Member validation module
Once the member receiving services has been uniquely identified, SCE applies logic to compare demographic data submitted on the claim to that in the system of record.
Under certain circumstances, discrepancies will trigger an event code on the claim. This logic is applied in the member validations module (SMV).
How member validations work in SCEMember validation event code triggering is based on several factors:
- The member fuzzy search settings
- The member search decision table
- The fuzzy search decision table
- The member search prefix length decision table
Because the SCE may apply system settings for fuzziness to defined demographic fields during the member match process, an expectation exists that members may be selected for adjudication even when an exact match on demographic information does not exist. This impacts the application of member validation logic to those data elements.
When both member fuzzy search settings are set to “Off”, the SCE simply compares the submitted claim information to the information on the member record selected during member match and raises the appropriate event code when there is a discrepancy.
When the primary and/or secondary member fuzzy search setting is set to “On”, the SCE will conditionally raise event codes following the logic described below. For each data element being considered for validation, the SCE will review the three tables to determine how to apply the event code logic. In the below situation, the field being compared has a variation against the member record of 1 character after the prefix length (for example: comparing a submitted last name of Johnson against Johnston).
| Member Search decision table configuration | Fuzzy search decision table configuration | Member search prefix decision table configuration | Event code triggered |
| Mandatory | 0 | 0 or not defined | Yes |
| Mandatory/Optional | 1 or 2 | 0 or not defined | No |
| Mandatory/Optional | 1 or 2 | 1 – 5 | No |
| Ignore | N/A | N/A | Yes |
Notes:
- A member match made using a data element defined as Mandatory with a fuzzy setting of 0 and a prefix length of 0 (or undefined) will trigger the relevant event code when the submitted data does not exactly match the data in the system of record.
- A member match made using a data element defined as Mandatory or Optional with a fuzzy setting of 0 or 1 and a prefix length of 0 (or undefined) will not trigger an event code as long as the data element is considered a match when the fuzziness degree is taken into account.
- A member match made using a data element defined as Mandatory or Optional with a fuzzy setting of 1 or 2 and a prefix length of 1 to N will trigger an event code if any of the characters included in the prefix length setting do not match the system of record.
- A data element defined as Optional is NOT considered as part of the member match logic, and a fuzzy setting of 1 or 2 and a prefix length of 1 to N is configured, an event code will trigger if any of the characters included in the prefix length setting do not match the system of record.
- When a data element is defined as Ignore or is not present in the Member search decision table, SCE will trigger the relevant event code when the submitted data does not exactly match the data in the system of record.
Smart Claims Engine provides logic to validate demographic information for both the patient and the subscriber. When the subscriber is the patient, validations are applied only to the subscriber fields. When the subscriber is not the patient, validations are applied to both the subscriber and the patient fields. Specific event codes are:
| Event code | Name | Description |
| SMV-0001 | Subscriber first name mismatch | The subscribers first name submitted on the claim does not match the first name of the member record stored in the system |
| SMV-0002 | Subscriber last name mismatch | The subscriber last name submitted on the claim does not match the last name of the member record stored in the system. |
| SMV-0003 | Subscriber ZIP code mismatch | The subscriber ZIP code submitted on the claim does not match the ZIP code of the member record stored in the system. |
| SMV-0004 | Subscriber city mismatch | The subscriber city submitted on the claim does not match the city of the member record stored in the system. |
| SMV-0005 | Subscriber state mismatch | The subscriber state submitted on the claim does not match the state of the member record stored in the system. |
| SMV-0006 | Subscriber address mismatch | The subscriber street address submitted on the claim does not match the street address of the member record stored in the system. |
| SMV-0007 | Subscriber DOB mismatch | The subscriber DOB (date of birth) submitted on the claim does not match the date of birth of the member record stored in the system. |
| SMV-0008 | Subscriber gender mismatch | The subscriber gender submitted on the claim does not match the gender of the member record stored in the system. |
| SMV-0009 | Subscriber ID mismatch | The subscriber identification number submitted on the claim does not match any of the identification numbers stored in the system. |
| SMV-0010 | Patient first name mismatch | The patient first name submitted on the claim does not match the first name of the member record stored in the system. |
| SMV-0011 | Patient last name mismatch | The patient last name submitted on the claim does not match the last name of the member record stored in the system. |
| SMV-0012 | Patient ZIP code mismatch | The patient ZIP code submitted on the claim does not match the ZIP code of the member record stored in the system. |
| SMV-0013 | Patient state mismatch | The patient state submitted on the claim does not match the state of the member record stored in the system. |
| SMV-0014 | Patient city mismatch | The patient city submitted on the claim does not match the city of the member record stored in the system. |
| SMV-0015 | Patient address mismatch | The patient street address submitted on the claim does not match the street address of the member record stored in the system. |
| SMV-0016 | Patient DOB mismatch | The patient date of birth (DOB) submitted on the claim does not match the date of birth of the member record stored in the system. |
| SMV-0017 | Patient gender mismatch | The patient gender submitted on the claim does not match the gender of the member record stored in the system. |
The SCE is not the source of truth for member validations, so typically any errors are due to data inaccuracies between the provider billing the claim and the payer member enrollment system. In the instance that the member enrollment system needs to be reviewed or updated, the SCE provides the ability to create a task requesting an update. The task is a notification NT- and is submitted to the system configuration work queue.
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