During the claims adjudication process, claims are evaluated to determine whether:
- Services provided to the member require referrals or authorizations;
- an active referral or authorization exists for the member according to the health plan’s policies and rules; and
- penalties apply to the member or provider according to those policies and rules.
During the execution of the CE_ProcessAuthorization module, SCE matches claim information with referral and authorization requirements, and then determines whether a claim or claim line complies with those requirements.
Actual authorization and referral instances are created in an external utilization management application, such as Pega’s Care Management Application (CMA). The comparison of authorization data elements to claim line data elements is accomplished using Elastic Search (ES) functionality, which is integrated into the CE_ProcessAuthorization module. In addition, the authorization processing work flow accommodates a robust approach to processing exact matching and non-exact matching authorizations. Fall-out for various authorization matching scenarios allows the user to resolve single and multiple non-exact authorization matches using SCE’s guided event resolution. This approach is explained in greater detail in Chapter 13, Event Code Resolution.
SCE also leverages the CE_ProcessAuthorization module to assess whether a penalty will be applied to a claim or claim line and then, if applicable, determines the specific penalty to be applied.Penalty conditions and requirements associated to authorizations are created in an independent benefit system, such as Pega’s Product Composer System (PCS) and are, through integration with SCE, stored on the D_BenefitCoverage page in PFHC’s flattened benefit structure. Those authorization and penalty variations are then “read” by SCE and translated into penalty calculations using decision tables and action codes.
- Accessing the authorization processing module
- How the authorization processing module works
- Auth matching queries and criteria
- Exact and non-exact auth matching work flow
- Authorization processing work flow
- Assigning member penalties
- Penalty work flow
- Pega-provided penalty variations & calculations in SCE
- Authorization event codes