Process Group

Claims Management

Objective

Provide timely status of submitted claims.

Input

• Claim identifier

• Beneficiary identifier

• Provider identifier

• Encounter date

Output

• Time-based claim status

• Claim status ( e.g., not received, In process, partially approved, approved, rejected, requires more information, In medical review)

Measurable Outcomes

• Time-based claim status

• Payment amount approved for claim

• Explanation of Benefits

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf