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Updated on April 26, 2021

The modules are the smallest element of the orchestration flow. These are the key pieces of functionality that organizes a key business capability. For example, benefit determination and third-party liability editing. The Smart Claims Engine provides a series of modules for specific out-of-the-box functionality that can be implemented. The modules provided by the Smart Claims Engine are all prefixed with an “S” identifier. Proprietary modules can also be created in the application for use in the Smart Claims Engine. The list of supplied modules is defined below. Each of these can be added as necessary to sequences to support orchestrations:

Claim adjustmentsSADClaim adjustment processing and validation
Authorization processingSAPAuthorization matching and adjudication
Claim business auditsSBAMultiple claim or multi-line editing against historical claims or the current claim
Benefit determinationSBDMatches the claim to an appropriate benefit
Claim business editsSBESingle claim or line business edits and core action codes
Benefit limit accumulator processingSBLBenefit limit calculations and accumulator processing
Coverages, accumulators and paymentsSCALiability calculations based on benefit coverage and accumulator use.
COB reductionsSCBPayment reductions based on claim submitted COB
ClaimsXtenSCXSCE adaptor for ClaimsXten integration and processing
Episode processingSEPEpisode of care identification and linking
Event code reviewSERReviews event codes assigned on the claim for disposition, routing, and next steps
Finalization claimSFCFinalizes the claim and performs any remaining calculations
Finalization pricingSFPFinalizes the pricing on the claim and applies any COB adjustments
Incentives and surchargesSISApplies any provider incentives or regulatory surcharges
Member eligibilitySMELegacy member match and eligibility module. Performs member lookup, checks eligibility, and validates member related data
Member matchSMMMatches the subscriber and/or patient on the claim to a member in the system
Policy selection and eligibilitySMPSelects the appropriate policy for adjudication and validates member eligibility
Member validationsSMVValidates patient and/or subscriber information on the claim against the matched member record
Process authorizationsSPAIdentifies if an authorization is required, matches, and processes the claim against an authorization
Provider eligibilitySPEMatches the provider on the claim to the provider records and validates the provider details
Price calculationSPCPrices the lines on the claim based on the submitted codes
Process updatesSPUUpdates the claim and any supporting accumulators based on the final status
Random auditsSRAApplies random audit event codes to the claim based on the audit configuration
Ratesheet selectionSRSSelects the appropriate ratesheet ID based on the provider’s contract
Split claimSSCApplies the generic system configured automatic split claims logic.
Subscriber lockSSLLocks the claims from subscribers from processing in parallel to ensure accumulators are in sync
NetworX pricerSSPSCE adaptor to integrate to NetworX pricer
TPL editsSTPApplies COB / TPL edits to the claim
Process validation editsSVEPerforms key field validations to the claim
Winning priceSWPPerforms the winning price logic to select the appropriate price for adjudication

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