Claims Processing & Adjudication

Libraries: claims, clmentry, clmforms, clmprint, clmrpt, clmshare, clmsproc, clmutils (94 windows, 553 DataWindows). Requirement prefix: CLM.

Purpose & business capability

This is the core module of HOMER. It captures health-benefit claims on form-specific entry screens (HCFA‑1500, UB92, dental, vision, drug, FSA/reimbursement, weekly-disability, repricing sheets, and others), moves each claim through a staged processing pipeline (corrections → code review → pre-adjudication → duplicate check → pricing → adjudication → payment allocation → audit → funding → paid), automatically applies plan benefit rules (exclusions, copays, deductibles, coinsurance, out-of-pocket, claimed/paid limits, holds), maintains member/family accumulators, coordinates benefits with other carriers, produces EOBs, member/provider letters and operational reports, and hands finished claims to the Funding module (fund register / check issuance). It also stages claims for outbound EDI to trading partners (e.g. PPO networks for repricing).

The pipeline stages themselves are executed by a background batch process (user id SFPIBACK appears throughout as the automated actor); the screens in this module are used to enter claims, correct errors raised as claim messages, override system decisions, and monitor the pipeline. The adjudication engine itself (clmsproc/n_claim_adjudication, 8,800+ lines) lives in this domain and is invoked both by the batch process and by interactive "send back to corrections" logic.

Actors

Actor	Evidence
Claims entry operator ("claim person")	claim id embeds first 3 chars of the entering user's id (clmshare/n_cst_claims, of_getnewclaimid)
Claims examiner	claims.claim_examiner_sys_key / claim_examiner_userid columns (clmshare/d_claims_master); examiner audit setup (claims/w_audit_examiners_selection)
Claims auditor	Audit status screens (claims/w_claim_editor "Claims Audit" mode; claims/w_setstatusfromaudit)
Claims supervisor / MIS	claim unlock (claims/w_claims_unlock), background monitor (clmutils/w_bkgd_monitor), rule utilities (clmutils/w_adjd_rule_utils)
Background batch process (SFPIBACK)	messages closed by sfpiback treated specially (clmsproc/n_claim_adjudication, of_adjudicateclaims); pricing rules created by SFPIBACK deleted on reset (clmshare/n_cst_return_claim_to_corrections)
Security-restricted user groups	group-level claim access; Returned Claims / develop groups may open RETURN/DELETE/UNIDENT claims (clmshare/n_cst_claim_control, of_checksecurityaccess)

Key workflows

Claim lifecycle (status pipeline)

The pipeline order and display names are data-driven from table claim_status_order (clmshare/d_claim_status_order, used by clmshare/n_claims_status). The nine processing stages monitored by the background monitor are hard-coded in clmutils/w_bkgd_monitor (dw_status_counts, pfc_retrieve):

ls_status = {'RFCP', 'RFCR', 'RFPA', 'RFDC', 'RFPR', 'RFA', 'RFAL', 'RFCA', 'RFF'}
ls_desc   = {'Corrections', 'CodeReview', 'Pre-Adjd', 'DupCheck', 'Pricing', 'Adjudication', 'Pmt Alloc', 'Audit', 'Funding'}

Statuses evidenced in code, beyond the nine pipeline stages: PAID, and the sub-statuses VOID, RETURN, DELETE, UNIDENT (claims/w_setclaimsstatus; clmshare/n_cst_claim_control of_checksecurityaccess), the HOLD variants formed by appending HOLD to a status (e.g. RFCPHOLD, RFAHOLD — clmshare/n_cst_claims of_setclaimsstatus strips the trailing "HOLD"; clmsproc/n_claim_adjudication references RFAHOLD), and REXOUT for electronically paid claims released from audit (clmshare/n_cst_claims, of_closemessage case 151).

Notes on the diagram: transitions between adjacent pipeline stages other than those cited are performed by the background batch application, which is outside these libraries (see Open questions). "Send back to corrections" (clmshare/n_cst_return_claim_to_corrections) is possible from any status above RFCPHOLD until funding data exists.

Stage behavior evidenced in this domain

1. Entry (→ RFCP). A claim is captured on a form-specific tab object; on first save it receives a generated claim id and status RFCP (clmshare/n_cst_claims, of_setnewclaim / of_getnewclaimid / of_save).
2. Corrections (RFCP). Errors raised by the pipeline appear as claim messages (claim_messages); the Claims Correction screen retrieves claims with open messages and drives resolution message-by-message (claims/w_claim_correction, clmshare/n_cst_claims of_closemessage).
3. Pre-adjudication (RFPA). clmsproc/n_claim_adjudication.of_processclaimdef assigns a benefit definition to every claim line from the benefit package's prioritized definition list, corrects UB92 room & board dates, performs whole-claim (per-diem) pricing for qualifying repricing sheets, and performs accident-record checking.
4. Duplicate check (RFDC). Lines flagged duplicate_claim_line_ind = 'Y' are rejected with the system duplicate reason; message 102 carries the list of candidate duplicate claim ids (DupClaims: system comment) for examiner disposition (clmsproc/n_claim_adjudication of_adjudicateclaims; clmshare/n_cst_claims of_closemessage case 102; claims/u_duplicate_claim).
5. Pricing (RFPR). Allowed amounts / write-offs are produced by the Pricing module (outside this domain); adjudication consumes allowed_amt and manual pricing entries from claim_line_pricing_rules (claims/w_claim_line_pricing_rules).
6. Adjudication (RFA). of_adjudicateclaims + of_applypackage + of_applyrule apply the benefit package's rules to each line, write claim_line_rules, claim_line_accums and member_accums, apply COB, and compute the payable waterfall.
7. Payment allocation (RFAL) & payment status. Fund-register rows (payments) are shown on the claim's Payment tab (clmentry/u_payment, DataWindow d_claim_history); missing-vendor message 140 sends a claim back for reprocessing (clmshare/n_cst_claims of_closemessage case 140).
8. Audit (RFCA). Claims selected for audit are held by message 151/171; release requires every other message closed and moves the claim to RFF (or REXOUT) or back to RFCP (claims/w_setstatusfromaudit; clmshare/n_cst_claims case 151).
9. Funding (RFF → PAID). Handled by the Funding module; this module enforces read-only behavior once funding data exists (clmshare/n_cst_claim_control, of_getfundingstatus).

