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

A claim can only be settled if

  • the claim has status FINALIZED

  • the claim is unsettled (no settlement reason on the external claims data)

  • 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.

Settling the claim sets the settlement reason on the external claims data record.

Unsettle

A claim can only be unsettled

  • if the claim has status FINALIZED,

  • the claim is settled

  • 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.

Unsettling the claim Removes the settlement reason on the external claims data record.

Unfinalize a Claim

A claim can only be unfinalized when

  • the claim has status PRICING FINALIZED or has status FINALIZED

  • when the claim is unsettled (no settlement reason on the external claims data)

  • and the user has a role with grants on one or more access restrictions of type 'Claim Unfinalization'

  • 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.

Source Reference Mandatory?

If the Source Reference Mandatory indicator on the selected unfinalize reason is set to Yes, then the source reference must be specified as well.

Status Related Operations

The following actions are only allowed if the claim has a specific status.

Price

Applying manual pricing is only allowed if the claim has status MANUAL PRICING.

Adjudicate Pricing

Applying manual pricing adjudication is only allowed if the claim has status MANUAL PRICING ADJUDICATION.

Apply Benefits

Applying manual benefits is only allowed if the claim has status MANUAL BENEFITS.

Adjudicate

Applying manual adjudication is only allowed if the claim has status MANUAL ADJUDICATION.