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claim_contract_resolution [2022/02/14 11:33] – lisa.maloneyclaim_contract_resolution [2025/09/18 18:03] (current) – tina.robles
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   - XREF_CONTRACT_PAID_CLAIM/XREF_USER_CONTRACT_SEQUENCE   - XREF_CONTRACT_PAID_CLAIM/XREF_USER_CONTRACT_SEQUENCE
   - CLAIMANT_CONTRACTEE_MATCH   - CLAIMANT_CONTRACTEE_MATCH
 +  - PAID_CLAIM (Deprecated)
   - CLAIMANT_CONTRACTEE_MATCH_RELAXED   - CLAIMANT_CONTRACTEE_MATCH_RELAXED
   - SAME_CONTRACT_NAME_AS_RESOLVED_LINE   - SAME_CONTRACT_NAME_AS_RESOLVED_LINE
 +
 +NOTE:  Any contracts with a type of AUTOPAY will not be part of the auto matching process for claims to contract. 
  
 ----- -----
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 If there is one and only one contract found for the line item’s product and time period where the contractee is the resolved company or group from the Claimant Contractee Xref, then we resolve to that contract. If there is one and only one contract found for the line item’s product and time period where the contractee is the resolved company or group from the Claimant Contractee Xref, then we resolve to that contract.
 +-----
 +
 +**PAID_CLAIM (Deprecated)**
 +
 +The system will look for a paid claim driven by the claimant contractee mapping and claimant contract name. If there are multiple contracts only found for the contractee, then a contract would not be matched.
 ----- -----
  
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 {{:pasted:20220214-113257.png}} {{:pasted:20220214-113257.png}}
 +
 +-----
 +
 +**CONTRACT-TO-CLAIMS MATCHING ENHANCEMENT: Phase 1**
 +
 +__Intelligent Scoring Implementation__
 +
 +Project Overview
 +
 +We are implementing an advanced scoring algorithm for contract-to-claims matching, leveraging the proven methodology from our existing deduction matching system. This enhancement will significantly improve matching accuracy and establish the foundation for future automation capabilities.
 +
 +__Key Features & Benefits__
 +
 +**Enhanced Decision Intelligence**
 +  * Scoring Algorithm: Implementation of a sophisticated scoring system that evaluates contract-to-claim compatibility
 +  * Data-Driven Decisions: Provides quantitative metrics to support optimal contract selection for claim matching
 +  * Future Automation Ready: Establishes the scoring framework necessary for automated matching in subsequent phases
 +
 +**Improved Search Functionality**
 +  * Intelligent Date Range Logic: When accessing claim details via the provided link, the system automatically determines the optimal search parameters
 +  * Dynamic Date Calculation:
 +  *   * Uses the claim start date as the baseline
 +  *   * Extends search period to January of the claim year
 +  *   * Includes an additional 12-month lookback period
 +  *   * Returns all qualifying contracts within this comprehensive timeframe
 +
 +**Technical Implementation**
 +  * Search Scope: 24-month maximum search window ensures comprehensive contract coverage
 +  * Performance Optimization: Focused date range reduces processing overhead while maintaining thoroughness
 +  * User Experience: Seamless integration with existing claim review workflows
 +
 +**Expected Outcomes**
 +  * Improved matching accuracy through quantitative scoring
 +  * Enhanced user confidence in contract selection decisions
 +  * Reduced manual review time for obvious matches
 +  * Foundation established for Phase 2 automation capabilities
 +
 +{{:pasted:20250918-175201.png}}
 +
 +{{:pasted:20250918-175229.png}}
 +
 +**Scoring Framework Overview**
 +
 +The scoring algorithm employs a comprehensive point-based system where each successfully matched field contributes to the overall compatibility score between contracts and claims. The methodology distinguishes between header-level and detail-level matching criteria to ensure accurate assessment across all contract dimensions.
 +
 +__Scoring Architecture__
 +
 +**Point Allocation System**
 +  * Base Scoring: 1 point awarded per successfully matched field
 +  * Header-Level Scoring: Binary scoring (0 or 1) for company-level attributes
 +  * Detail-Level Scoring: Proportional scoring (0.0 to 1.0) representing percentage match of claim elements against contract definitions
 +
 +__Scoring Criteria & Calculations__
 +
 +**Header-Level Matches**
 +
 +{{:pasted:20250918-175821.png}}
 +
 +**Score Interpretation**
 +  * Higher Scores: Indicate stronger contract-to-claim compatibility
 +  * Composite Scoring: Total score represents cumulative match strength across all evaluated criteria
 +  * Decimal Precision: Detail-level scores provide granular matching insights for partial alignments
 +
 +**Implementation Roadmap**
 +
 +Phase 1: Foundation
 +  * Deploy scoring algorithm for manual matching enhancement
 +  * Establish baseline scoring metrics and validation
 +
 +Phase 2: Analytics & Optimization
 +  * Conduct comprehensive analysis of matching outcomes versus scoring patterns
 +  * Identify optimal score thresholds for automated decision-making
 +  * Validate scoring accuracy through historical data correlation
 +
 +Phase 3: Automation
 +  * Implement client-configurable score thresholds for automated matching
 +  * Deploy intelligent auto-matching capabilities based on validated scoring criteria
 +  * Establish monitoring and continuous improvement protocols
 +
 +**Expected Benefits**
 +  * Enhanced Accuracy: Quantitative scoring reduces subjective matching decisions
 +  * Scalability: Systematic approach enables future automation capabilities
 +  * Transparency: Clear scoring methodology provides audit trail for matching decisions
 +  * Customization: Client-specific thresholds accommodate varying risk tolerances and business requirements
 +
 +This scoring methodology establishes a robust foundation for intelligent contract matching while maintaining the flexibility to adapt to diverse client requirements and operational scenarios.
 +
 +
 +
 +-----
 +
 +__**Splitting Claims**__
 +
 +**Invoice Consolidation**
 +
 +When multiple records share the same invoice number, the system consolidates them under a single invoice identifier to maintain data integrity and streamline processing.
 +
 +**Claim Generation Framework**
 +
 +Claims are systematically generated based on the invoice structure and associated contract family relationships.
 +
 +__**Contract Family-Based Claim Splitting**__
 +
 +**Single Contract Family Scenario**
 +
 +**Condition**: All line items within an invoice resolve to the same contract family
 +
 +**Result**: One consolidated claim is created for the entire invoice
 +
 +**Multiple Contract Family Scenario**
 +
 +**Condition**: Line items within an invoice resolve to different contract families
 +
 +**Result**: The system creates separate claims for each distinct contract family represented
 +
 +__**Line Item Validation Process**__
 +
 +Each line item within a generated claim undergoes comprehensive validation based on the following criteria:
 +
 +**Contractee Identifier Verification**
 +
 +The system validates that the contractee identifier associated with each line item is accurate and properly mapped to the corresponding contract.
 +
 +**Eligibility Assessment**
 +
 +Each line item is evaluated for eligibility across two primary categories:
 +  * SKU-Level Eligibility: Verification that the product/SKU is covered under the applicable contract terms
 +  * Lumpsum-Level Eligibility: Confirmation that any lumpsum components are authorized and properly allocated within the contract framework
 +
 +**__Processing Workflow Summary__**
 +
 +  - Invoice Consolidation: Group records by invoice number under single invoice ID
 +  - Contract Family Analysis: Determine contract family associations for all line items
 +  - Claim Segmentation: Create claims based on contract family groupings
 +  - Line Item Validation: Verify contractee identifiers and eligibility for each claim component
 +
 +
 +
claim_contract_resolution.1644838417.txt.gz · Last modified: 2022/02/14 11:33 by lisa.maloney

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