Adjudication engine flow (per claim line)

(All nodes: clmsproc/n_claim_adjudication.)

Business rules (requirements)

Claim identity, locking and access

1. CLM-1 The system shall generate claim identifiers as origin code + 3-character user tag + Julian date (YYYYDDD) + 6-digit sequence number (clmshare/n_cst_claims, of_getnewclaimid).
2. CLM-2 The system shall set every newly created claim to Corrections status (RFCP) (clmshare/n_cst_claims, of_setnewclaim).
3. CLM-3 The system shall place a logical lock (lock_seq_no drawn from sequence logical_lock_seq) on a claim before it may be edited, and shall open a claim locked by another user in read-only mode after warning the user who holds the lock (clmshare/n_cst_claim_control, of_setclaimlockid, of_getlockstatus).
4. CLM-4 Batch processing shall refuse to pre-adjudicate or adjudicate claims that are not locked (clmsproc/n_claim_adjudication, of_processclaimdef, of_adjudicateclaims).
5. CLM-5 The system shall permit a user to open a claim only when (a) the claim's group is in the user's security groups, or (b) the claim has no group and was created by the user, or (c) the claim is in DELETE/RETURN/UNIDENT status and the user belongs to the Returned Claims or develop security group (clmshare/n_cst_claim_control, of_checksecurityaccess).
6. CLM-6 A claim searched by an external claim id shall be resolved to its internal claim id before locking (clmshare/n_cst_claim_control, of_getlockstatus).
7. CLM-7 A claim in PAID status or later shall always open read-only ("Read Only - Paid") (clmshare/n_cst_claim_control, of_getfundingstatus).
8. CLM-8 A claim at Funding status (RFF) or later with no actual funding activity shall open read-only but remain returnable to corrections; a claim with actual payment activity (a fund-register row that is not backed out, whose payment type is not EXPECTED/PREPAID/FICA/MATCH FICA/FITW/SITW/LITW/UNEMPLOY/MISC, and that has a non-zero non-worksheet paid amount or a paid date) shall open read-only and shall not be returnable (clmshare/n_cst_claim_control, of_getfundingstatus).

Status management

9. CLM-9 Claim status ordering and screen groupings shall be data-driven from the claim-status-order table so screens can validate that a claim is still in the status family they service (clmshare/n_claims_status; clmshare/d_claim_status_order).
10. CLM-10 From the claim editor a user shall be able to Void, Return, Mark-for-Deletion, Reactivate (to RFCP), or Hold a claim, each action requiring confirmation and writing an informational claim message (Void=88, Return=87, Reactivate=89, Delete=144, Hold=86) (claims/w_claim_editor wf_setstatus; claims/w_setclaimsstatus).
11. CLM-11 Returning a claim shall currently mark it for deletion instead ("All claims sent to 'Return' status are now automatically being Marked for Deletion") (claims/w_setclaimsstatus, open event).
12. CLM-12 Placing a claim on hold shall append HOLD to its current status; removing hold shall strip the suffix and close message 86, which cannot be closed manually (clmshare/n_cst_claims, of_setclaimsstatus, of_closemessage case 86).
13. CLM-13 The Void action shall be disabled for any claim that has ever reached PAID status (checked against claim status history) (claims/w_claim_editor, ue_setscreenstatus and wf_setstatus).
14. CLM-14 When a claim above RFCPHOLD is edited in a way that requires reprocessing, or its status is manually set below RFCP, the system shall reset the claim: status to RFCP; every line's status, duplicate flag and reject reason cleared and code-review flag set; fund-register rows backed out (backout_ind='Y', register status cleared, backout date stamped when not yet on a register); claim line rules and accumulators deleted with member accumulators decremented; internal-CM service usage decremented and claim/service links removed; messages closed except control code DONOTCLOSE and deleted for DELONRESET; system-generated (SFPIBACK) pricing rules deleted; outstanding claim letters archived when moving to a sub-status (clmshare/n_cst_return_claim_to_corrections, of_returntocorrections; clmshare/n_cst_claims, of_resetclaim).
15. CLM-15 After a pipeline stage completes with no open messages the system shall advance the claim status: to RFDC (unless the claim is VOID/RETURN), and from RFA to RFAL (clmsproc/n_claim_adjudication, of_update_claim_status, of_update_adjudication_status).

