SCE’s ES process uses 1 of 5 discrete out-of-the-box queries when fetching matching authorization candidates. As indicated above, SCE selects the ES query to run based on the information returned in the RequestedAuthType decision table.
The 5 ES queries are:
- Inpatient Facility
- Outpatient Facility
- Referral, and
All ES queries are configurable, allowing the user maximum flexibility in creating auth matching scenarios that will accommodate specific business needs. The queries are designed to parse the auth instance data elements, then match those data elements to the claim line data elements, in order to determine whether those auth instances are an exact match to the claim line, a non-exact match, or no match, based on the auth matching criteria. A detailed description of the ES functionality is included in the Technical Details section of this chapter.