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Edit Claim Line Workflow Guide

Edit Claim Line Workflow: Adjusting Amount and Quantity After Resubmission

1. Overview

This guide explains the Edit Claim Line workflow, which allows providers to adjust the unit price and quantity of a claim line after a claim has been resubmitted and transitioned to an editable status (DRAFT_RESUBMIT). This workflow is designed to enable corrections while maintaining strict controls to prevent fraud.

1.1. What This Workflow Does

The Edit Claim Line workflow enables providers to:

• Edit Amount and Quantity: Adjust only the unit price and quantity for a specific claim line.
• Ensure Data Integrity: Restrict edits to prevent unauthorized changes to other claim details.
• Prepare for Accurate Resubmission: Make necessary corrections before the claim is resubmitted for payer review.

1.2. Why This Workflow Is Critical

• Prevents Fraud: Only amount and quantity can be changed, reducing risk of manipulation.
• Improves Accuracy: Providers can fix errors flagged by the payer or internal checks.
• Speeds Up Processing: Ensures claims are correct before final resubmission.

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2. Workflow Details: Edit Claim Line

2.1. Workflow Description

When a provider needs to edit a claim line, the following steps occur:

1. Input Reception: The provider submits a request with the claim’s consent token and the line ID to be edited.
2. Validation: The system checks that the claim is in an editable status (DRAFT_RESUBMIT) and that the line exists.
3. Edit Action: The provider specifies the new unit price and quantity for the claim line.
4. Outcome Delivery: The system updates the claim line and returns the revised details for review.

2.2. Key Validations: System Checks

• Editable Status Required:
  The claim must be in DRAFT_RESUBMIT status to allow edits.
• Valid Consent Token and Line ID:
  Both must be provided and match an existing claim and line.
• Allowed Fields:
  Only unit_price and quantity can be changed.

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 edit
line_id	Unique identifier for the claim line	String	Yes	Specifies which line to edit
unit_price	Adjusted unit price for the line	Number	Yes	New price for the claim line
quantity	Adjusted quantity for the line	Integer	Yes	New quantity for the claim line

2.4. Expected Outcomes from this workflow

• Successful Edit: The claim line is updated with the new amount and quantity.
• Edit Not Allowed: The claim is not in an editable status or the line does not exist.
• Input Error: Provided identifiers or values are invalid.

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3. Example API Usage

Endpoint:
PATCH /adapter/facade/is/v1/invoice_lines/adjust_virtual_claim_line

Request Body Example:

Code
 
{
  "consent_token": "DCW9JXNMDY",
  "line_id": "8d7dabfd-03ef-44fa-bfef-b360907a1cf2",
  "unit_price": 1000,
  "quantity": 1
}

Response Example:

Code
 
{
  "invoice": "11111111-d51c-4e91-91d0-24c8155f85bc",
  "item_code": "SHA-07-005",
  "item_name": "Post-partum Complications",
  "charge_date": "2025-09-23T15:24:23.182593+03:00",
  "unit": "DAYS",
  "unit_price": "1000.00",
  "quantity": 1,
  "line_total_amount": "1000.00",
  "line_net_amount": "1000.00",
  "id": "8d7dabfd-03ef-44fa-bfef-b360907a1cf2",
  "intervention_code": "SHA-07-005",
  "scheme_code": "UHC",
  "scheme_name": "SOCIAL HEALTH AUTHORITY",
  "bill_from": "2025-09-23T15:02:21.885861+03:00",
  "bill_to": "2025-09-23T15:24:23.174440+03:00",
  "is_active": true
}

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4. How Edit Claim Line Connects to Other Workflows

• Resubmit Claim: Must be performed after the claim is transitioned to DRAFT_RESUBMIT.
• Preview & Submission: After edits, the claim can be previewed and resubmitted to the payer.
• Audit Trail: All edits are tracked for compliance and fraud prevention.

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5. Key Success Factors for Edit Claim Line Workflow

• Use Valid Identifiers: Always provide the correct consent token and line ID.
• Edit Only Allowed Fields: Restrict changes to amount and quantity.
• Review Before Submission: Ensure all edits are accurate before resubmitting the claim.
• Maintain Compliance: Follow regulatory standards during claim editing.

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