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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>