OHI 3.19.2: Claim Statuses Out Of Sequence
(Doc ID 2773112.1)
Last updated on MAY 03, 2021
Applies to:Oracle Health Insurance Claims Adjudication - Version 22.214.171.124.0 and later
Information in this document applies to any platform.
There are several scenarios in production where claim statuses are out of sequence. Especially Manual Pricing and Manual benefits when claim pends.
There are situations where a claim actually went from Manual Benefits to Manual Pricing. Got a pend at Manual Benefits however, claim continued to process to Manual Pricing with the pend.
This poses an issue at our end as we have claim reprocess batch jobs to pick up pended claims at specific states for reprocess. In this case, Batch was looking for claim pended with 'REPR_NOREF' at manual benefit step however since claim continued to process after the pend and stopped at manual pricing, claim was not picked up by batch.
Claims statuses should be in defined sequence during processing and pends should occur at a status as configured and claim should stop processing after the pend.
We are not really sure of the exact root cause so are unable to reproduce it.
Issue was noticed by claims operations team while investigating pend resolution issue
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