Claim Lifecycle
Explains the end-to-end lifecycle of insurance claims from billing to claim resolution.
Overview
The insurance claim lifecycle represents the sequence of steps involved in processing insurance-based billing within the system. This lifecycle begins when a bill is finalized and continues until the claim is approved, rejected, or resubmitted.
Understanding this lifecycle is essential for developers working on the billing, insurance, or claims modules.
Lifecycle Flow
The typical claim lifecycle follows the sequence below:
Step 1 — Eligibility Verification
Before claim submission, the system may perform eligibility verification.
Eligibility verification retrieves insurance coverage information including:
- Copay
- Deductible
- Co-insurance percentage
- Insurance validity
The verification process integrates with external insurance processors such as Inmediata.
Step 2 — Billing Finalization
A claim can only be created once the bill has been finalized.
Conditions required for claim eligibility include:
- Bill source must be marked as Insurance
- Bill must be finalized
- Insurance details must be present
- At least one test must be eligible for claim submission
At this stage the bill becomes visible in the Pending Claims section.
Step 3 — Claim Creation
Claims are created from the Claims Dashboard.
Users can perform two types of claim creation:
Full Claim
Includes all tests in the bill.
Partial Claim
Includes only selected tests.
Tests marked with the Claim On Hold exception are excluded from claim creation.
Step 4 — Claim Submission
When a claim is submitted:
- Billing data is fetched in real time.
- Claim payload is generated.
- Claim records are created in the database.
The following tables are populated:
- InsuranceClaim
- ClaimProviderInfo
- ClaimTestRelation
- BillClaimRelation
These tables capture a snapshot of the claim data at submission time.
Step 5 — Claim Processing
After submission, the claim is sent to the insurance processor.
The processor evaluates the claim and determines the outcome.
Possible responses include:
- Claim Approved
- Claim Rejected
- Claim Partially Approved
- Additional remarks or corrections required
Step 6 — Claim Status Updates
The system periodically retrieves claim status updates from the processor.
These updates are mapped to the claim record in the system.
The claims dashboard reflects these statuses for users.
Step 7 — Claim Resubmission
Rejected or partially approved claims can be corrected and resubmitted.
Users may:
- Modify claim details
- Submit remaining tests
- Resubmit corrected claims
This ensures that claims can be processed successfully after corrections.