Entry & validation

16. CLM-16 Each claim shall be captured on the entry form matching its claim form type; the supported types are HCFA1500, HCFA_REPRICE, UB92, UB92_REPRICE_IN, UB92_REPRICE_OUT, GENERIC_REPRICE, GENERIC_MEDICAL, GENERIC_DENTAL, DED_SUPPLEMENT, SFPI_DENTAL, SFPI_VISION_EXAM, SFPI_VISION, SFPI_HCR, SFPI_DEPENDENT, SFPI_WDI, SFPI_INELIGIBLE, DRUG, SSO (clmshare/n_cst_claimform, of_getclaimsobject).
17. CLM-17 Saving a claim shall persist header, entry, diagnosis, line, pricing-rule, form-specific (UB92/HCFA/dental/vision/reimbursement/WDI/SSO/reprice), adjudication, message and fund-register data in a single transaction in referential order, rolling back everything on any failure (clmshare/n_cst_claims, of_save).
18. CLM-18 Deleting a claim line shall return the claim to RFCP and delete the claim's line diagnosis codes so the background process can rebuild them (clmshare/n_cst_claims, of_save).
19. CLM-19 The system shall validate required fields at save and record a claim message per missing field; a claim shall not be advanced to Funding while any error message is open (clmshare/n_cst_claims, of_save / of_checkrequiredfields).
20. CLM-20 For anesthesia procedure codes the entry screen shall capture start/end time and compute total units from base units + time units + modifier units with a unit conversion factor (clmentry/w_anesthesia_popup; clmentry/d_anesthesia_popup columns of table claims_anesthesia).

Pre-adjudication / benefit definition assignment

21. CLM-21 Pre-adjudication shall skip definition assignment for lines already rejected or on claims messaged "no coverage", assigning the system reject definition (key −1) (clmsproc/n_claim_adjudication, of_processclaimdef).
22. CLM-22 Dependent-care (DEPCARE) claims shall always receive the system dependent-care benefit definition; lines with procedure code CM2000 shall receive the system case-management-fees definition; MEDREIM, WDI and INELIGIBLE claims shall always have their benefit definition assigned manually (clmsproc/n_claim_adjudication, of_processclaimdef).
23. CLM-23 Definition assignment shall require the claim line's benefit plan to be in COMPLETE status and a benefit package to be assigned, otherwise messages 139 / 121 are raised (clmsproc/n_claim_adjudication, of_processclaimdef).
24. CLM-24 The system shall assign the first benefit definition, in package priority order, whose criteria all pass against the claim line: inpatient/outpatient indicator, procedure-group or procedure criterion, diagnosis-group or diagnosis criterion, procedure modifiers (modifier 1, then modifier 2), place of service, revenue code, and provider specialty; if all other criteria pass but the definition requires a specialty and the provider has none, message 164 "expected specialty" is raised (clmsproc/n_claim_adjudication, of_assigndef).
25. CLM-25 For UB92 inpatient room & board lines the system shall set the line through-date to from-date + units and raise an error when the resulting range falls outside the UB92 statement dates (message 156); for UB92 outpatient lines with 1 unit the through-date is set equal to the from-date (clmsproc/n_claim_adjudication, of_processclaimdef).
26. CLM-26 Room & board shall be identified by revenue code categories 10–17, 20 and 21 (first two digits) (clmsproc/n_claim_adjudication, of_isroomandboard).

Whole-claim (per-diem) pricing

27. CLM-27 A claim shall qualify for whole-claim pricing only when its repricing method is WHOLE, it is a UB92 repricing form, the member is on file, the provider is in network, code review did not change the claim, at least one line is inpatient room & board, not all lines are rejected, and all line networks (HCN) match the claim's network (clmsproc/n_claim_adjudication, of_iswholeclaimpriced).
28. CLM-28 Whole-claim pricing shall distribute per-diem amounts from the claim's reprice detail across each covered day, excluding the discharge day ("we do not pay discharge day"), and shall raise errors when units and room & board dates disagree, when multiple per-diem amounts exist for a day, or when a day has no per-diem amount (clmsproc/n_claim_adjudication, of_wholeclaimprice).
29. CLM-29 When the system determines a repricing sheet should not be a repricing claim (wrong network, unknown member, out-of-network provider, or code-review change), closing message 104 shall convert the claim to the equivalent standard form type (clmshare/n_cst_claims, of_closemessage case 104; claims/w_convert_to_reprice_form).

Accident processing

30. CLM-30 During pre-adjudication the system shall attach the claim to an existing accident record when the claim's diagnoses match the accident's diagnoses within 90 days of the accident; matches beyond 90 days, or accident-group diagnoses (ACC\INC diagnosis group) without a matching record, shall raise the "potential accident" message 191 (unless previously dismissed by a user) (clmsproc/n_claim_adjudication, of_accidentchecking, of_processclaimdef).
31. CLM-31 During adjudication, a claim attached to an accident record shall follow the record's action code: DENY raises message 193 for manual rejection, HOLD raises message 192, and PROCESS (or no record) closes both messages; user-closed accident messages are honored (clmsproc/n_claim_adjudication, of_adjudicateclaims; action codes HOLD/DENY/PROCESS in claims/d_accident_edit).

