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- Claim
- Beneficiary identifier
- Adjustments
- Voids
- Benefit plan
- Re-submitted claims
- Claims-related policies
- Pre-authorization match
- Eligibility status
- Benefit class
- Beneficiary accumulators
- Co-insurance
- Copayments
- Deductibles
- Fee schedule
- Provider identifier
- Provider accumulators
...
- Registration of incoming claim
- Assign claim identifier
- Pre-process and edit claim data
- Aggregate, merge and batch claims data
- Manage claims exceptions
- Apply adjudication rules (skip to approve or reject)
- Flag for fraud and abuse
- Route for medical review
- Approve and prepare payment transaction
- Reject and assign reason code
- Update beneficiary and provider accumulators
- Determine line items for claim (confirm for proper term: advice, Explanation of Benefits statement, receipt, remittance)
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