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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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Calculation the relative indexes : (Per Product and period)
For all product on chosen location (should also take product on sub locations),
all contribution will be added up
all valuated amount for the “relative priced“ Items and services for of that product will be added up
update of the remunerated amount (Per Product and period)
for all “relative priced“ Items and services for the produce product for which the claim was processed in the period
update all claims remunerated amount for that Product
add up the remunerated amount for 'R' claim items and services and remunerated amount (or valuated amount) for the non “r” claim items and service
Note: the claims of R1 but having a product from R2 should be taken into account when R2 batch run is launched
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