Standard Operating Procedure (SOP)
Medical Claims Validity Determination​
Table of Contents
1.​ Purpose
2.​ Scope
3.​ Definitions
4.​ Decision Logic Overview
○​ 4.1 Process Flow Chart
5.​ Detailed Decision Tables
○​ 5.1 Claim Amount Eligibility
○​ 5.2 Policy and Benefit Eligibility
○​ 5.3 Non-Disclosure Score Status
6.​ Claim Validity Decision Matrix
7.​ Roles & Responsibilities
8.​ Appendix
○​ Example Scenarios
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1. Purpose
This SOP outlines the decision-making process for determining the validity of medical
claims. It ensures consistency, accuracy, and compliance with policy guidelines and
fraud detection protocols.
2. Scope
Applies to all medical claims submitted for processing. Key decisions include:
●​ Claim Amount Eligibility
●​ Policy and Benefit Eligibility
●​ Non-Disclosure Score Status
●​ Claim Validity
●​ Early Claim Identification
3. Definitions
Term
Description
Claim Validity
Final determination: Valid, Not Valid, or
Questionable.
Non-Disclosure Score
Fraud risk score (0–100) based on undisclosed
information.
Early Claim
Claim submitted <180 days from the incident date.
STP (Straight-Through
Processing)
Automated eligibility checks.
4. Decision Logic Overview
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4.1. Process Flowchart (Textual Representation)
5. Detailed Decision Tables
5.1. Claim Amount Eligibility
Geographic Area
Billed Amount (USD/CAD)
Currency
Eligibility
USA
≤20,000
USD
Eligible
USA
>20,000
USD
Not Eligible
Canada
≤15,000
CAD
Eligible
Canada
>15,000
CAD
Not Eligible
Other
Any
Any
Not Eligible
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5.2. Policy and Benefit Eligibility
Policy Status
Current Claim
Eligibility
Active
Not Null
Eligible
Active
Null
Ineligible
Inactive
Any
Ineligible
5.3. Non-Disclosure Score Status
Score Range
Risk Level
Action
80–100
High
Reject
50–79
Moderate
Review
0–49
Low
Accept
6. Claim Validity Decision Matrix
Condition
Validity
All STP criteria met + Low risk
Valid (
High Non-Disclosure Score
Not Valid (
Unstructured Data/Exclusion Identified
Questionable (
Early Claim Identified
🟢)
🔴)
🟡)
Questionable (🟡)
7. Roles and Responsibilities
Role
Responsibility
Claims Processor
Input data validation
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Fraud Analyst
Review flagged claims
System Administrator
Maintain DMN rules
8. Appendices
Appendix A: Example Scenarios
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Appendix A: Example Scenarios
Scenario 1: Valid Claim with Approval
●​ Inputs:
○​ Pre-authorization Received: true
○​ Hospital Accreditation: true
○​ Policy Valid: true
○​ Treatment Covered: true
○​ Claimed Amount: ₹20,000
●​ Decision: Approved
●​ Reason: Verified, eligible, and low amount
Scenario 2: Rejected Due to Missing Accreditation
●​ Inputs:
○​ Pre-authorization Received: true
○​ Hospital Accreditation: false
○​ Policy Valid: true
○​ Treatment Covered: true
●​ Decision: Rejected
●​ Reason: Hospital not accredited
Scenario 3: Escalation for High Value
●​ Inputs:
○​ Pre-authorization Received: true
○​ Hospital Accreditation: true
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○​ Policy Valid: true
○​ Treatment Covered: true
○​ Claimed Amount: ₹75,000
●​ Decision: Escalated
●​ Reason: Verified and eligible, but high value
Scenario 4: Rejected Due to Policy Invalidity
●​ Inputs:
○​ Pre-authorization Received: true
○​ Hospital Accreditation: true
○​ Policy Valid: false
○​ Treatment Covered: true
●​ Decision: Rejected
●​ Reason: Policy not valid at time of treatment
●​
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