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Sample action code configurations

Updated on April 26, 2021

The Smart Claims Engine has preconfigured action codes for use as examples. They are found in the Action Codes screen and include, but are not limited to the following:

  • Catastrophe Action Code (A-418)

    This configuration allows a region to be associated with a natural catastrophe. If the claim meets the criteria associated with a catastrophe, the action code A-418 is reported in Smart Claims Engine.

  • Priority Handling Action Code (A-416)

    This configuration checks if the member, policy, contract or billing provider listed in the claim is listed in a decision table. If they are reported in the table, the action code A-416 is reported in Smart Claims Engine.

  • Latency Action Code (A-417)

    This configuration compares the difference between the submitted and received dates. If the dates exceed the threshold in the configuration, the action code A-417 is reported in Smart Claims Engine.

  • ClaimsXten Bypassing (A1 & A2)

    These configurations enable ClaimsXten to be bypassed, so that it is not called a second time.

  • Pricing Module Bypass (AUP1)

    This configuration enables the Pricing Module to be bypassed.

  • Split Line Action Codes (SP-101, SP-102)

    These configurations detail that the claim line has been split.

  • SANP Manual Pricing (SANP-101)

    This configuration details that Manual Pricing needs to occur for SANP, and as such call the SANP pricing module differently.

  • Member Special Handling (VIP1, EMP1)

    These configurations enable employee and VIP claims to be routed to specific work queues.

  • Manually Priced Claim Line (MPCL)

This action code is set when the user manually re-prices a claim line, either through guided event resolution or claims adjustment/correction workflows. This action code is designed to allow the user to alter the existing pricing logic to ensure that the manual price takes precedence over all other pricing sources.

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