Adjudication core

32. CLM-32 Adjudication shall reject processing when the subscriber/patient pair does not exist in the family enrollment table (message 209) (clmsproc/n_claim_adjudication, of_adjudicateclaims).
33. CLM-33 Before applying rules, adjudication shall delete and rebuild all claim-line rules and claim-line accumulators for the locked claims, backing amounts out of member accumulators (clmsproc/n_claim_adjudication, of_adjudicateclaims, of_deletelineaccums).
34. CLM-34 Lines that are rejected, flagged as duplicates, or on a no-coverage claim shall have all computed amounts set to zero; duplicates receive system reason −2 and no-coverage lines system reason −1; any other rejected line must carry an examiner-supplied reject reason (message 180 otherwise) (clmsproc/n_claim_adjudication, of_adjudicateclaims).
35. CLM-35 End-stage renal disease claims shall require a Medicare COB record; ESRD claims without one raise message 210 (clmsproc/n_claim_adjudication, of_adjudicateclaims, DataWindow d_adjd_esrd_without_cob).
36. CLM-36 The system shall warn when a member approaches the plan's lifetime maximum, raising one-time member-level messages at 50% (201), 75% (202), 95% (203) and at/over 100% (204) of LIFETIME_MAX_AMT, computed from lifetime paid amounts plus lifetime credits (clmsproc/n_claim_adjudication, of_adjudicateclaims).
37. CLM-37 Rules shall be applied in package rule order, adjusted by each rule's "Applies After" dependency; an unresolvable (circular) ordering raises message 231 and stops adjudication of the line (clmsproc/n_claim_adjudication, of_applypackage, of_reorderrules).
38. CLM-38 Paid-limit (PAID) rules shall additionally be pre-tested before all other rules (PAID$TEST copies) so a limit already satisfied before this claim rejects the line up front (clmsproc/n_claim_adjudication, of_insertpaidtestrules, of_applyrule case PAID$TEST).
39. CLM-39 A rule shall be skipped unless the claimant's relationship matches the rule's subscriber/spouse/dependent flags; the patient's relationship is taken from the most recent RELATIONS member category value, with Spouse, Common Law and Ex-Spouse treated as spouse (clmsproc/n_claim_adjudication, of_applypackage).
40. CLM-40 A rule shall be skipped when its PCP, authorization, pre-certification, pre/post-admission, or referral indicator contradicts the claim's utilization-management case data (um_cases per claim line, plus pre-cert/referral stub tables) (clmsproc/n_claim_adjudication, of_applypackage).
41. CLM-41 A rule shall be skipped when the patient's age at date of service is outside the rule's minimum/maximum age (period types YEAR/MONTH/WEEK/DAY; age computed from birthdate minus one day), or when the current payable amount is outside the rule's min/max consider amounts, or when the rule's accident indicator contradicts the claim's accident linkage, or when the claim line's benefit definition is not in the rule's definition list, or when the rule's contingency-definition requirement is not met within the contingency period (clmsproc/n_claim_adjudication, of_applypackage).
42. CLM-42 Rule quantities shall be derived per the rule's quantity type: DATES/DAYS = days in the line's service period (inclusive); RBDAYS = days excluding the last (discharge) day; otherwise the line's units — optionally divided by the rule's quantity ratio; when the per-unit flag is N and the rule is not per-day, quantity is treated as 1 (clmsproc/n_claim_adjudication, of_applyrule).
43. CLM-43 The amount a rule may still retain shall be limited by the lesser of the individual and family maxima remaining on the member's accumulators for the rule's accumulator and period (accumulate by RETAINED, CONSIDERED−RETAINED, or QTY per the rule's accumulator type), and by a maximum count of family members who have individually satisfied the rule; for coinsurance (COI) rules the maximum is scaled by the retain percentage so COI behaves like out-of-pocket (clmsproc/n_claim_adjudication, of_lefttosatisfy, of_rulemax, of_satisfiedcount).
44. CLM-44 Rule-type computations shall be:
    • EXCL — retain the entire payable amount and stop processing rules;
    • 100PCT — retain nothing, record the amount/quantity as "considered at 100%" so later DED/COI/OOP rules exclude it;
    • COPAY — retain Min(consider_amt, Min(retain_value × qty, left_to_satisfy)) (per-quantity when quantity-accumulated);
    • DED — retain Max(Min(left_to_satisfy, consider_amt), 0) after removing 100%-considered amounts;
    • COI / OOP — retain Min(left_to_satisfy, consider_amt × retain% / 100) (retain% capped at 100), optionally feeding the remainder into the 100%-considered bucket when the rule's pct100_consider_ind = 'Y';
    • CLAIMED / PAID — retain the amount (or quantity, prorated) exceeding the remaining limit; when already satisfied retain the entire considered amount;
    • HOLD — set the line to HOLD, retain the full payable, and raise message 124 carrying the rule and reason; a user response ACCEPT releases the amount, DENY retains it with the chosen reason (clmsproc/n_claim_adjudication, of_applyrule).
45. CLM-45 The HOLD\MULTSRG (multiple-surgery) hold rule shall be applied only when the claim has more than one line (clmsproc/n_claim_adjudication, of_applyrule).
46. CLM-46 Per-day rules (PERDAY/PERDAYDR, except copays) shall not re-apply to days already counted for the member; when every day was already applied the line pays normally if the accumulator is unmet and is fully retained if it is met (clmsproc/n_claim_adjudication, of_applyrule, of_perday).
47. CLM-47 Rules with minimum/maximum unit bounds shall prorate the considered amount to the units inside the bounds and shall still accumulate even when nothing is considered (clmsproc/n_claim_adjudication, of_applyrule).
48. CLM-48 After rules are applied the system shall compute the claim-line waterfall: considered = allowed − exclusions − claimed-limit; then successively subtract copay (→ allowed-after-copay), deductible (→ allowed-after-deductible), coinsurance/OOP (→ allowed-after-coinsurance) and paid-limit retention (→ benefit amount) (clmsproc/n_claim_adjudication, of_claimlinesubtotals).
49. CLM-49 Every rule application with a non-null retained amount shall be recorded as a claim-line-rule row (rule, rule type, reason, retained amount/quantity) and shall update the member accumulator for the rule's accumulator key and computed period, creating the accumulator row if absent, adding considered amount/quantity only once per claim line per accumulator, and maintaining separate carryover buckets when the claim date falls in the rule's carryover window (carryover percentage clamped to 0–100%) (clmsproc/n_claim_adjudication, of_claimlinerule, of_updateaccumulators).
50. CLM-50 Rules with accident period types shall accumulate from the accident date, and lifetime accumulators are stored with a from-date of 1950-01-01 and open through-date (clmsproc/n_claim_adjudication, of_updateaccumulators).

