linked to the access restriction(s) that the user has.
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Settling the claim sets the settlement reason on the external claims data record.
- Unsettle
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A claim can only be unsettled
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if the claim has status FINALIZED,
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the claim is settled
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the user has the access restriction of type 'Claim Settlement' (with read and update grants) that is linked to the settlement reason specified on the external claims data record.
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Unsettling the claim Removes the settlement reason on the external claims data record.
Unfinalize a Claim
A claim can only be unfinalized when
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the claim has status PRICING FINALIZED or has status FINALIZED
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when the claim is unsettled (no settlement reason on the external claims data)
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and the user has a role with grants on one or more access restrictions of type 'Claim Unfinalization'
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one or more unfinalize reasons exist that are linked to the access restriction(s) that the user has.
Lock Claim Lines?
If an unfinalize reason with a checked Lock Claim Lines indicator is used to unfinalize the claim, all claim lines will be locked for any changes. Locked claim lines will not be reprocessed when the claim is reprocessed; the previous results on these claim lines will be kept.
The operator can unlock the locked claim lines that are for example appealed and thus need to be reprocessed.
Status Related Operations
The following actions are only allowed if the claim has a specific status.
- Price
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Applying manual pricing is only allowed if the claim has status MANUAL PRICING.
- Adjudicate Pricing
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Applying manual pricing adjudication is only allowed if the claim has status MANUAL PRICING ADJUDICATION.
- Apply Benefits
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Applying manual benefits is only allowed if the claim has status MANUAL BENEFITS.
- Adjudicate
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Applying manual adjudication is only allowed if the claim has status MANUAL ADJUDICATION.