Claim with 2 Adjustments

This use case shows the financial transactions and the financial messages that would be created for an invoiced claim that is adjusted twice. The first adjustment increases the amount to be paid and the second reduces it. Each adjustment is done after the previous version has already been included in a financial message.

Summary:

Version 1
- Financial message includes;
  - an invoice to fully pay the covered amount of the claim
  - accounting details for all coverages of the claim
Version 2
- Financial message includes;
  - an invoice to pay the difference between version 1 and 2 of the claim
  - accounting details to fully reverse all coverages of version 1 of the claim
  - accounting details for all coverages of version 2 of the claim
Version 3
- Financial message includes;
  - an invoice (credit memo) to retract the difference between version 2 and 3 of the claim
  - accounting details to fully reverse all coverages of version 2 of the claim
  - accounting details for all coverages of version 3 of the claim

Version 1

Adjudicate Claim

The claim is adjudicated resulting in the following details in Claims:

$25.00 Copay
$110.00 Coverage

Table 1. Version 1: Working Copy Claim
Code	Person Code	Provider Code	Total Claimed Amount	Total Covered Amount
CL123	456	789AB	135.00	110.00

Table 2. Version 1: Working Copy Claim Lines
Sequence	Payment Receiver	Allowed Amount	Action	Amount	Label
1	789AB	75.00	Covered	50.00	Covered
			Withhold	25.00	Copay
2	789AB	60.00	Covered	60.00	Covered

Finalize (First Time)

The claim is finalized for the first time on 12 March 2014. The following are created at the same time:

First version claim transaction
A financial transaction with a Base Financial Object

Claim Transaction

The claim transaction has the following details.

Table 3. Version 1: CTR Claim
Claim Transaction Code	Version	Transaction Date	Person Code	Provider Code	Total Allowed Amount	Total Covered Amount	Reversal Ind
CL123	1	12-Mar-2014	456	789AB	135.00	110.00	N

Table 4. Version 1: CTR Claim Line ⇒ Coverages
Claim Transaction Code	Reversal Ind	Version	Claim Line Transaction Code	Allowed Amount	Action	Label	Amount
CL123	N	1	1	75.00	Covered	Covered	50.00
					Withhold	Copay	25.00
			2	60.00	Covered	Covered	60.00

Financial Transaction

The financial transaction has the following details:

Table 5. Version 1: Base Financial Object
Type	Claim code	Status
CLA	CL123	IN

Table 6. Version 1: Financial Transaction and Financial Transaction Process Data
Version	Processing Type	Reversal?	Creation Date	Total Amount	⇒	Due Date	Financial Message Mandatory	Financial Message Bulking Group	Financial Message ID	Financial Message Result
1	Regular	N	12-Mar-2014	$110.00		25-Mar-2014	N	CL123	NULL	NULL

Table 7. Version 1: Financial Transaction Detail and Financial Transaction Detail Process Data
Version	Reversal	Claim Line Code	Component Code	Amount	Invoice Indicator	Invoice Line Grouping	Accounting Detail Grouping	Payment Receiver
1	N	1	Covered	50.00	Y	N	N	789AB
			Copay	25.00	N	N	N
		2	covered	60	Y	N	N	789AB

Create Financial Messages

The financial messages are created on 14 March 2014. The claim is still in status Finalized. A financial message will be created:

The message is just for the claim (because Financial Message Bulking Group is set to the claim code)
It will have a single invoice
It will have a separate invoice line for each financial transaction detail that has its invoice indicator set
It will have a separate accounting detail for each of the financial transaction detail

Financial Message

The contents of the various parts of the financial message are as follows:

Table 8. Version 1: Financial Message
Job ID	Message Date	Message Bulking Group
132432	14-Mar-2014	CL123

Table 9. Version 1: Financial Message - Invoice
ID	Invoice Type	Vendor Num	Invoice Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)
89070	Standard	789AB	110.00	CL123	1

Table 10. Version 1: Financial Message - Invoice Line
ID	Line Number	Line Type	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal Indicator)	Attribute 4 (CTR Claim Line Code)
123572	1	ITEM	50	CL123	1	N	1
123573	2	ITEM	60	CL123	1	N	2

Table 11. Version 1: Financial Message - Accounting Detail
ID	Ledger ID	Accounting Date	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal Indicator)	Attribute 4 (CTR Claim Line Code)	Attribute 5 (Component Code)
8719048	32423432	14-Mar-2014	50	CL123	1	N	1	COVERED
8719049	32423432	14-Mar-2014	25	CL123	1	N	1	COPAY
8719050	32423432	14-Mar-2014	60	CL123	1	N	2	COVERED

Financial Transaction Process Data

In addition, the following financial transaction process data columns are set. These fields provide information back on the financial transaction to make visible which message the transaction is included in.