Coordination of benefits

51. CLM-51 COB shall be evaluated once per claim line — immediately before the first paid-limit rule, or after all rules — and only when the line's plan has a COB method (clmsproc/n_claim_adjudication, of_applypackage, of_applycob).
52. CLM-52 When primary-carrier EOB detail is attached to the line and the member has an active COB record for the claim's coverage type, the payable amount shall be adjusted by COB method:
    • NORMAL: payable = Min(payable, Max(claimed − (cob_paid + Max(cob_writeoff, claimed − allowed)), 0));
    • CARVEOUT: payable = payable − cob_paid (floor 0);
    • REDUCECLM: no further processing (claimed already reduced);
    • PAYBALANCE: payable = payable − cob_paid; and any COB reduction shall be recorded as a claim-line rule under the system COB rule (clmsproc/n_claim_adjudication, of_applycob).
53. CLM-53 EOB detail shall reconcile with the claim line: submitted amount must equal the line's claimed amount (message 185) and a non-zero allowed amount must equal submitted − write-off (message 186) (clmsproc/n_claim_adjudication, of_applycob).
54. CLM-54 The system shall message mismatches between EOB and enrollment COB data: EOB attached but no COB record (141); COB record without EOB when another internally administered plan is primary (143) or an external plan is primary (142) — except Medicare-primary drug claims, which process without an EOB (clmsproc/n_claim_adjudication, of_applycob).

Internal case-management services

55. CLM-55 For benefit definitions designated as CM-service definitions (therapy/DME), adjudication shall match the line to the member's open internal case-management service (by benefit definition, timeframe, and where needed procedure/diagnosis codes), raising message 225 when multiple services match, 226 when none match but similar services exist, and 227 when the claim would exceed the service's authorized units or dollars; matched usage updates the UM rule's units-used (unit-based) or soft-savings (dollar-based) (clmsproc/n_claim_adjudication, of_adjudicateclaims).
56. CLM-56 A user closing a CM-service message with response DENY shall cause the payable amount to be retained under the internal-CM rule (rule key 18443) with the user's chosen reason; response NOTSERVICE bypasses CM processing; response ACCEPT allows normal payment (clmsproc/n_claim_adjudication, of_adjudicateclaims).

Duplicates, audit, letters, EOB

57. CLM-57 Closing the duplicate message (102) shall present the candidate duplicate claims for side-by-side review; the examiner may mark the line "Not A Duplicate" (clearing the duplicate list) or retain an updated list (clmshare/n_cst_claims, of_closemessage case 102; claims/w_claim_message_duplicate; claims/u_duplicate_claim).
58. CLM-58 Audit selection shall be configurable by examiner (audit percentage, dollar limit, assigned weekday), by group (dollar limit, coverage type, all-claims flag), by member, by provider, by procedure code and by diagnosis code, each with effective date ranges (claims/w_audit_examiners_selection, w_audit_groups_selection, w_audit_members_selection, w_audit_providers_selection, w_audit_procedure_codes, w_audit_diag_codes_selection; tables audit_*).
59. CLM-59 Releasing a claim from audit (closing message 151/171) shall require every other error message closed, then either advance the claim to Funding (RFF, or REXOUT when the claim is electronically paid) with an immediate save/commit/unlock, or return it to Corrections (claims/w_setstatusfromaudit; clmshare/n_cst_claims, of_closemessage case 151).
60. CLM-60 Claim letters shall be issued from the claim (message 212/157 per letter), may be attached to or detached from related claims, and shall be archived when their message is closed or the claim moves to a sub-status (claims/w_claims_letters pfc_update; clmshare/n_cst_claims of_closemessage cases 157/212; clmshare/n_cst_return_claim_to_corrections).
61. CLM-61 The system shall print an EOB for a claim on demand (clmprint/w_claim_print_eob with n_check_copy), and shall allow unattached primary-carrier EOBs for a member (by SSN) to be attached to a claim (claims/w_eob_attach, w_eob_selection, w_eob_edit, w_eob_edit_claim_lines).

