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Ailaaj Academy

Process a claim

Steps

  1. Go to Claims Management → Claims and open a non-final claim (Submitted, Under Review, or Info Requested).
  2. Review Claim Summary, attachments, member balance, and the advisory panel (panel coverage, balance, copay, category rules).
  3. Click Process Claim.
  4. Choose a decision:
    • Approve — pay the claimed amount (capped by what you enter).
    • Partial — enter a lower approved amount.
    • Reject — deny the claim (no balance debit).
    • Request Info — send the claim back for more documents/notes.
  5. If advisories show a danger flag and you still approve/partial, enter a written reason (required for the audit trail).
  6. Click Submit Decision.
Claim detail with Process Claim button
Claim detail — Process Claim when the claim is still open.
Process Claim dialog with decision buttons
Process Claim — decisions, amount, and note.

Tips

  • Advisories are informational — they do not block a decision; your submit is authoritative.
  • Settled claims (Paid / legacy Approved, Partial, Rejected) can be Reopened when policy allows re-adjudication.