Re-evaluating claims on an encounter

Claims are prepared from an encounter when you record it, using the program rules and reference data available at that moment. When either changes — a new NIPVIP row, a fix to an evaluator, a correction to the underlying form — the prepared claims on existing encounters can drift. Re-evaluating the encounter re-checks it against the current rules and brings its prepared claims back into line.

Submitted claims are never touched. Only prepared claims that haven't gone to the provider yet are affected.

When to re-evaluate

• Encounter form was amended. After amending details on the underlying form, re-evaluating refreshes the prepared claims without needing to record the encounter again.
• Reference data updated. A program's eligibility data was refreshed (e.g. a new NIPVIP vaccine row, a CVCP cohort change) and encounters recorded before the update should be reassessed.
• Evaluator fix shipped. Light released a fix that affects how a program computes eligibility — re-evaluating picks up the corrected behaviour.

If nothing like that has happened, you don't need to re-evaluate — the prepared claims are already correct.

Re-evaluating

1. Open the service

   Open the service whose encounter you want to re-evaluate. The Claims card sits alongside the encounter form on the service page.

2. Tap Re-evaluate claims

   In the top-right of the Claims card, tap the Re-evaluate claims action. Light shows a confirmation dialog summarising what will happen.

3. Confirm

   Tap Re-evaluate. Light re-runs the evaluators against the current form data and reference rules.

4. Read the outcome

   A toast reports what changed — for example "2 added, 1 removed". If nothing changed, the toast says No changes and the claims on the card stay as they were.

What re-evaluation does

For each program the encounter qualifies for, Light:

• Creates a prepared claim if one should exist but doesn't.
• Updates a prepared claim's payload if the evaluator now produces a different result (e.g. a different fee tier, a corrected batch code).
• Removes a prepared claim that no longer applies — for example, if a reference-data change means the service is no longer eligible for that program.

Submitted, Accepted, Rejected, Failed, and Removed claims are left alone. Re-evaluation only affects claims in Ready or equivalent pre-submission states (including Ineligible, which can be reopened if rules or data now allow it).

What re-evaluation doesn't do

• Doesn't resubmit claims. A re-evaluated Ready claim still needs to be submitted from the Claims page.
• Doesn't amend rejected claims. For those, see Amending a rejected claim.
• Doesn't change the encounter's form data. If the form itself is wrong, amend the form first, then re-evaluate.

After updating the patient record

Changes to a customer's profile — Medicare, date of birth, Aboriginal or Torres Strait Islander status, address — don't automatically re-run the claim. The claim is evaluated against the encounter form, not the live patient record, so updating the profile alone won't move it.

The order is:

1. Fix the detail on the customer's profile — see Editing customer details.
2. Open the encounter and amend the form so the corrected detail is pulled through — see Amending submitted data.
3. Re-evaluate.

Editing the same field from within the encounter panel doesn't update the patient record — the profile is the source of truth for identity and eligibility data. Fix it there first, then amend the form.

If nothing changed after Re-evaluate

The toast says No changes and the claim looks the same. Usually one of:

• The claim isn't in a re-evaluable state. Submitted, Accepted, Rejected, Failed, and Removed claims are locked. Re-evaluation only affects claims in Ready, Pending, or Ineligible.
• Nothing that affects eligibility has changed. If the edit was to a note or other non-evaluated field, re-evaluation will correctly do nothing. Amend the field that actually feeds eligibility (identity, vaccine, dose, date, address) and try again.
• The form wasn't amended after the profile change. Re-evaluation reads the form, not the profile — amend the encounter first.

If the claim is still Ineligible

If the claim stays on Ineligible after re-evaluating, work through these in order:

• The patient genuinely doesn't qualify. Ineligible isn't always a mistake — sometimes Light is correctly telling you the encounter didn't meet the program's criteria (wrong age, wrong state, vaccine not covered by the program). Hover the Ineligible badge to read the reason before assuming something needs fixing.
• The detail that made it Ineligible hasn't been updated. If the reason shown is "Missing Medicare number", that specific field needs to change. Updating a different field won't clear the original reason. Always match the fix to the reason on the claim.
• The patient record was updated but the form wasn't amended. The evaluator reads the form, not the live profile. Unlock the form, amend it, re-submit, and re-evaluate — see After updating the patient record above.
• Nothing has changed since the last Re-evaluate. Identical form data produces an identical result. A persistent Ineligible after clicking Re-evaluate can just mean Light is confirming nothing has changed.
• A different claim on the same encounter is the Ineligible one. One encounter can produce multiple claims across programs (for example, a PPA claim and a state-funded claim). Check you're reading the right row — claims are evaluated independently and each has its own reason.

Submitted claims can't be re-evaluated in Light

Once a claim has reached Submitted, Accepted, or Rejected, Light can't change it — it's now part of the provider's record. To correct a submitted PPA claim, use the normal amendment or reversal process in the PPA Portal directly. For a rejected claim that hasn't been accepted, use Amending a rejected claim instead.