Financial Preprocessing – Select Transactions into a Set

A health insurance claim is a reimbursement request for services administered to a patient by a healthcare provider. The healthcare provider creates this request and sends it to the payer for that patient’s insurance. The payer has the member registered in one of its plans. Large healthcare payers typically process tens of thousands of claims per day. Oracle Health Insurance Claims processes these claims, determining the price and the member’s benefits. The fully adjudicated claim can be denied or approved at the end of that process. When approved, the claim typically leads to a payment. To represent this, OHI Claims creates a financial transaction whenever a payment is due.

Sometimes, after the claim is paid, the same claim is re-adjudicated. There are several possible causes for this. One common reason is that the payment receiver disagrees with how the claim adjudication happened. As a result, you need to change the payment amount. This requires you to unfinalize, modify, and reprocess the claims. The application creates a new financial transaction and a reversal financial transaction for the previous payments of the claims. Financial preprocessing is the process of converting all these financial transactions into a financial message for the subsequent accounts payable systems to make or collect payments. In general, the generation of a financial message happens daily.

Financial preprocessing consists of the following three steps:

Step I: Select Financial Transactions into a Set
Step II: Supersede
Step III: Generate a Financial Message

In the first step, you run the process that selects financial transactions into a set. The financial transaction set represents the unit of work for financial preprocessing. Further steps consolidate all of the financial transactions in the collection and map them to financial messages.

The application supports two scenarios. You can either add the financial transactions to an existing set or a new set. The best practice is to create a new set every day that includes all the financial transactions created on that same day.

As an end user, you initiate the Select Transactions into a Set activity. The activity has the following parameters. These parameters allow you to scope the addition of the financial transactions to the set.

Table 1. Select Transactions into a Set Activity Parameters
Name	Description
Financial Transaction Set Code	The code of the new financial transaction set. The application generates a code if the user leaves the code empty.
Description	The description of the new financial transaction set.
Transaction Created Date From Transaction Creation Time From / Transaction Created Date To Transaction Creation Time To	Evaluate to true if the creation date of the financial transaction falls within the parameters. If the time element is not specified, it works as follows: If the time element for Transaction Creation Date From is left unspecified, it translates to 00:00 If the time element for Transaction Creation Date To is left unspecified, it translates to 23:59
Penalty Date From / Penalty Date To	Evaluate to true if the penalty date of the financial transaction falls within the parameters.
Brand Code	Evaluate to true if a financial transaction uses the same product brand code
Grouping	Evaluate to true if the financial transaction set grouping matches the specified criterion. When not mentioned, no restrictions apply. The condition used to group financial transactions into a single financial transaction set. By default, this is not set.

Use Case

For the claims application, the common use case is to generate a financial message for all of the finalized claims on that day. The following is a stepwise explanation of how this works.

Consider the following three claims. They have been fully processed and finalized.

Figure 1. Financial Preprocessing Select Transactions into a Set - Three Claims.
When a claim finalizes, the application creates a financial transaction for that claim. The financial transaction contains the payment amount that is equivalent to the covered amount in the claim. For claims 1, 2, and 3, the corresponding covered amounts are 80 dollars, 450 dollars, and 170 dollars.

Figure 2. Financial Preprocessing Select Transactions into a Set - Financial Transactions
In this step, you run the Select Transactions into Set activity. This activity bundles the financial transactions into a set. Later in the process, you use this set to create a financial message.

Figure 3. Financial Preprocessing Select Transactions into a Set - Financial Transactions in a set
The previous step creates a set of financial transactions. Now, let us say you received an appeal for claim 2 from the provider, Dr. Allen. The appeal is about a disagreement in the claim. A provider appeals over a claim that was denied but believes it should have been accepted under the benefits of the plan. The claims operator unfinalizes the claim and changes the claim accordingly. After the claim is finalized, it is adjudicated to be the covered amount of 450 dollars instead of 490 dollars. As a result, the application creates a new financial transaction and a reversal financial transaction with covered amounts of 450 dollars and -490 dollars for the initial payment. The financial transaction set does not automatically include the latest transactions. Run the select transactions into the set activity again to add them. The financial transactions of version 2 and the reversal of version 1 of claim 2 are now included in the set.

Figure 4. Financial Preprocessing Select Transactions into a Set - Updated Claim - New Financial Transactions
In this step, you run the Supersede activity. This activity prevents the application from sending out unnecessary financial transactions. This activity consolidates all financial transactions for the same claim and sends out only the latest transactions. In our example for claim 2, this means that version 1, as well as the reversal of version 1, are ignored in the next steps. The application only needs to send version 2 of the financial transaction because it represents the first payment for this claim.

Figure 5. Financial Preprocessing Select Transactions into a Set - Superseded Transactions.
In this step, you run the Generate Financial Message activity. This activity takes all the financial transactions in the set and generates a financial message.

Figure 6. Financial Preprocessing Select Transactions into a Set - Financial Message - Set Closed.

As long as the financial transaction set is open, it is available for additions. After the application has processed all the financial transactions in the set, it closes the set. Once the set is closed, you can no longer add financial transactions to it.

Error Messages:

All of the mentioned activities apply validation checks before running. These are the errors that can occur. They appear in the response messages for this activity.

Table 2. Error Messages
Code	Severity	Message
FIN-FL-SIFS-001	Informative	Cannot add financial transaction to the transaction set because another version of this transaction is included in a set {code} that is open.
FIN-VL-SIFS-001	Fatal	Financial Transaction Set Code {code} is already in use.
FIN-VL-SIFS-005	Fatal	Cannot add financial transactions to financial transaction set with code {code} because the set is closed.
FIN-VL-SIFS-006	Fatal	Transaction creation date `From` should not be greater than transaction creation date `To`.
FIN-VL-SIFS-007	Fatal	Payment due date `From` should not be greater than payment due date `To`.
FIN-VL-SIFS-008	Fatal	Penalty date `From` should not be greater than penalty date `To`.
FIN-VL-SIFS-009	Fatal	Brand Code {0} is unknown.
FIN-VL-SIFS-010	Fatal	Cannot add financial transactions to financial transaction set with code {code} because the set is blocked.

NOTE:

If the claim is a large claim, its financial transactions must remain within a single set, and they cannot be distributed across multiple sets. All the financial transactions that share the same Large Claim Code attribute in the financial base object must be contained within a single set. If a financial transaction cannot be added to the financial transaction set, as a result of this condition, the message FIN-FL-SIFS-001 is created as an activity message. This condition will not stop the processing of other transactions that were selected by this activity.
If a financial transaction is subject to a system financial hold (FIN_FHTP_CLA_001) and pertains to a large claim, it cannot be added to any financial transaction set.