Outbound EDI & external adjustments

62. CLM-62 A user shall be able to mark a claim for outbound EDI to a chosen trading partner exactly once; the claim is inserted into the outbound EDI transactions table and message 223 records the selection (claims/w_claim_editor ue_outbound_edi; claims/w_claims_partners_select).
63. CLM-63 The outbound EDI processor shall stage claim, subscriber, patient, provider, line and form-specific data into the outbound_edi_* staging tables, write one fixed-width file per network/claim-form-type per day to the configured output directory (codes APPPATHS/OUTEDI), and purge staging rows once the file is created (clmutils/u_edi_outbound_edi; clmutils/w_edi_outbound_edi_processor).
64. CLM-64 External adjustment requests shall be tracked with statuses NEW / IN PROCESS / COMPLETED, with reports of outstanding adjustments and outstanding refunds (claims/w_ext_adjustment, claims/d_ext_adjustments; clmrpt/w_clmrpt_outstanding_adjustments, w_clmrpt_outstanding_refunds).

Manual adjudication support

65. CLM-65 The Adjudication tab shall show, per selected claim line, the benefit rules applied (with retained amounts, editable exclude flag), the manually entered pricing rules, adjudicated amounts, and rule totals; manually added claim-line rules receive new system keys at save (clmentry/u_adjudication; DataWindows clmshare/d_claim_line_rules_master, d_claim_line_pricing_rules_master).
66. CLM-66 Enrollment-confirmation gate: the annual-enrollment message (146) shall not be closable until enrollment records a CONFIRMED member category value covering the claim's earliest service date, or every claim line is rejected (clmshare/n_cst_claims, of_closemessage case 146).
67. CLM-67 Vision procedures on a medical form (message 211) shall require the examiner to choose processing under medical coverage (recorded as Response:MEDICAL) or to void and re-enter the claim on a vision form (clmshare/n_cst_claims, of_closemessage case 211).

Key formulas quoted from source

Copay / deductible / coinsurance retention (clmsproc/n_claim_adjudication, of_applyrule):

case 'COPAY'
    ld_retain_amt = Min(ld_consider_amt, Min( ld_rule_retain * ld_qty, ld_left_to_satisfy))
case 'DED'
    ld_retain_amt = Max(Min(ld_left_to_satisfy, ld_consider_amt), 0)
case 'COI' / 'OOP'   // ld_rule_retain capped at 100
    ld_retain_amt = Min(ld_left_to_satisfy, ld_consider_amt * (ld_rule_retain / 100))
case 'CLAIMED' / 'PAID'
    if ld_consider_amt > ld_left_to_satisfy then
        ld_retain_amt = ld_consider_amt - ld_left_to_satisfy

Claim-line subtotal waterfall (clmsproc/n_claim_adjudication, of_claimlinesubtotals):

ld_subtotal_amt = Dec(ads_clm_line.Object.allowed_amt[1])
ld_subtotal_amt = ld_subtotal_amt - ld_excl_total
ld_subtotal_amt = ld_subtotal_amt - ld_clmd_limit_total
ads_clm_line.Object.considered_amt[1] = ld_subtotal_amt
ld_subtotal_amt = ld_subtotal_amt - ld_copay_total
ads_clm_line.Object.allowed_after_copay_amt[1] = ld_subtotal_amt
ld_subtotal_amt = ld_subtotal_amt - ld_ded_total
ads_clm_line.Object.allowed_after_ded_amt[1] = ld_subtotal_amt
ld_subtotal_amt = ld_subtotal_amt - ld_coi_total
ads_clm_line.Object.allowed_after_coi_amt[1] = ld_subtotal_amt
ld_subtotal_amt = ld_subtotal_amt - ld_paid_limit_total
ads_clm_line.Object.benefit_amt[1] = ld_subtotal_amt

COB NORMAL method (clmsproc/n_claim_adjudication, of_applycob):

ld_payable_amt = Min(ld_payable_amt, Max((ld_claimed_amt - (ld_cob_amt
    + Max(ld_cob_write_off_amt,
          (Dec(ads_clm_line.Object.claimed_amt[1]) - Dec(ads_clm_line.Object.allowed_amt[1]))))), 0))

Status advance on clean claims (clmsproc/n_claim_adjudication):

// of_update_claim_status: no open messages, not VOID/RETURN
adw_claims.Object.claim_status_cd[ll_cur_claim] = "RFDC"
// of_update_adjudication_status: no open messages and status = RFA
adw_claims.Object.claim_status_cd[ll_cur_claim] = "RFAL"

Data touched (main tables)

CRUD summarized from _re/analysis/schema.json for the eight claims libraries.

