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Duplicate logic for predetermination

Updated on April 26, 2021
  • A submitted predetermination would still go through the duplicate match logic configured in the system and see if there is an exact match. [ Same Patient ID, Same Service Codes and Same Tooth Number]. If it finds the dup, the claim would be Pended with the Pend Code “The services are pending on an existing predetermination”
  • If a Member goes to a second provider and a predetermination is submitted for the same services as the first provider, the predetermination pends as a duplicate. The same event code is raised, “The services are pending on an existing predetermination.”

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