- If a Predetermination Claim (CLM19= PB) comes with a DOS, ignoring the DOS on all the lines if present, the system processes it as Predetermination Claim
- The system considers the claim submission date as service dates for claim and line
for predetermination claim.
After the cost share calculations are done, the system would do the following:
- Insert Adjustment Code would be: 101: Predetermination: anticipated payment upon completion of services or claim adjudication.
- Adjustment Amount = Remaining Approved Amount.
- The Approved Amount should be set to 0.
- Set the predetermination of benefit indicator to PB
- Make sure that the "PB" claim does not count towards the accumulators anymore.
- Claim Status-Resolved completed.
- Bypassing Existing dupe check logic and MUE logic for predetermination adjudication.