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Process Group
Claims Management
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Timely processing of approved modified payment amounts for claims that have been through the claims dispute process.
Input
Claim identifier
Beneficiary 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