Table 12. Version 1: Financial Transaction Process Data
Claim Transaction Code	Version Code	Reversal	⇒	Financial Message Handled Datetime	Financial Message ID	Financial Message Result
CL123	1	N		14-Mar-2014	132432	M

Financial Transaction Detail Process Data

The following financial message transaction detail process data columns are set. These fields provide information back on the financial transaction detail to make visible which invoice line and accounting detail the transaction detail has been included in.

Table 13. Version 1: Financial Transaction Detail Process Data
Claim Transaction Code	Version Code	Claim Line Transaction	Invoice ID	Invoice Line ID	Accounting Detail ID
CL123	1	1	89070	123572	8719048
CL123	1	1			8719049
CL123	1	2	89070	123573	8719050

Version 2

Unfinalize Claim

The claim is unfinalized on 16 March 2014 making the working copy of it available for changing and readjudication. When unfinalizing the following occurs:

Version 1 of the CTR Claim (transaction) is labeled as unfinalized
A reversal CTR Claim (transaction) for version 1 is created with the allowed and covered amounts reversed
A reversal Financial Transaction for version 1 is created with allowed and covered amounts reversed. It will be associated with the base financial object created when the claim was first finalized.

These reversals are shown below.

Adjust Claim

The claim is adjusted resulting in a change to the copay for line 1. It now has the following details in Claims:

Table 14. Version 2: Claim 123
Code	Person Code	Provider Code	Total Claimed Amount	Total Covered Amount
123	456	789AB	135.00	125.00

Table 15. Version 2: Claim Line ⇒ Coverages
Sequence	Payment Receiver	Claimed Amount	Action	Amount	Label
1	789AB	75.00	Covered	50.00 65.00	Covered
			Withhold	25.00 10.00	Copay
2	789AB	60.00	covered	60.00	covered

Finalize (Second Time)

The claim is finalized for the second time on 20 March 2014. The following are created:

A second version claim transaction
A second version financial transaction

CTR Claim Transaction

Table 16. Version 2: CTR Claim (Transaction)
Claim Transaction Code	Version	Transaction Date	Person Code	Provider Code	Total Allowed Amount	Total Covered Amount	Reversal Indicator
`CL123`	`1`	`12-Mar-2014`	`456`	`789AB`	`135.00`	`110.00`	`N`
CL123	1	16-Mar-2014	456	789AB	-135.00	-110.00	Y
CL123	2	20-Mar-2014	456	789AB	135.00	125.00	N

Table 17. Version 2: CTR Claim Line ⇒ Coverages
Claim Transaction Code	Reversal Indicator	Version	Claim Line Transaction Code	Allowed Amount	Action	Label	Amount
`CL123`	`N`	`1`	`1`	`75.00`	`Covered`	`Covered`	`50.00`
					`Withhold`	`Copay`	`25.00`
			`2`	`60.00`	`Covered`	`Covered`	`60.00`
CL123	Y	1	1	-75.00	Covered	Covered	-50.00
					Withhold	Copay	-25.00
			2	-60.00	Covered	Covered	-60.00
CL123	N	2	1	75.00	Covered	Covered	65.00
					Withhold	Copay	10.00
			2	60.00	Covered	Covered	60.00

Financial Transaction

The reversal financial transaction which is created when unfinalizing the claim is depicted below.

Table 18. Version 2: Financial Transaction and Financial Transaction Process Data
Version	Processing Type	Reversal?	Creation Date	Total Amount	Due Date	Financial Message Mandatory	Financial Message Bulking Group	Financial Message ID	Financial Message Result
`1`	`Regular`	`N`	`12-Mar-2014`	`$110.00`	`25-Mar-2014`	`N`	`CL123`	`132432`	`M`
1	Regular	Y	16-Mar-2014	-$110.00	25-Mar-2014	N	CL123	NULL	NULL
2	Regular	N	20-Mar-2014	$125.00	25-Mar-2014	N	CL123	NULL	NULL

