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Configuring the coverages, accumulators, and payment processing module

Updated on April 26, 2021

To configure this module:

  1. Click Dev Studio > Claims Engine > Claims Engine Configuration.

    All processing modules are displayed in the Modules section in the Module configuration tab.

  2. Click the CE_CoverageAccumulators hyperlink.

    The coverage, accumulators and payments module contains:

    • CT_NRTIndexClaim collection
    • SetActionCodeForPenaltyCalc collection
    • CalculateShares Collection
    • CE_DetermineBenefitLifeTimeMax
    • CE_DetermineCOBSavings collection

All the rules contained in the CalculateShare data transform and subprocesses enable the application to retrieve the benefit, accumulator, and cost share data, and perform a number of calculations. These calculations help determine:

  • The amount to be paid to the provider for services delivered.
  • The member’s financial responsibility for those services, for example, co-payments, deductibles, and co-insurance.
  • The dollar amounts that increment toward the financial accumulator limits, for example, individual and family deductibles, Lifetime Maximums and out-of-pocket maximums, according to the member’s plan benefits.
  • The cost shares should be contributed to how many accumulators by checking the count towards check box configured in the PCS instance.
  • Whether the accumulators being accumulated within one network should contribute across the networks as configured in the PCS instance.
  • Determine if if the plan is eligible for COB savings account and if eligible then for each member COB savings accumulators will be created. The member liability will be contributed from the COB savings account until the max configured by creating a separate COB savings accumulator which will be updated for each contribution.
  • Previous topic Business user information
  • Next topic How the application matches benefits and accumulators to claim lines

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