JLN Process - Claims dispute and appeals

[ 1 Process Group ] [ 2 Objective ] [ 3 Input ] [ 4 Output ] [ 5 Measurable Outcomes ] [ 6 Sources ]

Process Group

Claims Management


Facilitate timely resolution through secondary review  of adjudicated  claims which parties (e.g., beneficiary and insurance provider OR provider and insurance provider) do not agree .



  • Change claim status to dispute

  • Input into possible policy change

  • Advice to claim office ―factory‖ on how to deal with type of claim in future

  • Amount approved for claim

  • Claim identified for reprocessing

  • Financial transaction to GL (e.g., accounts receivable/payable) Case referred to arbitration  

Measurable Outcomes


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