Worked Example

This chapter uses sample claim data to show how work items are created and closed for regular claims and large claims. The example values are illustrative and show the expected decision flow. They are not required configuration values.

Regular Claim Worked Example

This example follows claim CLM-1001 through three submit cycles.

Claim Setup

Claim CLM-1001 has three claim lines.

Table 1. Regular Claim Setup
Field	Value
Claim	CLM-1001
Claim lines	CL-001, CL-002, CL-003

Cycle 1: Initial Submit Produces Pends

The operator submits claim CLM-1001 for processing. Adjudication raises pend reasons on the claim header and claim lines.

Table 2. Initial Pend Reasons for CLM-1001
Level	Source	Pend Reasons
Claim header	CLM-1001	PR-101
Claim line	CL-001	PR-205, PR-310
Claim line	CL-002	PR-205

Because no open work item exists yet, the system creates a new work item for the claim.

Table 3. Initial Work Item Creation
Field	Value
Work Item ID	WI-9001
Linked to	CLM-1001
Status	Open

Cycle 2: Operator Partially Resolves and Resubmits

The operator resolves pend reason PR-310 on claim line CL-001 and submits the claim again.

Before re-adjudication creates any new work item, the system closes the open work item on the claim.

Table 4. Work Item Closure Before Re-Adjudication
Field	Value
Work Item ID	WI-9001
Status change	Open to Done

Re-adjudication runs and the following pend reasons remain.

Table 5. Remaining Pend Reasons for CLM-1001
Level	Source	Pend Reasons
Claim header	CLM-1001	PR-101
Claim line	CL-001	PR-205
Claim line	CL-002	PR-205

Because pend reasons still exist, queue resolution runs again and creates a new work item for the claim.

Table 6. New Work Item After Partial Resolution
Field	Value
Work Item ID	WI-9002
Linked to	CLM-1001
Status	Open

WI-9001 and WI-9002 are separate records. The chain is preserved through work item history, not by changing the original work item into the new work item.

Cycle 3: Operator Fully Resolves and Resubmits

The operator resolves pend reasons PR-101 and PR-205 across the claim header and claim lines, and then submits the claim again.

Table 7. Final Regular Claim Work Item Closure
Field	Value
Work Item ID	WI-9002
Status change	Open to Done

Re-adjudication runs and no pend reasons remain. The claim finalizes, and no new work item is created.

Large Claim Worked Example

This example follows large claim LCL-6500, where pend reasons can be raised on sub-claims or claim lines but the work item is created for the parent large claim.

Large Claim Setup

Table 8. Large Claim Setup
Field	Value
Large claim	LCL-6500
Description	Inpatient hospital admission with related outpatient services
Sub-claim `SCL-6501`	Inpatient stay with lines `CL-IN1` and `CL-IN2`
Sub-claim `SCL-6502`	Radiology services with line `CL-RD1`
Sub-claim `SCL-6503`	Post-discharge follow-up with lines `CL-PD1` and `CL-PD2`

Cycle 1: Initial Submit Produces Sub-Claim and Line Pends

The operator submits large claim LCL-6500. Pend reasons are raised on sub-claim and claim-line records.

Table 9. Initial Pend Reasons for LCL-6500
Level	Source	Pend Reasons
Large claim header	LCL-6500	(clean)
Sub-claim header	SCL-6501	PR-530
Claim line	CL-IN1	PR-220
Claim line	CL-IN2	(clean)
Sub-claim header	SCL-6502	(clean)
Claim line	CL-RD1	PR-415
Sub-claim header	SCL-6503	(clean)
Claim line	CL-PD1	PR-220
Claim line	CL-PD2	(clean)

The sub-claim and line pend reasons trigger queue resolution, but the work item is created on the parent large claim.

Table 10. Large Claim Work Item Creation
Field	Value
Work Item ID	WI-4500
Linked to	LCL-6500
Status	Open

Cycle 2: Resolve Sub-Claim Pends and Resubmit

The operator resolves PR-530 on SCL-6501, PR-220 on CL-IN1 and CL-PD1, and PR-415 on CL-RD1. The operator then submits large claim LCL-6500 again.

The system closes the existing work item before creating any new work item from re-adjudication.

Table 11. Large Claim Work Item Closure Before Re-Adjudication
Field	Value
Work Item ID	WI-4500
Status change	Open to Done

Re-adjudication runs. All sub-claims finalize cleanly, but External Intervention Rules trigger on the large claim header.

Table 12. External Intervention Pend Reasons
Pend Reason	Reason for Trigger
PR-705	Aggregate billed amount exceeds USD 50,000 threshold.
PR-880	Out-of-state provider involved in admission.

Because pend reasons still exist on the large claim header, queue resolution creates a new work item for the parent large claim.

Table 13. New Large Claim Work Item
Field	Value
Work Item ID	WI-4501
Linked to	LCL-6500
Status	Open

Within Cycle 2, WI-4500 is closed first, and then WI-4501 is created. At no point are two work items open on the same large claim at the same time.

Cycle 3: Accept on Manual Adjudication

The operator reviews and accepts the claim. Accept routes through Submit, so the existing work item is closed during the submit process.

Table 14. Final Large Claim Work Item Closure
Field	Value
Work Item ID	WI-4501
Status change	Open to Done

What These Examples Show

A regular claim work item is linked to the claim.
A large claim work item is linked to the parent large claim, even when a sub-claim or claim line triggers the pend.
During submit processing, the system closes the existing open work item before it creates a new work item for any remaining pend reasons.
If no pend reasons remain after re-adjudication, no new work item is created.