Area	Tables (CRUD)
Claim core	claims (CRUD), claim_entries (CRUD), claim_lines (CRUD), claim_entry_diag_codes (CRUD), claim_line_diag_codes (R; deleted via embedded SQL on line delete), claims_xref (R)
Form-specific detail	claims_hcfa_info, claims_ub92_info, claim_ub92_conditions/occurrences/procedures/values, claims_ub92_itemized, claims_dental_info, claim_missing_teeth, claims_vision_info, claims_reimb_info, claims_wdi_info, claim_wdi_lines, claims_sso_info/diagnosis/procedure, claims_anesthesia, claim_other_ins_infos (all CRUD)
Adjudication results	claim_line_rules (CRUD), claim_line_accums (CRUD), claim_line_pricing_rules (CRUD), claim_line_payments (CRUD), member_accums (CRUD), member_accum_credits (CRUD)
Benefit configuration (read)	benefit_plans, benefit_pkgs, pkg_rules, benefit_rules (CRUD via rule utils), benefit_defs, benefit_def_diags/procs, rule_defs, rule_contingency_defs, pkg_rule_dependencies/fulfillments/requirements, level_scheds, carryover_rules, rounding_rules, group_periods (CRUD)
Messages & status	claim_messages (CRUD), global_messages (R), claim_statuses (R), claim_statuses_history (R), claim_status_order (R)
COB / EOB	coord_of_bens (CRUD), claim_eob_infos (CDU), claim_eob_info_details (CRUD)
Accidents	accidents, accident_members, accident_diagnoses, accident_claims (all CRUD)
Audit config	audit_examiners, audit_groups, audit_members, audit_providers, audit_procedure_codes, audit_diagnosis_codes (all create/update/delete, most read)
Repricing / networks	claims_reprice_info (CRUD), claims_reprice_detail (CRUD), edi_in_repricing (CRU), health_care_networks (R), moon_negotiations (R)
Payment / funding handoff	fund_register (CRUD), fundtrans (R), bank_acct_info (R), ext_adjust (CRUD), ext_output_transactions (R)
Letters	claim_letters_hist (CRUD), claim_letters_hist_claims (CRUD), claim_letters_data (D), letter_headers (R), report_archive (R)
Outbound EDI	outbound_edi_transactions (CRUD), outbound_edi_trading_partners (R), 11 outbound_edi_*_table staging tables (CRUD)
UM / internal CM	um_cases, um_services, um_rules (CRUD), um_case_mgt_claims (CRUD), um_cm_serv_excl_proc_cd (R), claim_precert_stub / claim_referral_stub (CRUD; labeled temporary)
Enrollment/provider (read)	members, family, member_cat_val, member_eligibilities, member_pcps, groups, providers, provider_addresses, provider_tins, vendors, specialties, procedure_codes/groups, diagnosis_codes/groups
Legacy conversion	wang_claims, wang_claim_lines, wang_claim_line_rules, wang_acm, wang_rej_map, wang_rule_map, wang_group_rule_map (CRUD; see Migration notes)

Reports produced (clmrpt)

Report window	Business purpose
w_clmrpt_accum_rpt (Member Accumulator Listing)	Accumulators for a group's members, incl. medical/dental deductible variants and pending (non-paid) claims affecting accums (d_clmrpt_accum_rpt*, d_clmrpt_accum_pending)
w_clmrpt_member_accum_search	Member/family accumulator search — claims affecting accumulators (d_clmrpt_member_accum_search_results)
w_rpt_group_selected_accums	Accumulators by member for selected accumulators/reasons
w_rpt_member_accum_rulemax	Member accumulators by benefit rule with maxima (d_rpt_member_accum_byrule)
w_rpt_group_claim_bendefs	Detailed claims listing by benefit definition
w_rpt_group_claim_benrules	Detailed claims listing by benefit rule type
w_clmrpt_status_count	Claims count per pipeline status (d_clmrpt_status_count)
w_clm_message_status_summary	Message/status summary per group
w_clmrpt_open_messages	All claims with open messages
w_clmrpt_claims_older_than_90_days	Claims older than 90 days for a group / parent group
w_clm_claimed_amt_morethan	Claims with claimed amount above a threshold
w_claimrpt_large_claim_report	Large-claim report
w_clmrpt_no_sub_or_pat	Claims lacking subscriber and/or patient assignment
w_no_group_id_fix	Claims with no group id assigned
w_clmrpt_outbound_aging_tv, w_clmrpt_outbound_edi_older_than_10_days	Outbound-EDI aging; claims sent to partners not returned within 10 days
w_clmrpt_outstanding_adjustments, w_clmrpt_outstanding_refunds	Outstanding external adjustments / refunds
w_cigna_p4p	Cigna pay-for-performance extract (d_clmrpt_cigna_p4p_out, cigna_report_groups)
w_ppaca_letters	PPACA letters
w_nobs_group_rpt	Group report (NOBS)
Lifetime/credits datastores	d_clmrpt_lifetime_rpt (lifetime amounts per member), d_clmrpt_credits_rpt

clmprint additionally provides print/reprint layouts for every claim form (d_claim_print_*), EOB printing (w_claim_print_eob, n_claim_print, n_check_copy) and check-payment views (d_check_payments, d_check_payments_backed_out, d_checkrun_claim_lines).

