JLN Process - Claims dispute and appeals

Process Group

Claims Management

Objective

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 .

Input

• Claim identifier
• Beneficiary identifier
• Provider identifier
• Claim information (e.g., encounter date, claim number) Dispute notes

Output

• 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

• Settlement of dispute

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf