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Close Claim Workflow Guide

Close Claim Workflow: Terminating Claims Not Scheduled for Submission

1. Overview

This guide explains the Close Claim workflow, which allows providers and integrators to terminate a claim that is not scheduled for submission to the payer. If, for any reason, a provider decides not to proceed with a claim, this workflow enables them to close the claim, changing its status to CLOSED.

1.1. What This Workflow Does

The Close Claim workflow enables users to:

• Terminate Unwanted Claims: End claims that are no longer needed or were created in error.
• Change Claim Status: Update the claim’s status to CLOSED, preventing further edits or submission.
• Document Cancellation Reason: Record the reason for closing the claim for audit and compliance purposes.

1.2. Why This Workflow Is Critical

• Prevents Unnecessary Processing: Stops claims that should not be submitted, reducing clutter and confusion.
• Supports Compliance: Ensures all claim closures are documented with a reason.
• Improves Data Integrity: Keeps the claims database clean and accurate.

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2. Workflow Details: Close Claim

2.1. Workflow Description

When a provider or integrator needs to close a claim, the following steps occur:

1. Input Reception: The user submits a request with the claim’s consent token and a cancellation reason.
2. Status Transition: The system updates the claim’s status to CLOSED.
3. Outcome Delivery: The claim is terminated and cannot be edited or submitted to the payer.

2.2. Key Validations: System Checks

• Consent Token Must Be Provided:
  The consent token uniquely identifies the claim to be closed.
• Cancellation Reason Required:
  Both the type and detailed explanation of the cancellation reason must be provided.

2.3. Workflow Data Dictionary

Field Name	Description	Data Type	Required	Purpose
consent_token	Unique code for the claim	String	Yes	Identifies which claim to close
cancel_reason_type	Type of cancellation reason	String	Yes	Specifies the category of cancellation
cancel_reason_text	Detailed explanation of the cancellation	String	Yes	Documents the reason for closing the claim

Allowed Values for cancel_reason_type:

• WRONG_PATIENT
• NO_SERVICE_GIVEN
• WRONG_BENEFIT
• EXPIRED_VISIT
• EXHAUSTED_BENEFIT
• TIME_BARRED
• OTHER_REASONS

2.4. Expected Outcomes from this workflow

• Successful Closure: The claim status is updated to CLOSED and no further actions can be performed.
• Input Error: Provided identifiers or cancellation reason are invalid or missing.

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3. Example API Usage

Endpoint:
POST /adapter/facade/is/v1/claims/close_virtual_claim_visit

Request Body Example:

Code
 
{
  "consent_token": "CSBHHZA2LU",
  "cancel_reason_type": "OTHER_REASONS",
  "cancel_reason_text": "Wrong claim"
}

Response Example:

Code
 
{
  "id": "8b4ddfb3-5da2-4d78-8fea-cc82776bbb9f",
  "claim_auth_status": "CLOSED",
  "total_claim_amount": "0.00",
  "invoices": [
    {
      "invoice_number": "INV/13545/70179-CLOSED-8822",
      "workflow_state": "INVALID"
    }
  ],
  "interventions": [
    {
      "intervention_code": "SHA-18-001",
      "intervention_name": "Haemoglobin A1C (HbA1C)"
    }
  ],
  "cancel_reason_type": "OTHER_REASONS",
  "cancel_reason_text": "Wrong claim"
}

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4. How Close Claim Connects to Other Workflows

• Claim Lifecycle: Provides a way to terminate claims that are not proceeding to submission.
• Audit Trail: Ensures all closures are documented for compliance and reporting.

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5. Key Success Factors for Close Claim Workflow

• Use Valid Consent Tokens: Always provide the correct consent token for the claim.
• Document Cancellation Clearly: Choose the appropriate cancellation reason and provide a clear explanation.
• Review Before Closure: Ensure the claim truly needs to be closed, as this action cannot be undone.

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