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- Health Insurance Claims
- Process
- Operation reconciliation
Operation reconciliation
An operation receipt records the attempted action, stable key, expected policy revision and resulting state. Finance Reconciler uses it to find work that is pending, failed or needs review. Completion means the intended records agree on identity, scope and revision; it cannot be inferred from a successful screen response alone.
Step by step
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Find the operation Finance Reconciler
Finance Reconciler opens a pending or failed receipt and identifies its parent policy and action.
- Identifies the action and expected revision
- Updates Operation receipts, Policies
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Read persisted effects Finance Reconciler
Compare the referenced policy, request, claim or review decision with the expected identity and revision.
- Tests actual local effect identity and scope
- Updates Claims, Preauthorizations, Review decisions, Policies
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Resolve discrepancy Finance Reconciler
Record the failure reason and bring mismatched effects to the domain owner.
- Keeps mismatch and supporting evidence
- Updates Operation receipts, Record attachments
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Reconcile operation Finance Reconciler
Mark the receipt completed only when the actual effects match the intended action.
- Records the confirmed result state
- Updates Operation receipts, Policies
Who does what
Roles and permissions- Finance Reconciler
- Investigates receipts.
- Policy Operations Specialist
- , Preauthorization Reviewer and Claims Decision Reviewer explain their domain decisions when a linked effect differs from the intended one.
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