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page under construction |
Submit claims
Once the claim is “final“ from the HF point of view, the claim admin can submit the claim
at the claim submission automatic admin check are done one the claim
Check if the insuree exist
check insuree coverage
check claimcode uniqueness
check Item and service exist
check that the Item and service are on the pricelist of the HF
check Item and service limits (mask, frequency, ….)
Beyond health missing requirements:
calculation of cash payment
review claims
Once the claim is submitted the scheme clerc can scutinize the claim
check the claim based on supporting evidence (invoice, medical procedure results, coherence trreatment/items and services)
Beyond health missing requirements:
Assigning claim to reviewer groups based on claim characterisitic (type fo claim, values … )
Definition of different kind of review: admin, medical, audits
Process claims
Batch run
original design : <TO be uploaded>
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