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- Acknowledgement to provider of receipt of claim
- Claim identifier
- Claim status (in process, partially approved, approved, rejected, requires more information, in medical review)
- Amount approved for claim
- Explanation of Benefits
- Financial transaction to GL
- Update beneficiary accumulators
- Update provider accumulators
- Line items for claims advice
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- 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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