This list is based on the Gherkin scenarios to enable further refinement and discussion.

Submitting a valid claim

TBC

Submitting a partially valid claim

There are many ways to submit an invalid claim. Some of the checks performed by the backend cannot even be performed from the web interface.

Here is a list of possible rejection scenarios:

Invalid family

This validation will fail if the insuree is invalid, or his/her family itself is invalid.

Rejection reason code: 7

Invalid target date

The target date is the “date to” field of the claim or, if unspecified, the “date_from” field.

Rejection reason code: 9

Claim item/service refers to an invalid item/service

Rejection reason code: 1

Claim item/service is not the right pricelist

The claim item/service refers to an item/service that should be listed (price list detail) in a pricelist linked to the claim health facility with the appropriate mask.

Rejection reason code: 2

Claim item/service is not the right care type

If the claim item/service has a care type of in-patient but the health facility is out-patient and the target date equals the date-from (so single day), the claim item/service is rejected.

Same if the item/service care type is out-patient but the health facility is in-patient and the care occurred over several days.

Rejection reason code: 10

Claim item/service mask limitation

The item or service has a patient mask associated to it. If the patient doesn’t fit the mask, the claim item is rejected.

For example, a pediatrics service has a mask of 11 and the patient is an adult male (mask 5), this will fail.

Rejection reason code: 4

Claim item/service waiting period

This validation is a bit complex and in the stored procedure was computed with a Gregorian calendar.

The general idea is that the Product (Item/Service) can have a waiting period for children or adults, depending on the type of care. When the Claim is requested before the waiting period or after the expiration of the product, the claim is rejected.

Rejection reason code: 17

Claim item/service is not the right care type

The product item/service can have a limit for adults and for children. If this limit is reached, the claim is rejected.

Rejection reason code: 16

Claim service maximum consultations

If the claim service is of category C and the product has a maximum number of consultations, this is verified.

Rejection reason code: 13

Claim service maximum surgeries

If the claim service is of category S and the product has a maximum number of surgeries, this is verified.

Rejection reason code: 14

Claim service maximum deliveries

If the claim service is of category D and the product has a maximum number of deliveries, this is verified.

Rejection reason code: 15

Claim service maximum hospital admissions

If the claim service is of category H and the product has a maximum number of admissions, this is verified.

Rejection reason code: 11

Claim service maximum visits

If the claim service is of category V and the product has a maximum number of visits, this is verified.

Rejection reason code: 12

Claim item/service could not be found

If the process could not find a suitable/valid product item/service, the claim is rejected.

Rejection reason code: 3

Submitting a none valid claim

TBC

Submitting multiple claims

TBC