Claim management and operations screens
Search
claims/w_claim_search — Claims search
- Criteria (
claims/d_claim_search_criteria, logic in claims/u_claims_search): claim/coverage type, service date range, member vs family scope (member_type M/F), SSN, last name, member id, group id/name.
- Results open the selected claim through the standard lock/status flow (
n_cst_claim_control.of_lockclaim in mode 1, which lets the user open a locked or status-changed claim read-only after a prompt).
Accumulator inquiry
| Window | Purpose |
|---|
claims/w_claims_member_accum (Member Accumulators) | Member's accumulators (retained/considered/qty, carryover, period dates); opens family accums and family-member list |
claims/w_claims_family_accum / w_claims_family_members | Family-level accumulators and members |
claims/w_claims_member_accum_claims, w_claims_accum_display_claims | Claims contributing to a selected accumulator (incl. carryover indicator) |
claims/w_claims_mem_accum_credits | Member accumulator credits (converted/prior-carrier amounts credited to accums, member_accum_credits) |
clmutils/w_acm_accum_errors | Surface and correct accumulator errors using n_claim_adjudication.of_getaccumerrors / of_correctaccumerrors / re-accumulation routines |
Accident subsystem (claims)
| Window | Purpose |
|---|
w_accident_selection (Select/Create Accident Report) | Find or create an accident record (accidents) |
w_accident_edit | Edit accident detail: description, dates, subrogation indicator, and the action code that steers adjudication — Hold / Deny / Process (d_accident_edit; consumed by CLM-31) |
w_accident_member_edit (Assign Member to Accident) | Attach members to the accident (accident_members) |
w_accident_claims_selection | List claims that might apply to an accident and attach them (accident_claims) |
COB / EOB screens (claims)
| Window | Purpose |
|---|
w_eob_selection | List primary-carrier EOB records for an SSN |
w_eob_attach | Show unassigned EOB records for an SSN and attach one to the open claim |
w_eob_edit | Edit an EOB header + detail (claim_eob_infos, claim_eob_info_details: submitted, allowed, write-off, payable per line) |
w_eob_edit_claim_lines | Popup EOB editor opened from claim lines |
The EOB amounts feed COB adjudication (CLM-52..54).
Letters
| Window | Purpose |
|---|
claims/w_claims_letters | Issue claim letters and manage letter/claim associations. Letter history rows (claim_letters_hist) can be attached to additional claims (claim_letters_hist_claims); each association writes message 212 with the letter key, detaching closes it with an audit note (pfc_update) |
claims/w_view_claim_letters (Print Queue Manager) | View and print the user's queued claim letters (criteria: my-claims, printed, archive) |
claims/w_delete_letter | Delete a letter from claims correction |
claims/w_daterange | Date-range prompt used by claims letters |
clmrpt/w_ppaca_letters (PPACA Letters) | Generate PPACA letters |
Letter templates are the clmforms library — some 40 form-letter DataWindows (d_claims_frm_*) covering: requests for information (itemized bill, operative report from employee/provider, dental x-rays, RX for PT/OT, claim form from employer, annual statement), COB inquiries (to employee, to other employer, divorce info, primary carrier / primary EOB / Medicare EOB requests), pre-existing-condition letters (to employee, to physician, HIPAA), subrogation (inquiry, signed reimbursement agreement, subrogated interest), workers' compensation, student status, dependent age-out, hold prenatal charges, refund/overpayment requests (member and provider), delay letters, carve-out explanation, IRS/PPACA statements, MRS letters and a free-form letter. Each template merges claim/member/provider data with user-selected paragraph checkboxes (see e.g. claims/d_claims_frm_delete option checkboxes).
Audit configuration (feeds Audit stage RFCA)
Edit/search windows maintaining the audit-selection tables with effective-date ranges:
| Window | Table | Key fields |
|---|
claims/w_audit_examiners_selection | audit_examiners | claim person, from/to, audit %, dollar limit, day assigned |
claims/w_audit_groups_selection | audit_groups | group id, from/to, dollar limit, coverage type, audit-all-claims flag |
claims/w_audit_members_selection | audit_members | member, from/to |
claims/w_audit_providers_selection | audit_providers | provider, from/to |
claims/w_audit_procedure_codes | audit_procedure_codes | proc code + type, from/to |
claims/w_audit_diag_codes_selection | audit_diagnosis_codes | diagnosis code, from/to |
Claims matching these criteria are held in Audit by message 151/171 and released via w_setstatusfromaudit (CLM-58/59).
External adjustments
claims/w_ext_adjustment: track adjustment/refund requests against processed claims (ext_adjust), status NEW → IN PROCESS → COMPLETED (d_ext_adjustments).
Outbound EDI operations (clmutils)
w_edi_outbound_edi_processor — the outbound EDI main window. Drives u_edi_outbound_edi: loads marked claims (from outbound_edi_transactions) into the outbound_edi_* staging tables (subscriber, patient, provider, claim, lines, UB92, dental, conditions, occurrences, procedures, values), then writes one fixed-width file per network (HCN) and claim-form type per day — record types 1000 (recipient header), 2200 (patient) etc. — into the directory configured under codes APPPATHS/OUTEDI, marks file_created='Y' and purges staged rows. Errors are logged per claim (of_log_err).w_caremark_non_claim_record (Caremark Non Claim Records) — creates Caremark/Matria non-claim adjustment files (caremark_edi_table; adjustment reason codes: wrong provider, ingredient cost, dispensing fee, deductible/copay, sales tax, charge-back, …).
Monitoring & administration
| Window | Purpose |
|---|
clmutils/w_bkgd_monitor (Background Monitor) | Auto-refreshing dashboard of the batch pipeline: throughput (d_claim_status_history_throughput), per-stage claim counts split New vs Errors (open messages) for RFCP/RFCR/RFPA/RFDC/RFPR/RFA/RFAL/RFCA/RFF, current claim locks, last claim processed within the hour |
clmforms/w_claim_status_listing | Claim status listing |
claims/w_claims_disp_status_history | Status history of a claim (claim_statuses_history) |
clmutils/w_adjd_rule_utils | Adjudication-rule utilities: interrogate benefit plans/definitions/rules across groups (opens the response-selection pickers below); supports rule listing (clmsproc/d_clm_rules_listing) and re-accumulation by rule |
clmutils/w_benefit_def_response_selection, w_benefit_plan_response_selection, w_benefit_rule_response_selection, w_group_response_selection, w_reason_response_selection | Picker popups for the rule utilities and reports |
clmsproc/w_adjd_datastore_display | Developer utility: display any adjudication datastore (used with of_dsdisplay / trace log) |
clmrpt/w_group_select, clmrpt/w_bank_acct_select | Group and group-bank-account pickers for reports |
claims/w_assoc_list | Associated claims/messages list for a claim |
The adjudication engine also has a built-in trace facility (of_tracelog / of_traceprint writing d_tracelog / d_adjd_trace rows) toggled by an instance flag — useful to replicate as structured logging in a migration.