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PB Claim adjudication

Updated on April 26, 2021
  • 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.

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