Item

Task
Ref Information/Function

Description

Business
Rule

Ensure that claims received from a specialist are routed to the specialist work
destination queue for vetting and approval. This must be executed on the
basis of an ICD10 code carried in the claim data-block.
Approved claims must be routed to the claims capture work destination
queue.

BRD

Rejected claims must:

Automatically generate a comms matrix event with the relevant document per
the finalized document list.
Be routed to the REJECT case queue.
All events in this BRD must update the Case Register with the applicable user,
date and timestamp.

Task Group

Specialist Claim Referral

Task (Ref Process Map)

11,12,13,14,15

Actors

Members, Brokers,
Physicians, RA

Function

Background routing task

Screens/Form(s) to
View

Claims Processing Screen

(Specialist)

Images(s) to View

Attached indexed claims

invoice.
Supporting documents (if
applicable)

2.1

Action-Auto

Routing based upon

supervisor verification.
K2 Comments/Notes

If ICD10= 20691
then route.

Service request
on 2nd
submission
(Pathology) must
be manually
identified by the
specialist. If so
then routing key
must be updated
to Y (via refer
button) to route
case for closure.
(Process will
continue
manually)

Interface

8.1

To

WinForm (Refer)

8.2

From

K2

9
9.1
9.1a
9.2

Action-Manual (Actors)
Enter data

No

Data Required

Refer to Rowang datablock

Evaluate

Yes Manual evaluation

Refer event button
Yes

9.3

Add notes

10

On completion

10.1

Validate

No

10.2

Rule(s)

As per 7

10.3

11

11.1

12

Yes

Update case
register with
event date and
time stamp

Yes - 7

If Reject is
executed then
submit document
as per document
list.

Communicate

Communications

Event No:

Routing-Task

12.1

From

CLAIMS VIEW

12.2

To

SPECIALIST PROCESS

13

Routing-Group/Basket
SPECIALIST

13.1

If not actioned,
this event must
be forced.

To