1. The process starts with the CE_DetermineBenefitES collection rule.
2. The collection first calls the CE_DetermineBenefitES Collection. The CE_DetermineBenefitES collection further breaks the collection into three different steps.

   Within the above collection, the first step would be to find the benefit network by cross walking through the PCS network. If the benefit network is found the claim will be adjudicated as In-network/Participating network or else will try to find out the out of network/Non-participating network and if non-participating network is not found then system will raise an event.

3. The DetermineBenefitES Activity, contains the DetermineBenefitES Data Transform which retrieves the needed data from the claim, to make the call to the Flattened structure of the foundation.
4. Step 2 and Step 3 within the DetermineBenefitES Activity uses java code to create a query to perform elastic search on the Medical and Dental benefits. Different Values are taken from the claim to match to a benefit.
   Note:

   1. For a dental claim line, the system expects that along with tooth information there could be a tooth code/tooth surface, a tooth code only with no surface, or an oral cavity with no tooth number. There will not be a tooth number and an oral cavity.
   2. For a claim line that has tooth code/surfaces combinations, the system can derive the dentition (primary, permanent) and choose the benefit accordingly. The dentition determination logic would be as follows:
      • Tooth code is in the range 1 through 32 -> dentition: Permanent
      • Tooth code is in the range A through T -> dentition: Primary
   3. For a claim line that have the oral cavity designation codes, there would not practically be any tooth code information. Since in the application the dentition can only be derived based on the tooth code information, the dentition cannot be derived in claims that have the oral cavity designation codes or oral quadrant information. For these claims the benefit selection logic should ignore the dentition mentioned in the benefit while matching against the CDT code.

   Sample Flattened form (fragment) of the above benefit configuration as per current flattening logic.

   Listed below are a few examples of selection logic of a benefit based on claim line parameters Smart Claims Engine:

   

   PCS Dental Benefit Configuration Parameters: Listed below are all the dental parameters considered for Dental benefit matching.

   Field name	Mandatory/Optional
   Code	Mandatory
   Description	Auto populated
   Dental coverage details	Optional
   Dental coverage details -> Dentition	Optional
   Dental coverage details -> Dental definition	Optional
   Dental coverage details -> Dental definition (=Range and surface) -> Tooth range (multiple)	Mandatory when Dental definition = Range and surface
   Dental coverage details -> Dental definition (=Range and surface) -> Tooth range -> Tooth surface (multiple)	Optional
   Dental coverage details -> Dental definition (=Oral quadrant) -> Oral quadrant (multiple)	Mandatory when Dental definition = Oral quadrant

   The Proposed flattened concatenated strings is as follows:

   Dentition	Definition	Tooth range (one string per item)	Tooth surface(s) (Delimiter separated items)	Oral quadrant (Delimiter separated items)
   None	None	None	None	None
   CDTCodes.<value>.Dentition.AllValues.Definition.AllValues
   None	Range and surface	From T1 to Tn	None	N/A
   CDTCodes.<value>.Dentition.AllValues.Definition.RangeAndSurface.Range.!<T1>!<T1+1>!..!<Tn>!.ToothSurfaces.AllValues
   Permanent	Range and surface	From T1 to Tn	None	N/A
   CDTCodes.<value>.Dentition.<Permanent/Primary/Both>.Definition.RangeAndSurface.Range.!<T1>!<T1+1>!..!<Tn>!.ToothSurfaces.AllValues
   Permanent	Range and surface	From T1 to Tn	S1, S2, S3	N/A
   CDTCodes.<value>.Dentition.<Permanent/Primary/Both>.Definition.ToothRangeAndSurface.Range.!<T1>!<T2>!..!<Tn>!.ToothSurfaces.!<S1>!<S2>!..!<Sn>!
   Permanent	Oral quadrant	N/A	N/A	Q1, Q2, Q3
   CDTCodes.<value>.Dentition.<Permanent/Primary/Both>.Definition.OralQudrant.!<Q1>!<Q2>!<Q3>!

   Note: Separate strings are required for each of the tooth range entries for “Range and surface” type CDT codes.

   Sample elastic search query strings for each claim line parameters that matches with concatenated strings is as follows:

   Procedure code	Tooth code	Tooth surface	Oral cavity designation code
   D0120	None	None	None
   Query string: /CDTCodes\\.D0120\\..*/ Matching flattened string: CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!7!8!9!10!11!12!13!14!15!.ToothSurfaces.!F!D!B!
   D0120	None	None	00, 01
   Query string: /CDTCodes\\.D0120\\.Dentition\\..*.\\.OralQuadrant\\..*?!00!.*/ OR /CDTCodes\\.D0120\\.Dentition\\..*.\\.OralQuadrant\\..*?!01!.*/ Matching flattened string: CDTCodes.D0120.Dentition.Permanent.Definition.OralQuadrant.!00!05!
   D0120	14	D, L	None
   Query string: /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!D!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!L!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces.AllValues OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range.AllValues\\.ToothSurfaces\\.AllValues Matching flattened string: CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!7!8!9!10!11!12!13!14!15!.ToothSurfaces.!F!D!B! CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!11!12!13!14!15!.ToothSurfaces.AllValues CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.AllValues.ToothSurfaces.AllValues
   D0120	14	D, L	None
   	12	L, F	None
   Query string: /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!D!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!L!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!12!.*\\.ToothSurfaces\\..*?!L!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!12!.*\\.ToothSurfaces\\..*?!F!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!12!.*\\.ToothSurfaces\\.AllValues OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\.AllValues OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\.AllValues\\.ToothSurfaces\\.AllValues Matching flattened string: CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!7!8!9!10!11!12!13!14!15!.ToothSurfaces.!F!D!B! CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!7!8!9!10!11!12!13!14!15!.ToothSurfaces.AllValues
   D0120	14	D, L	None
   	21	L, F	None
   Query string: /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!D!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\..*?!L!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!21!.*\\.ToothSurfaces\\..*?!L!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!21!.*\\.ToothSurfaces\\..*?!F!.*/ OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!14!.*\\.ToothSurfaces\\.AllValues OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\..*?!21!.*\\.ToothSurfaces\\.AllValues OR /CDTCodes\\.D0120\\.Dentition\\.Permanent\\.ToothRangeAndsurface\\.Range\\.AllValues\\.ToothSurfaces\\.AllValues Matching flattened string: CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!7!8!9!10!11!12!13!14!15!.ToothSurfaces.!F!D!B! CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!20!21!22!23!.ToothSurfaces.!O!L! CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.!20!21!22!23!.ToothSurfaces.AllValues CDTCodes.D0120.Dentition.Permanent.ToothRangeAndSurface.Range.AllValues.ToothSurfaces.AllValues

5. Service Covered check: The service covered or not covered will be checked as part of CE_DetermineBenefitES collection in the last step.

The ServiceCoveredCheck DT will run after the benefit is determined to check whether the returned benefit should be considered for benefit adjudication or not.

If the Service covered flag is enabled, then the benefit will not be considered for benefit adjudication.

If the service is not covered then the system will raise a suspend event SBD-0006 showing benefit not covered.

• Technical details