Entering claims requires the employee name, date of service (service start date), and either a plan name or a service category code. 

The plan selected on the new transaction page determines the employee account that is debited by the claim. When a plan is selected, the claim can only debit one employee account. The only way for the claim to debit more than one employee account is if a service category code is selected instead of a plan.

The total claim amount is the sum of the amount you enter in the amount approved field, the amount pended field, and the amount denied field.

The amount that you approve on the new transaction page is just the basis for the amount that the employee will actually receive for the claim. After you submit the claim, the system will process the original approved amount with the following steps:

• First, the system determines whether any of the amount entered in the Amount Approved field should be excluded due to your predefined business rules. Business rules that can reduce the final approved part amount include:
  • Limits on maximum transaction amounts specified for the plan, service category code, or merchant category code (MCC).
  • Limits on plan year maximum total amounts specified for the plan, service category code, or merchant category code (MCC).
  • The claim’s service start date falling outside the employee eligibility date range
• Then, WCA determines if there are sufficient funds in the account to cover the claim. If there are insufficient funds and partial payment is enabled, the approved amount is reduced to the amount of available funds. Otherwise, the claim is denied.
• Finally, WCA determines if any of the claim’s reimbursement amount should be further reduced by:
  • The application of any portion of the claim to a deductible.
  • The application of any portion of the claim to offsetting a prior ineligible card transaction.

At the top of the participant entered claim adjudication page is a button banner. The buttons display as follows:

• Submit claim – When clicked, claim details are saved, and WCA creates a transaction.
• Approve and submit – When selected, WCA changes the transaction status field to ‘approved’ and submits the claim with one single click!
• Request review – Tied to the ‘claim audit controls’ feature. It saves the claim’s current status and details, but flags it for additional review. For complete details on this functionality, see the claim audit controls page in Online Resources.
• Reset – Resets all of the claim details to the original values submitted by the participant.
• Cancel – Exits the participant entered claim page, without saving changes. When clicked, you are returned to the transaction adjudication page.

Most commonly used fields appear on the left side, and most commonly referenced data appears prominently on the right side, allowing you to quickly review information while you tab through the fields to make any necessary edits. Lesser utilized fields can be found in each of the expandable panels at the bottom of the screen. Hiding these fields behind panels provides a less cluttered adjudication screen, while still allowing all of these fields to be easily accessible.

• Claim details
• Pended and denied details
• Advanced processing details
• Recurrence settings