Why Claims Management
The problem
Clinic CMS books and bills outpatient visits at a practice. POS sells retail medicines at the counter. Neither is built to adjudicate employer-funded benefit claims against annual allowances, panel networks, and copay rules.
Corporate care operators need a queue that answers: Is this member covered? How much balance remains? Is the hospital on-panel? What should we pay?
What Claims Management optimises for
- Operator throughput — dashboard pending queue → filtered claims list → one-click process.
- Eligibility context, not hard blocks — advisories (panel, balance, copay, category) inform the decision; the operator’s submit remains authoritative, with a required reason when overriding danger flags.
- Balance integrity — approvals debit the member’s enrollment pool; reopen credits it back for re-adjudication.
- Employer structure — organizations → plans → members/dependents → claims, with panel hospitals shared across plans.
- Audit trail — messages, events, and decision flags stay on the claim.
What it is not
- Not Clinic CMS — no appointment calendar or waiting-room queue.
- Not retail POS — no till session or FBR retail invoice from this console.
- Not the employee mobile app — staff create claims on behalf here; members may also submit from their own channel.