Process Group
Claims Management
Objective
Timely and accurate processing of claims to determine the validity of the claim and the amount to be paid. Input
Output
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Task Set
- 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)
Measurable Outcomes
- Claim assigned status and determination of payment
- Claims status sent to provider, beneficiary and other appropriate authorities Explanation of Benefits sent to provider and/or beneficiary
- Timeliness of claims processing
- First time claim pass rate