Claim management and operations screens

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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).

COB/EOB operating practice (User Guide ch. 10 & 11)

• Enter EOBs before claims: the background process auto-links EOB detail lines to claim lines by patient SSN, service date and submitted-amount = claimed-amount, skipping EOB lines already attached elsewhere (one EOB can serve multiple claims, one claim can need multiple EOBs); unmatched lines message the examiner, who searches the EOB table and, failing that, requests an EOB from the subscriber. Drug claims with Medicare primary are not EOB-checked.
• Severing ties: changing patient-identifying data clears all EOB/claim-line matches for the claim; changing a line's service dates or claimed amount clears that line's match only.
• COB record model: at most one active Primary, Secondary, Tertiary and Unknown record per period; plan types "Internal"/"Internal Medicare" mark SFPI-administered plans. An Unknown record (typically created by UR on conflicting information) holds all of the member's claims until an examiner resolves it. The claims department adds COB data through the claims COB screen, not the enrollment screen.
• ESRD procedure (message 210): determine the Medicare eligibility date (usually 30 months after treatment starts), enter two COB records — Medicare secondary with a termination date for current claims and Medicare primary from the proposed effective date — then close the message.

Accident-review procedure (User Guide ch. 11)

Complements CLM-30/31: a claim already attached to an accident record proceeds without intervention; an automatic attach happens on same-diagnosis-within-90-days; otherwise the "possible accident" message asks the examiner to decide — close it (not an accident; the system never re-asks), or create/attach an accident record whose action code (HOLD / DENY / PROCESS) then steers adjudication, with hold/deny handled manually by the examiner. Accident records also drive subrogation: the subrogation indicator plus letter-generated/response dates live on the record, subrogation letters (Reimbursement + Subrogated Interest, or the partner's referral form for Subrogation Advantage / Trans General) are generated when the first positive-payment claim against the accident reaches funding, and common accidents across family members share deductible treatment per plan rules.

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).

Audit practice and defaults (User Guide ch. 16)

The guide documents how these tables were operated — see CLM-77 for the trigger list and defaults:

• Defaults: master-group dollar limit $5,000 (zero = audit every claim of the client; a zero coverage-type limit audits zero-pay claims that were not duplicate rejects); examiner dollar limit default $1,000; examiner day assignment accepts "All" or "Random" (default Random). An examiner with no row in audit_examiners as of the claim's create date is audited at 100% — which is also how new examiners are handled for their first three months (they are added to the table with a start date after the waiting period). Date ranges are matched against claim create dates (the group table uses incurred dates).
• Claim state during audit: audited claims are already resolved to a fund page and written to fund_register, but the register process bypasses them until release moves the claim to Ready-For-Funding (matches CLM-59).
• Workflow: auditors work read-only from the standard claim screens (audit windows must not update claim data). Findings are recorded on a Daily Audit worksheet (categories: claimant, charge, diagnosis code, line code, date of service, CPT, COB/subrogation investigated, UCR administered, EE statement, pre-cert, second opinion, payment to proper party, duplicate payment, non-covered expense, Rx for PT/OT, pre-existing, PPO discount, incorrect benefits, misc.) with the error dollar amounts. Proposed corrections go back to the entering examiner — the auditor never makes the change; the examiner has 3 days to fix or dispute, disagreements escalate to the manager for a binding right/wrong ruling. COBRA and Enrollment data are outside the auditor's change-request scope. Daily worksheets roll up to weekly/monthly/quarterly/yearly per-examiner error reports (counts and dollars, procedure ratio, financial ratio).
• Aging: claims sent back from audit and not returned within 3 days are found by report (keying on audit status date) — automation was deferred because held/returned claims can be anywhere in the pipeline.

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.