Payments and operations

A claim payment records the amount, paid date, provider event identifier and verification value. It links to both the claim and the decision that authorized the benefit. Creation of a payment advances the linked claim to Settled and creates an operation receipt under the claim policy. These records allow the team to inspect the decision, claimed amount, payment amount and recorded operation together.

Operation receipts hold an operation key, action, expected revision, result state and occurrence date. Failed and review-needed results can carry a failure reason; external and effect references give the operator more context. Operations Overview brings open claims, assessment backlog, review pressure and failed provider operations into one work surface. The operator can start with an exception and open the underlying policy or claim.

• Follow the decision. Compare the authorized benefit with the linked payment amount.
• Read the operation. Check the action, result and policy on the receipt.
• Verify the provider. Compare the event identifier and recorded verification value with the provider result.

Agree who checks the payment after an approval creates it. The claim can read Settled as soon as the payment record is created, so set a separate check for the provider event and verification value. Decide who investigates failed operation receipts and how repeated event identifiers are handled. Rehearse an approval and a failed result before the first live case.

Take an approved decision with its raised payment. Check the decision link and payment amount, then inspect the claim status and policy operation receipt after payment creation. If the receipt shows a failed result, open the failure reason and compare the operation key before another action. Use the provider event identifier to discuss the outcome with the payment service.

Payment Operator should trace the amount from decision through payment and compare the provider event with the source response. If the operation receipt is Failed or needs review, the operator follows its key and failure reason. Claims Reviewer should be able to explain why the benefit was approved even when the provider result still needs checking.

• Claim payment verification — Find payment records whose provider outcome remains unverified.
• Failed operations — Inspect failed or review-needed operations by policy and action.

Follow the related operating process and use the record definitions when checking a field or relationship.