Integration points

• Outbound EDI staging — outbound_edi_transactions plus 11 outbound_edi_* staging tables flattened to fixed-width files per trading partner/HCN and claim-form type; directory from codes (APPPATHS/OUTEDI) (clmutils/u_edi_outbound_edi). Claims marked from the editor (claims/w_claim_editor ue_outbound_edi); returns monitored by aging reports.
• HCN repricing — repricing claim forms carry hcn_sys_key (network chosen via claims/w_claims_hcn_list), reprice header/detail in claims_reprice_info/claims_reprice_detail, inbound repriced data in edi_in_repricing; whole-claim per-diem pricing consumes reprice detail (CLM-27/28).
• Aetna electronic claims — claims with id prefix EAET show the transmit date from ext_output_transactions; electronically paid claims leave audit as REXOUT (clmentry/u_payment; clmshare/n_cst_claims case 151).
• Funding module — fund_register rows (worksheet/expected/paid amounts, register status, backout) written at save and consumed by check runs; funding-status rules gate editing (CLM-8, CLM-14).
• Utilization management / internal CM — um_cases, um_services, um_rules, um_case_mgt_claims; adjudication decrements/increments service authorizations (CLM-55/56); claims can be attached to internal CM cases (claims/w_add_claim_to_internal_cm).
• Moon negotiations — negotiation checking moved out of adjudication to the Moon background process (comment in clmsproc/n_claim_adjudication, of_adjudicateclaims).
• Caremark (pharmacy) — non-claim record file creation (clmutils/w_caremark_non_claim_record, caremark_edi_table).
• Letters/print archive — letters archived through the reprint subsystem (n_cst_reprint_print_reports.of_ArchiveItem('CLMLETTERS', …)).

Migration notes

• Data-driven pipeline: status order, display names and screen families live in claim_status_order; do not hard-code the pipeline — except the nine background stages listed in clmutils/w_bkgd_monitor, which a migrated orchestrator must reproduce.
• The adjudication engine is the crown jewel: clmsproc/n_claim_adjudication implements definition assignment, rule ordering/filters, nine rule types, accumulator maintenance with carryover, COB and CM-service integration. The formulas in CLM-42..CLM-54 should be treated as the executable specification and covered by regression tests before migration.
• Message-driven workflow: every edit/exception is a claim_messages row with message number, field_name (often Row:n;DBName:col), system_comment key-value text (e.g. DupClaims:, RuleKey:, Response:), and control codes (DELONRESET, DONOTCLOSE, SC; = system-closable only). Closing a message can trigger status transitions and saves (cases 151/167). A migration must preserve these semantics or redesign the exception workflow wholesale.
• User-closed message memory: adjudication honors messages previously closed by a human (close user id not sfpiback) — e.g. no-coverage, accident deny/hold, potential accident. Idempotent re-adjudication depends on this.
• Known technical debt flagged in source: precertification and referral use "temporary stub tables" (claim_precert_stub, claim_referral_stub); accumulate-by-tooth is a workaround via pseudo benefit definition −110; COI is "kind of a mess" (treated as OOP); several TBC! markers (days-of-week rule check unimplemented, possible rounding error in COI 100%-consider back-computation).
• Magic keys: system rule/definition keys are negative or hard-coded — COB rule −100, DEPCARE definition −101, write-off rule −102, case-management fees −111, whole-claim reason −201, reject definition −1, no-coverage reason −1, duplicate reason −2, internal-CM retain rule 18443. These must be carried or remapped.
• Wang legacy conversion: of_wang_* functions and wang_* tables are one-time claim-history conversion from a prior (Wang) system; likely dead code for a future migration but the converted history feeds accumulators.
• Return-to-corrections is the transactional heart of edit-after-the-fact behavior (CLM-14); any migrated design needs an equivalent compensating-transaction routine.
• Oracle-specific SQL throughout (sequences logical_lock_seq, claim_seq, all_purpose_seq; (+) outer joins; DECODE, NVL, FROM dual).

Open questions

1. Where do stage transitions RFCP→RFCR→RFPA and RFDC→RFPR→RFA run? The batch driver that invokes of_processclaimdef / of_adjudicateclaims (and performs code review, duplicate detection and pricing) is not in the eight claims libraries; only the engine and monitors are. The SFPIBACK user and n_batch_scheduler references imply a separate background application (possibly built from these PBDs).
2. Duplicate-detection algorithm: lines arrive at adjudication already flagged (duplicate_claim_line_ind) and message 102 already carries DupClaims:; the matching criteria are implemented elsewhere (RFDC stage of the background process) and could not be extracted from this domain.
3. Message catalog: message numbers (42, 86–89, 102–105, 109, 119–231…) reference global_messages (read-only here). A full catalog of message text/severity/control codes needs to be pulled from that table or the system-admin domain.
4. Message 167 dual use: the adjudication engine defines 167 as "whole claim error" while the corrections screen treats closing 167 as the pre-adjudication release popup (w_setstatusfrompreadj → RFDC/RFCP). They are consistent if the whole-claim-pricing error is the designated pre-adjudication hold, but this should be confirmed against global_messages.
5. RETURN vs DELETE: the "temporary" 04/2000 change routing Return to Delete (CLM-11) was never reverted; a migration must decide whether Return remains a distinct state.
6. REXOUT lifecycle: set when releasing electronically-paid claims from audit; downstream handling (presumably in Funding/EDI-out) is outside this domain.
7. Accumulator error correction: of_getaccumerrors / of_correctaccumerrors / of_reaccum (clmsproc/n_claim_adjudication, surfaced by clmutils/w_acm_accum_errors) imply known accumulator drift; the operational procedure around them is undocumented.
8. Pre-cert/referral stubs: whether real UM data superseded the stub tables (um_cases is retrieved and the stubs are still checked in of_applypackage) needs business confirmation.