Standard Claim Vs Test Claim

	Standard Claim	Test Claim
Understanding	Standard claims are claims that are very similar to claims submitted by pharmacies. Standard claims are claims that are submitted from our Procella portal. Standard claims submitted from the claim submission tool can be POS or DMR claim	Test Claims are claims which are also very similar to claims submitted by pharmacy. But is processed ONLY for testing / observe the outcome of the claim. Test Claims are also submitted from our procella portal to Claim submission tool (CST)
Purpose	Standard claims are used to actually adjudicate the claims in the system. Similar to a pharmacy claim but Relay Health is skipped when you submit a standard claim through CST.  For eg., it may be required to process DMR claims in the system. And when we do, it needs to be submitted as a Standard claim as we want the claim history to be stored in the member's history	Test claims are usually used in order to see the actual outcome of the claim. It uses actual member’s / group / Plan information to adjudicate but does not save/affects the accumulations/history of the Member.
When to Use	Standard claims are used to process DMR (Direct Member Reimbursement) claims. Standard claims can also be used to submit POS claims (Pharmacy Claims). This may not be a real-time case. But the system allows us to do it.	Cash / Commercial claims Testing - If the user has a plan constructed and it needs to be tested then Test claims can be used. Commercial Claim - If the user wants to test and view the outcome of a claim that is processed against a member to see how deductible/accumulator is applied /how to get a claim paid if it gets rejected for some reason (A PBM/CSR may use the test claim feature to verify claim outcome)
What differentiates Standard Vs Test	Software Vendor / Certification ID (110-AK)  Value could be blank value could be anything other than 'TEST324765'	Software Vendor / Certification ID (110-AK)  The value HAS TO BE 'TEST324765'
Where data is stored	Its stored all/necessary claim history tables claim_* claim_history_* all other relevant tables	It is NOT stored in ANY of the Claim history table. Details are stored in Test Claim tables test_claim_*
During Adjudication	Standard Claim processing uses the actual data thats is stored in all above tables	Test Claim processing also uses the actual data that is stored in claim_* claim_history_* all other relevant tables (NOT THE test_claim_* tables)

How to Submit Test Claim

• Submitting a test claim is similar to submitting a standard claim. Use the Claim submission tool (Benefit Manager → Claim Submission Tool OR Customer Services → Claim Submission Tool)
• Create a New Template OR Open an Existing Template in the Claim Submission Tool

• Select the Test Claim option in the claim submission tool

• Once you select Test Claim option, the "software vendor/cerification ID will be automatically populated. Note: Software Vendor / Certification ID (110-AK) field value in the claim is the one that differentiates between STANDARD and TEST CLAIM submission.

How to View a Test Claim

• Submitting a test claim is similar to submitting a standard claim. Once you click SUBMIT option. You will see the Raw Claim Request and Raw Claim Response

• Just like a standard claim, processing a test claim will also generate a transaction ID as highlighted in the above image. To view the test claim, click on View in Customer Service option OR navigate to Customer Service → Claim History

• In the Customer Service → Claim History screen, choose the Claim-test option. Choose the adjudicated date from and to data’s as per your search period. Click on Search button. The test claims will be displayed in the list.

• Click on the ellipsis icon (three dots icon). Select View Claim Summary options. (Note: You can observe the same transaction ID on this screen as well. The first two characters in this screen are different from what you see in the Claim submission tool). The test claim transaction id starts with TC. (Currently, the Claim submission tool may show AC but the actual transaction id starts with TC)

• You can also use other search options in the claim history screen to look up for the test claim transaction (Make sure to select Claim-test option)
• Test Claim transaction view is very similar to standard claim view

• As of today, ONLY the following claim history screens show actual claim data for Test Claims

Summary Tab

Claim Tab

Provider & Prescriber

Financial

Accumulators

Transaction Data → Rules Audit

Transaction Data → Network Rules Audit

• When you navigate to the screens that are not supported, you may see an error message like this

• Also please note TEST CLAIM cannot be reversed and it is NOT necessary to reverse because these test claims do not add to any financial (Deductible / Member OOP / Plan Amount Stop Loss / Plan Pay Max) or Non financial accumulators (Day Supply Max / Quantity Max / Fills Max / Units Max). You will see a Claim Reverse Reject if you try to reverse a Test Claim.