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Claim status and compensability

Resolve claim status, compensability, original acceptance decision, and legacy MCO enrollment date; reject retired WCIS activity queries.

Field Value
Operation ID OP-SD-14
Trigger Caller requests claim status/compensability/acceptance data.
Inputs Claim id
Outputs Status/code data, or NotImplementedException
Primary components ClaimQueryProvider
Entry point Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs

Steps

  1. GetLatestClaimStatus: when there is no history, fall back to the WCD status; otherwise use the latest non-removed history entry (SD-BR-041, SQL-056, SQL-058, SQL-059, SQL-061, SQL-062).
  2. GetCompensabilityStatus: "Claim Denied" maps to "D"; otherwise use the first letter, upper-cased (SD-BR-042).
  3. GetOriginalAcceptance: RequestType = "I" and decision "A" (SD-BR-043). Data: ClaimRequestDecision (CL_CLAIM_REQUEST_DECISION).
  4. GetMcoEnrollmentDate (obsolete): returns a date only when the eligibility status is "Y" (SD-BR-044).
  5. The following throw NotImplementedException: GetWorkReleaseStatus, GetLatestClaimTypeActivity, GetClaimTypeActivity ("data retired"), GetClaimStatusActivity, GetClaimRequestDecisions (SD-BR-045).

Process flow

The following diagram visualizes this operation's control flow.

flowchart TD
    Start([Caller requests claim status/compensability/acceptance data.]) --> S1["`ClaimQueryProvider`"]
    S1 --> S2{"Rules satisfied?"}
    S2 -->|Yes| EndOk([Result returned])
    S2 -->|No| EndErr([Exception / empty result])

Failure and edge-case behavior

  • Retired WCIS activity queries: always throw NotImplementedException, never partially execute.

Sources

  • Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs
  • Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs:100
  • Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs:182
  • Data/SAIF.Data/Queries/Claims/ClaimQueryProvider.cs:223