Remittance

Copy page

Remittance Process Guide: Get Claims Paid by Remittance Workflow

1. Overview: Accessing a Detailed Claim Breakdown for a Specific Payment

This guide focuses on the Get claims paid by remittance workflow, which is part of the larger Remittance Process. It examines a specific payment to determine which claims were covered by that payment. The primary purpose of this workflow is to provide a detailed, claim-by-claim breakdown of a specific remittance, enabling accurate financial reconciliation.

1.1. What This Workflow Does

This workflow retrieves a list of all claims that were paid under a given remittance. It uses the unique bank_reference and the facility's ID to return individual claim-level payment information.

1.2. Why This Workflow Is Critical (The "Why It Matters")

A claim-by-claim breakdown is essential to proper reconciliation. Without this:

• Unreconciled Claims: The facility won't know which specific claims were paid.
• Billing Discrepancies: Partial, full, or denied claims go untracked, causing accounting errors.
• Inefficient Follow-up: Outstanding claims can't be pursued without clarity.
• Audit Deficiencies: Missing links between payments and claims create audit trail gaps.

This workflow ensures every payment is mapped to its respective claims for clean accounting and tracking.

---

2. Workflow Details: Get Claims Paid by Remittance

2.1. Workflow Description: Step-by-Step System Behavior

1. Input Reception
   Receives:

   • facility_id
   • facility_id_type
   • bank_reference

2. Validation

   • Confirms the facility is valid.
   • Confirms the bank_reference is valid for that facility.

3. Claim Data Retrieval
   Queries the system for all claims associated with the given bank_reference.

4. Data Compilation
   Gathers claim details:

   • Claim ID
   • Payment amount
   • Payment status

5. Output Delivery
   Returns the complete claim list for that remittance.

---

2.2. Key Validations: Our System’s Essential Checks

• Valid Remittance Identifier
  bank_reference must exist and be linked to the specified facility.

• Valid Facility Identification
  facility_id must be valid, and facility_id_type must be one of:

  • fr-code
  • registration-number
  • fid

---

2.3. Workflow Data Dictionary: What Information We Work With

Field Name	Description	Data Type	Required	Purpose
facility_id	Unique identifier of the healthcare facility	string	Yes	Primary key used to locate remittance and claim data
facility_id_type	Format/type of facility_id (e.g., fr-code, fid)	string	Yes	Informs the system how to interpret and validate the facility
bank_reference	Unique identifier for a specific remittance payment	string	Yes	Connects the request to a specific remittance for claim lookup

---

2.4. Expected Outcomes from this Workflow

• Success: Claims Breakdown Retrieved
  A detailed list of claims paid under the specified remittance is returned.

• Failure: Invalid Remittance Reference
  The bank_reference is not valid for the specified facility.

• Failure: Invalid Facility Identification
  The facility_id or facility_id_type is incorrect or not recognised.

• Failure: No Claims Found
  The remittance exists, but no claims are linked to it.

• Failure: Missing Required Data
  One or more required fields (facility_id, bank_reference) is missing or malformed.