This version keeps Jamie Ma'am's business needs, but presents them as a CaptiveView product flow instead of copying the reference screens.
Inbound files today42TPA, PBM, clinical and manual uploads
Auto matched31Matched to claimant, policy, year and claim type
Needs review17Missing data, duplicate, or unusual amount
SLA risk8Items aging beyond target
Proposed End-to-End Flow
CaptiveView acts as the controlled data hub between external sources and the medTRANS working screens.
1. ReceiveTPA/PBM feeds, Excel files, PDFs, images, emails, and manual packages enter one controlled intake point.
2. StandardizeCaptiveView validates fields, normalizes names, formats dates, and checks minimum required data.
3. MapData is tied to employer, policy year, claimant, claim sequence, attachment type, and payment category.
4. ReviewClaims intake, analysts, and clinicians work from queues with notes, status changes, and assignments.
5. ReportClean data feeds Tableau dashboards, audit reports, aggregate reports, and management views.
What Makes This Different From the Reference Screens
| Reference Need | CaptiveView Design Response |
|---|---|
| Claims intake receives packages manually | Dedicated intake workspace with file status, missing item checks, assignment and SLA aging. |
| Documents need to attach to group or claimant | Document mapping screen lets the user attach to policy month, claimant, claim, notification, or aggregate report. |
| Clinicians need review notes | Structured note workflow with tags, participants, follow-up date, attachments, and prior-note review. |
| Management needs visibility | Reporting layer separates operational work queues from Tableau-ready metrics and executive summaries. |
Role-Based Views
Claims IntakeReceive and file
Claims AnalystValidate and route
ClinicianReview and note
Admin / medTRANSAll data access
Client / Captive UserRestricted view
Received today24New packages and feed records
In intake37Being classified or matched
Awaiting documents19EOB, itemized bill, claim detail, or notes
Ready for review26Complete minimum data set
Intake Work Queue
| Item | Source | Employer | Claimant | Matched To | Status | Owner |
|---|---|---|---|---|---|---|
| INT-2026-00541 | TPA feed | Green Valley Schools | T. Green | Claim CLM-987654321 | Matched | Lisa M. |
| INT-2026-00542 | Email package | Waste Pro | Aurora Johnson | Claimant record | Needs EOB | Mark T. |
| INT-2026-00543 | Excel upload | ABC Manufacturing | Group file | Policy month | Classify | Unassigned |
| INT-2026-00544 | PBM feed | Green Valley Schools | James Thompson | Medication review | SLA risk | Lisa M. |
Minimum Data Check
Claimant name and DOBReceived
Employer / policy yearReceived
Diagnosis / ICD-10Partial
Paid amountReceived
Itemized bill / EOBMissing
Other supporting docsOptional
Claim Snapshot
ClaimantT. Green
EmployerGreen Valley Schools
LayerSpecific Deductible
Paid to Date$91,550
Pending / Pended$28,942
Risk Score82 High
Review Workspace
Clinical Context
Primary diagnosis: Hemophilia A. Treatment plan active. Factor VIII therapy every other day. Next review scheduled for 07/22/2026.
High Risk Specialty DrugFinancial Context
Specific deductible is 91.6% reached. Reserve recommendation is $325,000 with variance from current reserve.
| DOS | Type | Provider | Amount Paid | Status |
|---|---|---|---|---|
| 07/10/2026 | Inpatient facility | City Medical Center | $91,550 | In review |
| 06/24/2026 | Infusion | Hematology Associates | $12,874 | Paid |
| 06/17/2026 | Factor VIII drug | OptumRx | $12,760 | Paid |
Document Mapping Console
Incoming Package
Aurora_Johnson_EOB.pdfUnmapped
Itemized_Bill_070126.xlsxUnmapped
Provider_Notes.jpgUnmapped
Claim_Detail.csvParsed
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Attach To
MSL Policy MonthGroup data
Claimant RecordPerson
Specific ClaimRecommended
Aggregate ReportIf group level
Drag files here or choose upload to add supporting documents
Audit Trail
10:42 AMClaim detail parsed and matched to Aurora Johnson by member ID and DOS.
10:49 AMItemized bill requires manual confirmation because billed amount differs from paid amount.
10:55 AMEOB flagged as required before payment attribution can be marked complete.
Tableau-Ready Reporting Dataset
Claims paid$3.42MNormalized by policy year and employer
Loss ratio62.4%Filtered by captive user permissions
Reserve variance-$85KAvailable for management review
Dashboard Security Model
CaptiveView should enforce login, role permissions, row-level filtering, and audit logging before any Tableau or downstream dashboard is exposed.