Claim entry, correction and editor screens

The claim workspace is built from three host windows that dynamically load a claim-form tab object (one per claim form type) plus shared tabs for adjudication results and payment history. All of them delegate business logic to clmshare/n_cst_claims (data orchestration, save, message handling) and clmshare/n_cst_claim_control (locking / status / security).

Host windows

claims/w_claim_entry — Claims Entry

• Purpose: capture a brand-new claim. Loads the tab object for the selected claim form (of_setform), sized to the form.
• Actions: choose claim form; enter data; Save (claim id generated, status RFCP — see CLM-1/2). Menu m_claim_entry.

claims/w_claim_correction — Claims Correction

• Purpose: work claims that have open error messages. A claim-list DataWindow with a search-criteria panel (ue_search) retrieves claims for the screen's status family; clicking a claim opens it in the embedded editor surface (ue_retrieveclaim).
• Notes: the same window class also serves "show deleted" mode for returned/deleted claims (ue_showdeleted).

claims/w_claim_editor — Open Claim ("Claims editor")

• Purpose: the general claim viewer/editor. Opens in a screen mode that determines title, help text and which actions are enabled: AUDIT (Claims Audit), CORRECTIONS (Claims Corrections), RETURN (Returned Claims), ADJUDICATION (Claims Adjudication), VOID, RFF and default Open Claim (ue_setscreenstatus).
• Layout: claim-id header (dw_claim_id), dynamically loaded claim-form tab (ue_setclaimstab via clmshare/n_cst_claimform), messages grid (dw_messages, shared with n_cst_claims), original-values view (dw_original), action log (dw_action), status text (st_status shows Read Only reasons).
• Actions (menu/toolbar m_claims_correction):
  • Void / Return / Mark-for-Deletion / Reactivate / Hold — all via wf_setstatus + confirmation popup w_setclaimsstatus (info messages 88/87/144/89/86). Void is disabled once the claim has ever been PAID (claim_statuses_history check).
  • Message operations: add / edit / close (close triggers the per-message-number workflows in n_cst_claims.of_closemessage).
  • View: benefit definitions applied (w_claim_lines_benefit_definition), claim lines before code review (w_before_claim_lines via of_viewbeforeclaimlines), status history (w_claims_disp_status_history), original values, notes, associated claims (w_assoc_list), claim letters (ue_issueletters → w_claims_letters), EOB (ue_vieweob), enrollment.
  • Assign provider / subscriber / patient (lookup + assignment events ue_setprovider / ue_setsubscriber / ue_setpatient).
  • Mark claim for Outbound EDI (ue_outbound_edi): checks the claim is not already in outbound_edi_transactions, prompts for a trading partner (w_claims_partners_select), inserts the transaction row and logs message 223.
  • Duplicate viewer (claims/u_duplicate_claim, titled View Duplicates): lists the claim ids from the message-102 DupClaims: comment; double-click opens each candidate in another w_claim_editor sheet (read-only if locked).

Entry-desk operating conventions (User Guide ch. 10)

How the screens above were actually used, per the official user guide — useful for validating migrated UX against real workflow:

