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Process Group
Claims Management
Objective
Timely processing of approved modified payment amounts for claims that have been through the claims dispute process.
Input
- Claim identifier
- Beneficiary identifier
- Provider identifier
- Claim information (Encounter date, claim number)
- Claim adjustment amount
- Increase of claim payout
- Decrease of claim payout
- Void
Output
- Explanation of Benefits sent to provider and/or beneficiary
- Financial transaction to GL (positive if amount has been adjusted up, negative if amount has been adjusted down or claim voided)
- Update beneficiary accumulators
Update provider accumulators
Task Set
Measurable Outcomes
- Claim status sent to provider
- Explanation of Benefits sent to provider and/or beneficiary