Operating procedure

An exception-handling procedure with correction, validation, recovery and escalation controls.

Product decision
Keep each correction authorized and each handoff reconcilable.

Document type

Operating procedure

Lifecycle stage

Operate & learn · 29 / Operate & learn

Contents

3 sections · 1 table · about 1 min

Status

Portfolio sample · written from my healthcare claims experience

Product decision

Keep each correction authorized and each handoff reconcilable.

Portfolio sample from my healthcare product experience. Requirements, thresholds and review records are illustrative; they are not employer documents or historical sign-offs.

Purpose and scope

The operator’s objective is to return a held claim to an authorized processing path without losing evidence or duplicating work. This procedure follows document quality, provider identity and receiver state in that order.

1. document quality
2. provider identity
3. receiver state in that order

Procedure

Each action preserves the control needed for the next handoff.

Step	Action	Control
1	Inspect form type and extraction	Unsupported or uncertain content held
2	Inspect provider result	Original/normalized evidence; unresolved outcomes explicit
3	Correct with authority	Reason and lineage retained
4	Revalidate applicable 837	No handoff while invalid
5	Inspect receiver status	Acknowledgement distinct from adjudication
6	Recover timeout or replay	Stable identity and reconciliation before retry
7	Close or escalate exception	Reporting inventory remains complete

Escalation

Operations handles workflow questions, provider specialists resolve identity gaps, and claims/integration teams interpret receiver errors. Security and compliance handle access concerns; care and patient-safety partners join where downstream consequences require them. Corrections do not bypass authorization or change benefit policy. Pharmacy claims retain their separate transaction workflow.

1. Operations handles workflow questions
2. provider specialists resolve identity gaps
3. claims/integration teams interpret receiver errors
4. Security and compliance handle access concerns care and patient-safety partners join where downstream consequences require them

Corrections do not bypass authorization or change benefit policy