Process and reconcile specialized reimbursements

Trigger: A specialized reimbursement request, such as for out-of-network care, specialty pharmacy, or complex medical procedures, is submitted by a provider or member.

1. Receive specialized reimbursement documentation
2. Verify member eligibility and specialized coverage rules
3. Review clinical documentation for medical necessity and coding accuracy
4. Calculate reimbursement based on specialized fee schedules or provider contracts
5. Disburse payment to the provider, facility, or member
6. Reconcile the payment against financial ledgers and funding accounts

Outcome: The specialized claim is accurately adjudicated, payment is disbursed, and the transaction is fully reconciled in the financial ledger.