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

• Claim

• Beneficiary identifier

• Adjustments 

• Voids

• Benefit plan  

• Re-submitted claims

• Claims-related policies

• Pre-authorization match

• Eligibility status

• Benefit class

• Beneficiary accumulators

• Co-insurance

• Copayments

• Deductibles

• Fee schedule

• Provider identifier

• Provider accumulators

Output

• 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

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

Task Flow Diagram

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf