{"version":"0.38.0","built_at":"2026-10-24T19:53:00.313Z","license":"CC BY 4.0 © Mike Reams","canonical":"https://catalog.mikereams.com","value_stream":{"id":"VS-530","name":"Claim-to-Payment","industries":["healthcare"],"description":"Receive a provider's or member's claim, check it against eligibility, benefits, authorizations and the provider's contract, decide and price it, pay it, and find and recover any payment that should not have been made. A provider's billing of the claim is Encounter-to-Cash.","outcome":"Every claim is decided correctly and promptly, paid at the right amount to the right party, and improper payments are prevented or recovered.","trigger":"A health plan receives a claim from a provider or member.","aliases":["Claims Lifecycle","Claim Processing","Adjudicate-to-Pay","Payer Claims Flow"],"stages":[{"id":"VS-530.10","order":1,"name":"Receive & Validate","description":"Receive the claim, validate its data and match it to the member and the provider.","capability_ids":["BC-1870.40","BC-1870.10","BC-1870.30"],"events":[]},{"id":"VS-530.20","order":2,"name":"Check Authorization","description":"Check the claim against prior authorizations and medical necessity decisions.","capability_ids":["BC-1870.50"],"events":[]},{"id":"VS-530.30","order":3,"name":"Adjudicate & Price","description":"Apply benefits, coverage policies and contract terms to decide and price each service.","capability_ids":["BC-1870.40","BC-1870.20","BC-1870.30"],"events":[]},{"id":"VS-530.40","order":4,"name":"Screen Payment","description":"Screen the claim before payment for errors, duplicates, coordination of benefits and possible fraud.","capability_ids":["BC-1870.60"],"events":[]},{"id":"VS-530.50","order":5,"name":"Pay & Explain","description":"Pay the provider or member and send the remittance and the member's explanation of benefits.","capability_ids":["BC-1870.40"],"events":[]},{"id":"VS-530.70","order":6,"name":"Resolve Appeals & Disputes","description":"Hear member appeals and provider disputes of the decision, and reprocess the claims that are overturned.","capability_ids":["BC-1870.40"],"events":[]},{"id":"VS-530.60","order":7,"name":"Recover & Settle","description":"Recover overpayments, pursue other liable parties and settle value-based contract amounts.","capability_ids":["BC-1870.60","BC-1860.30"],"events":[]}]}}