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Updated on April 26, 2021

Process and Manage pre-determination processing of claims: A request for predetermination of benefits (or predetermination) is a pre-service request for a statement of the exact benefits that would have been paid had the predetermination request been an actual claim. The predetermination request would include all data necessary to fully adjudicate a claim except for date(s) of service.

As part of business rules, New field for Claim Submission Reason Code (CLM19) is introduced.

  • The mandatory check for service dates if Claim Submission Reason Code is checked (Yes) is removed.
  • Claim Submission Reason Code and Predetermination of benefit identifier properties are mutually exclusive on header screen.
  • New property on system configuration page was introduced to mention the no of days of Predetermination expiry.

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