• Who keys what: the Claims Data Entry department keys UB92, HCFA1500, SSO, generic-medical, HCR/DepCare and all repricing sheets; examiners key dental, vision, WDI, drug, ineligible and EOB forms, all foreign claims, and any claim arriving with an EOB attached (those bypass data entry). Ineligible claims may only be entered by examiners and require an active "Ineligible" coverage election.
• Keyboard/mouse conventions: Enter can act as Tab (user preference); F6 hops between form sections and out of multi-line areas; tabbing out of the last line of a repeating area auto-adds a row; right-mouse adds/deletes rows in box areas; keying SAME in patient (or subscriber) name/address copies the other party's data during the next background run.
• Common header fields on every form: Source (Provider / HCN / Subscriber — defaults Provider; implies whether a repricing sheet is expected, so it is critical to set correctly); Received On (defaults today; override with the mailroom date stamp); Operative Notes checkbox; Foreign Claim checkbox.
• Foreign claims can only be entered on generic forms, with provider entry inhibited; amounts must be manually converted to US dollars before entry, and the foreign flag cannot be changed in Data Correction.
• Mandatory fields are not enforced at keypunch: the claim always saves, and missing-mandatory messages are generated at save for later correction (CLM-19). Field-level numeric/date validation happens at keypunch; unresolvable forms are bypassed to the responsible examiner.
• Insured's signature accepts exactly three states: Signature on file (pay provider), Pay subscriber, or blank (possible split — resolved in adjudication) — see CLM-74.
• EOB-first rule: primary-carrier EOBs must be entered before the claim so the background process can auto-attach EOB lines to claim lines; the EOB modal on the claim form only attaches/detaches existing EOB records.
• Anesthesia popup is auto-raised when a line indicates anesthesia (anesthesia CPT/HCPCS/ASA code, modifier 23/47, type of service 7, anesthesia revenue code on UB forms); dental forms instead carry an anesthesia-minutes column. On generic forms it must be requested manually. Claims recognized as anesthesia but keyed without times/units fall back to corrections.
• Repricing sheets: entry must check HCN considers member not on file / HCN considers provider OON per the stamp on the sheet and pick the HCN from the dropdown — these three fields drive the whole reprice-vs-convert decision tree in the background process. UB92 outpatient sheets needing per-diem pricing go on the generic reprice form (box 4 distinguishes in/outpatient).
• HCFA box 33 with four address lines: the extra line is a second provider name — key the business name, or the name matching box 31.
• Dental tooth rules: tooth number and (for restorative ADA ranges 02110–02387, 02510–02530) tooth surface are required for the ADA codes listed in the guide; entry is allowed without them but the background process raises the error.
• Line limit: no more than 100 detail lines per claim (code-review software limit); larger claims must be split at entry.
• Batch filing: each day's entered claims are stamped with batch number + claim id, verified against a batch-control sheet, and filed by batch (claim storage procedure).

Correction-desk conventions (User Guide ch. 10)

• Background process contention: a claim open in any window is invisible to the background process and to code review — operators must close claims so they can process. Locks orphaned by crashes are cleared via the supervisor unlock window.
• Worklist routing: correction lists are filtered by the user's security groups plus message routing — Claims Data Correction users see batches from their assigned entry users; Enrollment/Provider/COBRA/UM users see claims whose open messages carry their area prefix (EN, PV, …) from global_messages.area.
• Do not close messages prematurely: the background process auto-closes system error messages when the underlying data is fixed. Manually closing specific messages suppresses future processing — e.g. "member has never had correct coverage" (skips coverage lookup, duplicate check and pricing; line rejects at adjudication), "user has manually assigned column value", the HCN member-unknown/provider-OON messages, and code-review question/error messages. Closing the enrollment-wait messages (no coverage / no eligibility / initial enrollment / line partially in eligibility period) rejects the associated line.
• Closing a not-found message (provider, subscriber, patient, coverage, package) offers to open the matching Select popup; manual member reassignment requires changing the SSN on the claim, otherwise the background process resets the name from the old SSN.
• Generated fields: claim type and examiner are system-assigned but user-overridable; once overridden the system leaves them alone until cleared (an override writes a message). Member/provider syskeys and claim id are never user-editable.
• Hold discipline: any claim waiting on an outside department or information request should be put on Hold (with a user message) so it stops recycling through the background process; enrollment/provider requests are routed as user messages to the department, and the claim comes off hold when the response arrives.
• Provider errors: look up box 31 (with degree) first, then box 33; if not found, message Provider Relations and hold the claim. A selected provider is remembered — the system links the claim's provider strings to the chosen provider and auto-assigns future identical claims (active providers only). TINs flagged "unsearchable" (e.g. Cleveland Clinic) cannot be searched by tax id alone.
• Duplicate disposition (message 102 popup): manually review each candidate claim id in claim history; confirm to let the system deny the lines, or mark Not A Duplicate to release the claim.
• Manual line rejection: right-click the claim line and assign a reject code to the whole line; partial rejections require splitting the line first.

