The Smart Claims Engine provides a feature to support the automatic grouping and subsequent reprocessing of pended claims with common shared attributes. This enables claims to be grouped together that can be resolved via a single action creating operational efficiencies. This may be used as an alternative to mass adjustments for claims that have a smaller population to resolve.
The event group function is one of several tools available for claims reprocessing and offers certain advantages over mass reprocessing and event code recycling under specific circumstances. Consider the following use case:
- A recently negotiated provider contract will not be configured in the payer’s claim system in time for the first date of the new contract year; consequently, all future claims associated to the provider are in jeopardy of paying incorrectly.
- Payer and provider agree that to avoid the incorrect payment of future claims, all claims with dates of service on or after the first date of the new contract year will be suspended until the new contract has been configured. Payer will deploy OOTB Event code SGB-0009: Contract Configuration Incomplete to hold those claims, and then create an event group configuration and associate it to event code SGB-0009.
- As a result, all claims associated with the provider beginning on the first day of the new contract year are suspended and captured in a single event group. When the contract is configured the payer will manually resolve that event on a single claim belonging to the event group. When that single event is manually resolved, SCE will automatically reprocess the same event for all the remaining claims in the event group.
Information on the use of event groups to perform event resolution is detailed in the chapter on Claims Operations.