Process Group

Claims Management

Objective

Timely processing of approved modified payment amounts for claims that have been through the claims dispute process.

Input

• Claim identifier

• Beneficiary identifier

• Provider 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

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf