Verify Claim Condition - Eligibility Reasoning
Condition Eligiblity Reasoning
There are occasions where the condition is eligible but the claim itself is NOT eligible (e.g. duplicate claims, closing due to LOI, etc.). In these circumstances, Claim Advocates should keep the following in mind:
Condition Eligibility Unknown
Condition Eligibility Known
If the condition is KNOWN to be eligible (but the claim is not), please mark the condition as "Yes, Eligible" in the Verify Claim Conditions task. Do NOT mark is as ineligible even if the claim is ineligible (including do NOT use "UW" as a condition ineligibility reason).
If the eligibility of the condition is UNKNOWN, meaning we don't have enough information to make an accurate determination, please DISMISS the Verify Claim Conditions task entirely. This will leave the condition as undetermined in the Claim History signified by a (?).
Why?
Marking a condition as ineligible will block ICs for that condition. If we know the condition is eligible (or don't know with 100% certainty), we don't want to block future ICs unnecessarily.
Wisdom Bites - Verify Claim Condition - Eligibility Reasoning
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Transcript
Verify Claim Condition - Eligibility Reasoning
Condition Eligiblity Reasoning
There are occasions where the condition is eligible but the claim itself is NOT eligible (e.g. duplicate claims, closing due to LOI, etc.). In these circumstances, Claim Advocates should keep the following in mind:
Condition Eligibility Unknown
Condition Eligibility Known
If the condition is KNOWN to be eligible (but the claim is not), please mark the condition as "Yes, Eligible" in the Verify Claim Conditions task. Do NOT mark is as ineligible even if the claim is ineligible (including do NOT use "UW" as a condition ineligibility reason).
If the eligibility of the condition is UNKNOWN, meaning we don't have enough information to make an accurate determination, please DISMISS the Verify Claim Conditions task entirely. This will leave the condition as undetermined in the Claim History signified by a (?).
Why?
Marking a condition as ineligible will block ICs for that condition. If we know the condition is eligible (or don't know with 100% certainty), we don't want to block future ICs unnecessarily.