Claim form tab objects (clmentry)

clmshare/n_cst_claimform.of_getclaimsobject maps claims.claim_form_type to the tab object; each tab is composed of DataWindows over claim_entries, claim_lines and form-specific tables.

Claim form type	Tab object	Window title	Extra tables
HCFA1500	u_claims_tab_hcfa	HCFA 1500	claims_hcfa_info
HCFA_REPRICE	u_claims_tab_hcfa_reprice	HCFA 1500 Repricing	+ claims_reprice_info
UB92	u_claims_tab_ub92	UB92	claims_ub92_info, conditions/occurrences/procedures/values, itemized
UB92_REPRICE_IN / _OUT	u_claims_tab_ub92_reprice_in / _out	UB92 Inpatient / Outpatient Repricing	+ reprice info/detail
GENERIC_REPRICE	u_claims_tab_generic_reprice	Generic UB92 Repricing	+ reprice info/detail
GENERIC_MEDICAL	u_claims_tab_generic_medical	Generic Medical
DED_SUPPLEMENT	u_claims_tab_dedsupp	Deductible Supplement
SFPI_DENTAL	u_claims_tab_sfpi_dental	SFPI Dental	claims_dental_info, claim_missing_teeth
SFPI_VISION_EXAM	u_claims_tab_sfpi_vision_exam	SFPI Vision Examination	claims_vision_info
SFPI_VISION	u_claims_tab_sfpi_vision_lens	SFPI Vision Lens and Frames	claims_vision_info (lens detail)
SFPI_HCR	u_claims_tab_sfpi_hcr	SFPI Healthcare Reimbursement	claims_reimb_info
SFPI_DEPENDENT	u_claims_tab_sfpi_dependent	SFPI Dependent Care	claims_reimb_info
SFPI_WDI	u_claims_tab_sfpi_wdi	SFPI Weekly Income Benefits	claims_wdi_info, claim_wdi_lines
SFPI_INELIGIBLE	u_claims_tab_sfpi_ineligible	SFPI Ineligible Benefit
DRUG	u_claims_tab_drug	Prescription Drug	line-level refill_ind (New/Refill)
SSO	u_claims_tab_sso	Second Surgical Opinion	claims_sso_info + diagnosis/procedure sections

Common header/entry fields (clmentry/d_claim_entries_common and per-form variants)

Grouped summary — the DataWindows carry 80–100 columns each; do not enumerate in migration UI specs, map from the claim_entries table:

• Receipt: received-from (Provider / HCN / Subscriber), received method, received/entered dates.
• Subscriber: name, address, phone, gender, birth date, SSN/member id, employer (group) name & address.
• Patient: name, gender, birth date, relationship (Self/Spouse/Child/Other), marital status (Single/Married/Other), student status (Full/Part/None), employment status.
• Claim classification: claim type (Medicare / Medicaid / Champus / Champva / Group plan / FECA / Other — HCFA box 1), accident indicators (auto / employment / other), COB indicator, operative-notes and attachment indicators, QMCSO flag.
• Provider: billing/attending/facility provider name, address, TIN + TIN type (SSN/EIN), degree, signature/assignment indicators (accept_assignment_ind, outside_lab_ind on HCFA).
• Payee: initial_payee — Subscriber or Provider (clmentry/d_claims_infoa).
• Repricing forms only: HCN (network), Member Not on File and Provider Out of Network checkboxes (drive conversion message 104 / whole-claim-pricing eligibility).

Claim lines

Line grids (clmentry/d_claim_lines_*, master clmshare/d_claim_lines_master) capture per service line: from/thru dates, place of service, procedure code + type + modifiers, revenue code (UB), diagnosis reference, units, claimed amount; and display system results: allowed amount, considered, allowed-after-copay/deductible/coinsurance, benefit amount, payable amount, line status (REJECT/HOLD), duplicate indicator, reject reason, assigned benefit definition and package. Line sequence numbers are auto-incremented (n_cst_claims.of_incrementsequence); deleting a line forces reprocessing (CLM-18).

