The following graphic represents the processing of authorizations, following auth matching. The work flow includes validating authorizations, applying auth units (including partial auth units), and updating authorization accumulators.
SCE validates each authorization by determining whether the authorization is active (A1: Certified in Total), or inactive (A3-Not Certified, or A4-Pended). If the authorization is not active, the claim line is pended for manual review. If active, SCE then determines whether there are enough authorization units available to accommodate the claim line requested units (based on the accumulator returned in the previous step). If no units are available from the existing accumulator, the claim line pends. If the authorization is new and requires an accumulator, a new accumulator is created.
Unit processing and adjustments
Once SCE validates that an authorization is active, and that authorization units are available, SCE then determines whether the units requested on the claim line are greater than the units available on the authorization. If the claim line units are equal to or less than the authorization units, SCE processes the approved units and updates the authorization accumulator. The authorized units are then applied to the benefit, and the accumulator is updated according to the processed transaction before moving to the next step in the adjudication process.The following graphics represent processing of claim line units against an authorization when the requested claim line units ≤ the available auth units. A screen shot of the associated auth accumulator is also included.
Partial unit processing
If the requested claim line units are greater than the available units on the authorization, SCE then executes a “cutback” by (a) approving the claim line units up to the number of available auth units, and (b) adjusting the claim line units based on the difference between the billed claim line units and the approved units from the auth.The following graphics represent processing of claim line units when the requested claim line units > auth units. In this scenario, the claim line units are approved up to the remaining units on the auth, and the non-approved units are adjusted on the claim line to ensure unit balancing. In addition, the updated accumulator is displayed, which was exhausted during the processing of this claim line.
Processing a claim line against an exhausted accumulator
When a claim line is processed against an exhausted accumulator, the claim line is suspended. As there are no available units in this authorization (which was exhausted in the previous example), an event code SPA-0021 is triggered and the claim line is suspended.