Claims handling in FIMMAS consists of four elements: Claims entry and determination of eligibility; Claims adjudication (calculation of payment); Disbursement processing; Claims tracking, inquiry and reporting.
FIMMAS handles all four of these elements for life, AD&D, and disability products. For medical and dental products, FIMMAS provides elements 1, 3, and 4, with an interface to specialized systems for claims adjudication.
In other words, FIMMAS manages claims for all types of products. It creates the claim record, checks eligibility, and passes eligible claims to the appropriate claims adjudication system (FIMMAS for life, AD&D, and disability; an external system for medical, dental, vision, and prescription drugs products).
Once the claims adjudication system has calculated the payment, the payment information is returned to FIMMAS, which creates the disbursement, allocates the disbursement to appropriate General Ledger accounts, and updates the client database to reflect the payment. The FIMMAS database then retains all transaction detail for tracking of claims history and payment history. All detail is available for inquiry and reporting. Detail records are retained on-line until users decide to archive or delete them.
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