Issue: New AETNA Versioning Rule

0082

60054A

Jul 15, 2021

AETNA medical clams utilize Versioning Approach 1 which groups on Claim Number (MC004) and Claim Line (MC005), and uses Version Number (MC005A) to determine the latest claim line.

AETNA has now identified an additional requirement to version their claims. They advise that Versioning Approach 3 should integrated with Versioning Approach 1. Versioning Approach 3 Stan uses the presence of Original Claim Number (MC139) and Paid Date (MC017) to determine that the claim line was the newer version of an older claim line.

When the value in MC139 on one AETNA claim matches MC004 of another claim, the two claims should be used together for the complete event. For example, MC063 - Paid Amount - should be added together on the two claims to understand the full paid amount.

Right now, both the original and replacement claims are kept so merging them as described above can be done.

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Versioning

Data Quality

Issue