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Process Group
Claims Management
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Facilitate timely resolution through secondary review of adjudicated claims claims which parties (e.g., beneficiary and insurance provider OR provider and insurance provider) do not agree .
Input
Claim identifier
Beneficiary identifier
Claim information (e.g., encounter date, claim number) Dispute notes
Output
Change claim status to dispute
Input into possible policy change
Advice to claim office ―factory‖ on how to deal with type of claim in future
Amount approved for claim
Claim identified for reprocessing
Financial transaction to GL (e.g., accounts receivable/payable) Case referred to arbitration