Claim Center

Overview

The claim centre runs the whole reimbursement process: pulling allocation data from the benefit engine, assembling the submission, validating it, and tracking its status afterwards.

Why it matters

For many facilities reimbursement is the largest revenue stream, and a rejected claim is money delayed or lost. Checking completeness before submission — and warning about the items most likely to be queried — is what keeps cash flow steady.

Readiness validation

Before a claim is submitted, the system checks it against each scheme’s own requirements:

• Required fields — what is missing for this particular scheme, such as an authorisation number or a diagnosis code
• Code validation — do the diagnosis and procedure codes match the current standard?
• Cap compliance — does this exceed the patient’s annual ceiling?
• Attachments — are the supporting documents present, such as referral letters and certificates?

All of it is checked automatically and presented as a list, so staff can fix problems before submitting rather than after a rejection.

Policy version snapshots

Every claim records the version of the coverage policy used to calculate it. When the rules are later updated, older claims still reference the version in force at the time — so when a scheme audits a submission months afterwards, the facility can show exactly which rules applied.

How it connects

The claim centre draws eligibility results from the eligibility module, allocations from the benefit engine, diagnosis codes from the medical record, and orders from outpatient, inpatient, laboratory and pharmacy — assembling a complete submission in each scheme’s required format.