Table 19. Version 2: Financial Transaction Detail and Financial Transaction Detail Process Data
Version	Reversal?	Claim Line Code	Component Code	Amount	Invoice Indicator	Invoice Line Grouping	Accounting Detail Grouping	Payment Receiver
`1`	`N`	`1`	`Covered`	`50.00`	`Y`	`N`	`N`	`789AB`
			`Copay`	`25.00`	`N`	`N`	`N`
		`2`	`Covered`	`60.00`	`Y`	`N`	`N`	`789AB`
1	Y	1	Covered	-50.00	Y	N	N	789AB
			Copay	-25.00	N	N	N
		2	Covered	-60.00	Y	N	N	789AB
2	N	1	Covered	65.00	Y	N	N	789AB
			Copay	10.00	N	N	N
		2	Covered	60.00	Y	N	N	789AB

Create Financial Messages

The financial messages are created on 22 March 2014. The working copy claim has not been unfinalized. A financial message is created with the following details:

An invoice with a delta amount calculating the difference between the current and previous financial transaction
Both the financial transaction details of the current version, and the financial details of the reversal details are included in the financial message

Financial Message

The contents of the various parts of the financial message are as follows:

Table 20. Version 2: Financial Message
Job ID	Message Date	Message Bulking Criteria
132732	22-Mar-2014	CL123

Table 21. Version 2: Financial Message - Invoice
ID	Invoice Type	Vendor Num	Invoice Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)
89171	Standard	789AB	15.00	CL123	2

Table 22. Version 2: Financial Message - Invoice Line
ID	Line Number	Line Type	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal)	Attribute 4 (CTR Claim Line Code)
123574	1	ITEM	-50	CL123	1	Y	1
123575	2	ITEM	-60	CL123	1	Y	2
123676	1	ITEM	65	CL123	2	N	1
123677	2	ITEM	60	CL123	2	N	2

Table 23. Version 2: Financial Message - Accounting Detail
ID	Ledger ID	Accounting Date	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal)	Attribute 4 (CTR Claim Line Code)	Attribute 5 (Component Code)
8719051	32423432	22-Mar-2014	-50	CL123	1	Y	1	COVERED
8719052	32423432	22-Mar-2014	-25	CL123	1	Y	1	COPAY
8719053	32423432	22-Mar-2014	-60	CL123	1	Y	2	COVERED
8719154	32423432	22-Mar-2014	65	CL123	2	N	1	COVERED
8719155	32423432	22-Mar-2014	10	CL123	2	N	1	WITHHOLD
8719156	32423432	22-Mar-2014	60	CL123	2	N	2	COVERED

Financial Transaction Process Data

In addition, the following financial transaction process data columns is set.

Table 24. Version 2: Financial Transaction Process Data
Claim Transaction Code	Version Code	Reversal	Financial Message Datetime	Financial Message ID	Financial Message Result
`CL123`	`1`	N	`14-Mar-2014`	`132432`	`M`
CL123	1	Y	22-Mar-2014	132732	M
CL123	2	N	22-Mar-2014	132732	M

Financial Transaction Detail Process Data

The following financial message transaction detail process data columns are set.

Table 25. Version 2: Financial Transaction Detail Process Data
Claim Transaction Code	Reversal	Version Code	Claim Line Transaction	Invoice ID	Invoice Line ID	Accounting Detail ID
`CL123`	`N`	`1`	`1`	`89070`	`123572`	`8719048`
`CL123`	`N`	`1`	`1`		`8719049`
`CL123`	`N`	`1`	`2`	`89070`	`123573`	`8719050`
CL123	Y	1	1	89171	123674	8719151
CL123	Y	1	1		8719152
CL123	Y	1	2	89171	123675	8719153
CL123	N	2	1	89171	123676	8719154
CL123	N	2	1		8719155
CL123	N	2	2	89171	123677	8719156

Version 3

Unfinalize Claim

The claim is unfinalized on the 25th of March 2014. This results in a the version 2 claim transaction being labeled as unfinalized. The following records are created:

A reversal CTR claim transaction, with the allowed and covered amount reversed
A reversal financial transaction, with allowed and covered amounts reversed, associated with the base financial object created earlier

These reversals are shown below.

