Claims
A file that cannot claim a history it has no evidence for.
The claim opens after discharge and runs to the closing statement. Its statuses are the lifecycle, and two of them cannot be set by hand.
- Reference
- CLM-2026-000271
- Statuses
- 10, with a real appeal path
- Set by the system
- Settled · Closed
- Audit trail
- Every status change, with actor
The problem
A claim could be marked settled from a dropdown with no payment recorded anywhere in the database. 'Has this been paid' was answerable only by asking a person, and 'who received the money' was not answerable at all.
What it does
Claims, in practice.
The full lifecycle as status
Collecting → scrubbing → ready for audit → in audit → approved, partially approved or rejected → awaiting settlement → settled → closed. Cancelled is kept distinct from rejected: withdrawn is not the same as declined.
Backward steps that are real operational paths
Foreign records arrive incomplete constantly, so an auditor who opens a file and finds the itemised bill missing can send it back to collecting. An appeal is a re-audit rather than a new claim, so the history stays attached. A closed file can be reopened for recovery or correction.
Server-computed totals
The amount claimed is the sum of the line items, not a number somebody typed. Approval takes either a total or per-item approved amounts, and the per-item figures are kept.
Line items freeze when the auditor gets the file
Items are editable while collecting and scrubbing, then lock. Changing them under a reviewer is how an audit ends up describing a claim that no longer exists.
Charges and bill review
What the provider billed, and what a reviewer allowed — two jobs, two grants. The gap between them is the savings figure the assistance fee is often based on, which is exactly why one person should not produce both halves.
Rules that are not obvious
Why it behaves this way.
Each of these is a decision with a cost behind it. They are the difference between software that records what happened and software you can defend in an audit.
A claim settles because money moved, not because somebody chose it.
Settled is refused on the manual path. It is set by a confirmed settlement, and the refusal names the act instead: record the disbursement and confirm it once the money has moved.
A claim closes because a statement went out.
Closed is likewise refused by hand and set by issuing the explanation of benefits.
A rejection requires a reason.
It is the sentence quoted back on an appeal.
A settlement confirmed against a claim still being collected is filed, not forced.
That is not a missing keystroke; it is something a person needs to look at. The money moved either way, so the fact goes on the timeline and the status is left alone.
The settled timestamp comes from the bank's confirmation, not from when the job ran.
Those can be minutes apart, and one of them is what somebody reconciles against a bank statement.
Works with
The modules next to this one.
Guarantees of payment
The letter the assistance business turns on — drafted, issued, sent to the hospital and measured against what actually gets billed.
ExploreSettlements & EOB
The disbursement and the closing statement — four-eyes approval, exactly one payee, and totals frozen at issue.
ExploreReimbursements
The traveller already paid. Receipts as lines, adjudication line by line, and a reason required on every reduction.
Explore
See it against one of your own files.
The fastest way to judge CareTrack is to walk a real case through it — intake, guarantee, charges, adjudication, settlement, statement. Bring one and we will do exactly that.
Or email contact@sthiramtechnologies.com