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Exact and non-exact auth matching work flow

Updated on April 26, 2021

Following the execution of the ES query, SCE determines through a series of steps whether: (a) one or multiple exact matching authorizations were found, (b) one or multiple non-exact matching authorizations were found, or (c) no matching auths were found. SCE resolves each condition according to the following work flow.

  1. If a single exact matching auth is found, SCE then retrieves an existing auth accumulator in order to facilitate the validation of that matching authorization. If no accumulator exists, a new one is created by SCE.
  2. If multiple exact matching auths are found, SCE parses and rank-orders each from the ES query according to its certification date (oldest first). The available units from each exact matching auth are then applied against the requested claim line units, until all have been satisfied by available auth units. If, having exhausted all of the units from the available auths, there are remaining claim line units; SCE then executes a cutback by first processing all available auth units, then applying an adjustment to the claim line to ensure balancing.
  3. If 1 or more non-exact matching authorization is found, SCE offers the user 2 options for resolution. Option 1 - have all non-exact matching authorizations process automatically, without manual intervention, or Option 2 – manually review, through guided event resolution, all non-exact matching authorizations. The user may configure either option in the Authorization section of the System settings section of the BA portal.

    Note: Configuration section, contains a detailed description of changing these system settings.
  4. If the ES query results in multiple non-exact matching authorizations, and SCE is configured to process all non-exact auths automatically, SCE will automatically rank-order multiple non-exact matching auths according to their certification date, and then apply the available auth units against the requested claim line units until they have all been satisfied. If the option to manually process non-exact matching auths is off, the user manually selects which non-exact matching auths will be applied through the guided event resolution process.
  5. If no exact or non-exact matching authorization is found, SCE triggers an event which suspends the claim/line, allowing the user to manually resolve the no auth found issue through guided event resolution.
  6. At the end of the authorization matching work flow, SCE then retrieves any existing accumulators in order to facilitate the validation of the selected authorization(s).

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