Adjust Claim

The claim is unfinalized on 25 march 2014. The claim is adjusted resulting in a $20 coinsurance for claim line two. The working copy claim now has the following details:

Table 26. Version 3: Working Copy Claim
Code	Person Code	Provider Code	Total Claimed Amount	Total Covered Amount
CL123	456	789AB	135.00	105.00

Table 27. Version 3: Claim Line -→ Coverages
Sequence	Payment Receiver	Allowed Amount	Action	Amount	Label
1	789AB	75.00	Covered	65.00	Covered
			Withhold	10.00	Copay
2	789AB	60.00	Covered	60.00 _ 40.00_	Covered
			Withhold	20.00	Coinsurance

Finalize (Third Time)

The claim is finalized for the third time on 27 March 2014, creating a third claim transaction:

A third version claim transaction
A third version financial transaction

CTR Claim Transaction

Table 28. Version 3: Claim Transaction
Claim Transaction Code	Version	Transaction Date	Person Code	Provider Code	Total Allowed Amount	Total Covered Amount	Reversal Indicator
`CL123`	`1`	`12-Mar-2014`	`456`	`789AB`	`135.00`	`110.00`	`N`
`CL123`	`1`	`16-Mar-2014`	`456`	`789AB`	`-135.00`	`-110.00`	`Y`
`CL123`	`2`	`20-Mar-2014`	`456`	`789AB`	`135.00`	`125.00`	`N`
`CL123`	`2`	`24-Mar-2014`	`456`	`789AB`	`-135.00`	`-125.00`	`Y`
CL123	3	27-Mar-2014	456	789AB	135.00	105.00	N

Table 29. Version 3: Claim Line Transaction ⇒ Coverages
Claim Transaction Code	Reversal Indicator	Version	Claim Line Transaction Code	Allowed Amount	Action	Label	Amount
`CL123`	`N`	`1`	`1`	`75.00`	`Covered`	`Covered`	`50.00`
					`Withhold`	`Copay`	`25.00`
			`2`	`60.00`	`Covered`	`Covered`	`60.00`
`CL123`	`Y`	`1`	`1`	`-75.00`	`Covered`	`Covered`	`-50.00`
					`Withhold`	`Copay`	`-25.00`
			`2`	`-60.00`	`Covered`	`Covered`	`-60.00`
`CL123`	`N`	`2`	`1`	`75.00`	`Covered`	`Covered`	`65.00`
					`Withhold`	`Copay`	`10.00`
			`2`	`60.00`	`Covered`	`Covered`	`60.00`
CL123	Y	2	1	-75.00	Covered	Covered	-65.00
					Withhold	Copay	-10.00
			2	-60.00	Covered	Covered	-60.00
CL123	N	3	1	75.00	Covered	Covered	65.00
					Withhold	Copay	10.00
			2	60.00	Covered	Covered	40.00
					Withhold	Coinsurance	20.00

Financial transaction

The financial transaction which is created is associated with the base financial object that was created for claim transaction version 1. The following financial transaction is created.

Table 30. Version 3: Financial Transaction and Financial Transaction Detail Process Data
Version	Processing Type	Reversal?	Creation Date	Total Amount	Due Date	Financial Message Mandatory	Financial Message Bulking Group	Financial Message ID	Financial Message Result
`1`	`Regular`	`N`	`12-Mar-2014`	`$110.00`	`25-Mar-2014`	`N`	`CL123`	`132432`	`M`
`1`	`Regular`	`Y`	`16-Mar-2014`	`-$110.00`	`25-Mar-2014`	`N`	`CL123`	`132432`	`M`
`2`	`Regular`	`N`	`20-Mar-2014`	`$125.00`	`25-Mar-2014`	`N`	`CL123`	`132732`	`M`
2	Regular	Y	24-Mar-2014	-$125.00	25-Mar-2014	N	CL123	NULL	NULL
3	Regular	N	25-Mar-2014	$105.00	25-Mar-2014	N	CL123	NULL	NULL

Table 31. Version 3: Financial Transaction Detail and Financial Transaction Process Data
Version	Reversal?	Claim Line Code	Component Code	Amount	⇒	Invoice Indicator	Invoice Line Grouping	Accounting Detail Grouping	Payment Receiver
`1`	`N`	`1`	`Covered`	`50.00`		`Y`	`N`	`N`	`789AB`
			`Copay`	`25.00`		`N`	`N`	`N`
		`2`	`Covered`	`60.00`		`Y`	`N`	`N`	`789AB`
`1`	`Y`	`1`	`Covered`	`-50.00`		`Y`	`N`	`N`	`789AB`
			`Copay`	`-25.00`		`N`	`N`	`N`
		`2`	`Covered`	`-60.00`		`Y`	`N`	`N`	`789AB`
`2`	`N`	`1`	`Covered`	`65.00`		`Y`	`N`	`N`	`789AB`
			`Copay`	`10.00`		`N`	`N`	`N`
		`2`	`Covered`	`60.00`		`Y`	`N`	`N`	`789AB`
`2`	`Y`	`1`	`Covered`	`-65.00`		`Y`	`N`	`N`	`789AB`
			`Copay`	`-10.00`		`N`	`N`	`N`	`789AB`
		`2`	`Covered`	`-60.00`		`Y`	`N`	`N`	`789AB`
3	N	1	Covered	65.00		Y	N	N	789AB
			Copay	10.00		N	N	N
		2	Covered	40.00		Y	N	N	789AB
			Coinsurance	20.00	N	N	N

