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Preview Payer Claim Workflow Guide

Preview Payer Claim Workflow: Tracking Claim Status After Submission to Payer

1. Overview

This guide explains the Preview Payer Claim workflow, which allows providers and beneficiaries to view the details and status of a claim after it has been submitted to the payer. This workflow provides visibility into the claim’s progress, status, and any updates or actions taken by the payer.

1.1. What This Workflow Does

The Preview Payer Claim workflow enables users to:

• Track Claim Status: View the current status of the claim as seen by the payer (e.g., AUTHORIZED, CLOSED, REJECTED).
• Review Claim Details: See all claim data, including invoices, interventions, diagnoses, and attachments as processed by the payer.
• Monitor Updates: Stay informed about any changes, approvals, or rejections made by the payer.
• Facilitate Communication: Understand what the payer sees, helping resolve issues or follow up on pending claims.

1.2. Why This Workflow Is Critical

• Transparency: Users can track the claim’s journey and status after submission.
• Accountability: Ensures both provider and beneficiary are aware of payer actions.
• Faster Resolution: Helps identify and address issues or delays in claim processing.

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2. Workflow Details: Preview Payer Claim

2.1. Workflow Description

When a user requests to preview a payer claim, the following steps occur:

1. Input Reception: The user submits a request with the claim’s consent token and facility identifiers.
2. Claim Lookup: The system queries the payer’s records for the claim.
3. Status & Data Retrieval: The payer returns the claim’s current status and all associated data.
4. Outcome Delivery: The user reviews the claim as seen by the payer, including any updates or actions taken.

2.2. Key Validations: System Checks

• Consent Token Must Be Provided:
  The consent token uniquely identifies the claim to preview.
• Facility Identifiers:
  Facility ID and type may be required for multi-facility providers.
• Required Fields:
  All mandatory claim fields must be present for accurate tracking.

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 preview
facility_id	Facility identifier	String	No	Specifies the facility for the claim
facility_id_type	Type of facility identifier	String	No	Indicates the identifier type

Returned Data Includes:

• Claim status (claim_auth_status)
• Total claim amounts
• Invoices and invoice lines
• Interventions
• Diagnoses
• Attachments
• Workflow state

2.4. Expected Outcomes from this workflow

• Successful Preview: Claim details and status are returned as seen by the payer.
• Claim Not Found: No claim matches the provided consent token; input may need verification.
• Input Error: Provided identifiers are invalid or missing.

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3. Example API Usage

Endpoint:
POST /adapter/facade/edi/v1/claims/claims

Request Body Example:

Code
 
{
  "consent_token": "7EE5HKBV6L"
}

Response Example:

Code
 
{
  "id": "8b4ddfb3-5da2-4d78-8fea-cc82776bbb9f",
  "claim_auth_status": "CLOSED",
  "total_claim_amount": "0.00",
  "total_claim_net_amount": "0.00",
  "invoices": [
    {
      "id": "628d5077-f691-43a0-a1d2-6f7e68311ffc",
      "invoice_number": "INV/13545/70179-CLOSED-8822",
      "total_inv_amount": "800.00",
      "workflow_state": "INVALID",
      "lines": [ /* ... */ ],
      "scheme_name": "SOCIAL HEALTH AUTHORITY",
      "patient_name": "CLIFFORD OCHIENG OUMA",
      "provider_name": "HALCYON HEALTHCARE LIMITED",
      "member_number": "CR6996401484997-0"
    }
  ],
  "payer_name": "Social Health Authority",
  "provider_name": "HALCYON HEALTHCARE LIMITED",
  "scheme_name": "SOCIAL HEALTH AUTHORITY",
  "patient_name": "CLIFFORD OCHIENG OUMA",
  "currency": "KES",
  "authorization_code": "CSBHHZA2LU",
  "workflow_state": "CLOSED"
}

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4. How Preview Payer Claim Connects to Other Workflows

• Billing: Confirms the payer’s view of billing lines and invoices.
• Interventions: Validates interventions as processed by the payer.
• Attachments & Diagnoses: Shows all supporting documents and diagnoses as received by the payer.

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5. Key Success Factors for Payer Claim Preview

• Use Valid Consent Tokens: Always provide the correct consent token for the claim.
• Review All Data: Check every section of the claim for completeness and accuracy.
• Follow Up Promptly: Address any issues or discrepancies with the payer as soon as possible.
• Maintain Compliance: Ensure all claim data meets regulatory and payer requirements.

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