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Enhancement: New Step after Manual Adjudication to Run Rulef or High Pend Amount (Doc ID 2341037.1)

Last updated on FEBRUARY 10, 2020

Applies to:

Oracle Health Insurance Claims Adjudication - Version and later
Information in this document applies to any platform.


This request is for a new step after Manual Adjudication and before Finalization where an external intervention rule for High Dollar (HD) pending can be run. Having the HD Pends in their own step will simplify the logic that determines if a claim has been manually touched, an attribute of high dollar pending. Currently the logic is complex, as it duplicates all pend logic in the Manual Adjudication step; thisis a maintenance strain and our logic falls out of date with every new MA pend. So there are two parts to this request:

1. The ability to trigger pend rules in a sequence, given this groovy logic can be written based on a predictable pattern of events. This simplifies the code.


2. A new step in the process after manual adjudication and before finalization. This will simplify the high dollar pending logic which has extensive code written to determine that a claim was pended with a pend that has to be manually touched by a claims processor in order to be resolved. The manually touching is a critical factor for High Dollar auditing.Moving this to a new step before finalization will eliminate extensive amounts of hard coded duplicate pending logic.


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