Create Financial Messages

The financial messages are created on 29-Mar-2014. The claim has not been unfinalized. A financial message will be created with the following details:

An invoice with a negative calculated delta amount displaying the difference between the current and previous financial transaction

Financial Message

Table 32. Version 3: Financial Message Table
Job ID	Message Date	Message Bulking Criteria
132932	29-Mar-2014	CL123

Table 33. Version 3: Financial Message - Invoice
ID	Invoice Type	Vendor Num	Invoice Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)
89271	Standard	789AB	-20.00	CL123	3

Table 34. Version 3: Financial Message - Invoice Line
ID	Line Number	Line Type	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal)	Attribute 4 (CTR Claim Line Code)
123772	1	ITEM	-65	CL123	2	Y	1
123773	2	ITEM	-60	CL123	2	Y	2
123774	1	ITEM	65	CL123	3	N	1
123775	2	ITEM	40	CL123	3	N	2

Table 35. Version 3: Financial Message - Accounting Detail
ID	Ledger ID	Accounting Date	Amount	Attribute 1 (CTR Claim Code)	Attribute 2 (CTR Version)	Attribute 3 (Reversal)	Attribute 4 (CTR Claim Line Code)	Attribute 5 (Component Code)
8719261	32423432	29-Mar-2014	-65	CL123	2	Y	1	COVERED
8719262	32423432	29-Mar-2014	-25	CL123	2	Y	1	COPAY
8719263	32423432	29-Mar-2014	-60	CL123	2	Y	2	COVERED
8719264	32423432	29-Mar-2014	65	CL123	3	N	1	COVERED
8719265	32423432	29-Mar-2014	25	CL123	3	N	1	COPAY
8719266	32423432	29-Mar-2014	40	CL123	3	N	2	COVERED
8719267	32423432	29-Mar-2014	20	CL123	3	N	2	COINSURANCE

Financial Transaction Process Data

In addition, the following financial transaction processdata columns are set.

Table 36. Version 3: Financial Transaction Process Data
Claim Transaction Code	Version Code	Reversal	Financial Message Datetime	Financial Message ID	Financial Message Result
`CL123`	`1`	`N`	`14-Mar-2014`	`132432`	`M`
`CL123`	`1`	`Y`	`22-Mar-2014`	`132732`	`M`
`CL123`	`2`	`N`	`22-Mar-2014`	`132732`	`M`
CL123	2	Y	29-Mar-2014	132932	M
CL123	3	N	29-Mar-2014	132932	M

Financial Transaction Detail Process Data

The following financial message transaction detail process data columns are set.

Table 37. Version 3: Financial Transaction Detail Process Data
Claim Transaction Code	Reversal	Version Code	Claim Line Transaction	Invoice ID	Invoice Line ID	Accounting Detail ID
`CL123`	`N`	`1`	`1`	`89070`	`123572`	`8719048`
`CL123`	`N`	`1`	`1`			`8719049`
`CL123`	`N`	`1`	`2`	`89070`	`123573`	`8719050`
`CL123`	`Y`	`1`	`1`	`89171`	`123674`	`8719151`
`CL123`	`Y`	`1`	`1`			`8719152`
`CL123`	`Y`	`1`	`2`	`89171`	`123675`	`8719153`
`CL123`	`N`	`2`	`1`	`89171`	`123676`	`8719154`
`CL123`	`N`	`2`	`1`			`8719155`
`CL123`	`N`	`2`	`2`	`89171`	`123677`	`8719156`
CL123	Y	2	1	89271	123772	8719261
CL123	Y	2	1			8719262
CL123	Y	2	2	89271	123773	8719263
CL123	N	3	1	89271	123774	8719264
CL123	N	3	2			8719265
CL123	N	3	1	89271	123775	8719266