Adjudication tab — clmentry/u_adjudication

• Top grid: the claim's lines (select a line to filter the panels).
• Benefit Rules Currently Applied to Claim Line (clmshare/d_claim_line_rules_master): rule code, type, reason, retained amount/qty, editable exclude flag; users may manually add a rule from the pricing-rules grid (duplicate rule keys prevented; new rows get keys from ALL_PURPOSE_SEQ).
• Pricing Rules Applied to Claim Line (clmshare/d_claim_line_pricing_rules_master).
• Line adjudication amounts (d_claim_lines_adjudication) with buttons Select (opens claims/w_select_benefit_definition to pick a benefit definition) and Clear (clears the definition, recording the change).
• Rule totals summary (d_claim_line_rules_totals, excludes rows flagged exclude_ind='Y').

Payment tab — clmentry/u_payment

• Fund-register activity for the claim (clmentry/d_claim_history): applied/paid dates, amounts, paid/void/backout/hold/waiver/check-cleared indicators; default filter shows applied activity only, with a Show All Activity checkbox.
• For Aetna electronic claims (id prefix EAET) shows "Sent to Aetna: date" from ext_output_transactions.

Message-resolution and utility popups

Window	Purpose / behavior
claims/w_setclaimsstatus	Confirmation for Void/Return/Delete/Reactivate/Hold; writes the matching info message; Return currently redirected to Delete (CLM-11)
claims/w_setstatusfromaudit	Close audit hold (msg 151/171): blocks if other messages open; choose Return to Corrections (RFCP) or Proceed to Funding (RFF, REXOUT if electronically paid); comment required
claims/w_setstatusfrompreadj	Close pre-adjudication hold (msg 167): choose RFCP or advance to Dupe Check (RFDC)
claims/w_claim_message_duplicate	Disposition duplicate message 102: mark Not A Duplicate or keep/adjust the duplicate-claim list
claims/w_claim_message_multiple_benefit	Resolve msg 40 — pick the coverage (type_of_claim) when multiple benefits could apply
claims/w_claim_message_select_package	Resolve msg 109 — pick the benefit package for a claim line
claims/w_claim_message_claim_line_hold	Resolve msg 124 (benefit-rule HOLD): Accept or Deny the held amount with reason
claims/w_claim_message_cm_hold	Resolve internal-CM messages 225/226/227: Accept / Deny (reason) / Not-a-service
claims/w_claims_message_wizard (2 steps, u_wizard_user_message1/2)	Add and route a user-defined claim message
claims/w_claims_message_edit	Edit a claim message
claims/w_claims_select_reason_code	Pick a reject/denial reason code
claims/w_comment_prompt	Free-text comment prompt used by status flows
clmentry/w_anesthesia_popup	Anesthesia units: start/end time, elapsed/total time, base + time + modifier units, unit conversion → total units (claims_anesthesia)
claims/w_select_benefit_definition	Search/select a benefit definition for a claim line (manual assignment, msg 128)
claims/w_claim_lines_benefit_definition	Read-only view of the definition applied to each line (includes duplicate flag)
claims/w_claim_line_pricing_rules	Record manually entered pricing data for a line
claims/w_claim_lines_remove_modifiers	Change/remove procedure modifiers on claim lines
claims/w_before_claim_lines	Side-by-side current lines vs lines before code review (claim_lines_before)
claims/w_convert_to_reprice_form / w_select_reprice_form	Despite its name, this window drives message 104 in the opposite direction — converting a repricing sheet into its non-repricing equivalent when the system decides it should not be repriced (CLM-29); w_select_reprice_form chooses the UB92 reprice in-vs-out form
claims/w_claims_hcn_list	Choose the HCN (network) for a repricing claim
claims/w_add_claim_to_internal_cm	Attach the claim to an internal case-management case (um_case_mgt_claims)
claims/w_claims_unlock	Supervisor: clear a stuck claim lock
claims/w_claim_search_by_claim_id	Open a claim directly by claim id
clmshare/w_cm_select	Case-management case picker (shared)