System settings list
The following table shows the list of fields in the system settings screen and the descriptions. More information on some of these settings will be detailed in the SCE capabilities where they are utilized.
| Section | Field | Description |
| System configuration | Effective date | Indicates the start date for the systems settings instance. |
| System configuration | End date | Indicates the expiration date for the systems settings instance. |
| System configuration | Timely filing: system default | Indicates the timely filing days limit for the timely filing event code should no other configuration exist. More information is available in the business edits section related to the timely filing event code. |
| System configuration | Timely filing: federal contract | Indicates the timely filing days limit configured for a federal contract. More information is available in the business edits section related to the timely filing event code. |
| System configuration | Retrieve claim history for the last (365) | Defines how many days to look back from the claim service from date when retrieving historical claims. This is used for gathering claims to be compared in the system audits: Duplicate Claim, Interim Bill processing, etc. |
| System configuration | Accumulator: Threshold Utilization (%) | Defines the percentage of an authorization accumulator’s use that triggers a note to be routed to a workbasket for review. |
| System configuration | Allow manual ICN entry | This setting indicates whether an ICN may be manually entered by operators when entering the claim. In the instance an ICN is not entered, the SCE will automatically generate one. |
| System configuration | Hospital Readmission: Match Days | Defines the lookback period used to define a hospital readmission. More information is available in the business edits section detailing the hospital readmission functionality. |
| System configuration | Hospital Readmission: Readmission copay lookback | This setting is used to trigger the waiving of a copay for a hospital readmission. The period qualifier is expressed in Hours or Days. More information is available in the business edits section detailing the hospital readmission functionality. |
| System configuration | Subrogation: Subrogation dollar limit | This limit defines the minimum billed amount for a claim to be identified as a subrogation claim along with the other criteria. More information is available in the business edits section detailing the COB subrogation functionality. |
| System configuration | Subrogation: COB cutback model | Defines how COB payment information is used to calculate the final liability on claims in SCE. More information is available in the business edits section detailing the COB calculations. |
| System configuration | Review required for copy of old claim changes for adjustments | This setting is a yes/no setting which defines whether a claim that had previously been modified by an examiner needs to pend or ignore the updates when the provider submits an adjustment. If the setting is Yes, an adjustment submitted via EDI would automatically pend for review if the original claim was manually touched or corrected by a Claims Examiner. |
| System configuration | Predetermination: Predetermination match days | This setting defines the range (expressed in number of days) within which SCE matches a billable claim to a predetermination for dental services. |
| Events | Default claims examiner workbasket | Defines the workbasket used when the one defined for the event code configuration cannot be found or does not exist. |
| Events | Default system management workbasket | Defines the workbasket used when the one defined for the event code configuration cannot be found or does not exist. |
| Events | Claim level event resolution process | Defines the default resolution process used for event codes set at the claim level. |
| Events | Claim line level event resolution process | Defines the default resolution process used for event codes set at the claim line level. |
| Events | Default event resolution role | Defines the default role of the user assigned to event code resolution. |
| Events | Default end date | Defines the end date for system configurations where not otherwise defined. |
| Authorization | Minimum search results | This setting represents the minimum number of authorizations that will be returned when looking for a matching authorization. Along with the maximum search results setting, it defines the range of results to be returned. More information is available in the claim adjudication section on authorization processing. |
| Authorization | Automatic non exact authorization resolution | This setting defines whether the authorization should be utilized or an event code set, if the authorization is above the matching threshold, but does not match the claim information exactly. More information is available in the claim adjudication section on authorization processing. |
| Authorization | Authorization match days | Defines the period in which to search for authorizations (regardless of the status). All matched authorizations will be noted in the authorization history. More information is available in the claim adjudication section on authorization processing. |
| Authorization | Maximum search results | This setting represents the maximum number of authorizations that will be returned when looking for a matching authorization. Along with the minimum search results setting, it defines the range of results to be returned. More information is available in the section on authorization processing. |
| ClaimsXten | Allowed history claim lines | The setting allows users to define the maximum number of lines which would be sent to ClaimsXten. The maximum would include the current claim lines along with the historical claim lines for the member. More information is available in the section on ClaimsXten integration. |
| ClaimsXten | Send history | This indicator allows a user to configure if history needs to be sent to ClaimsXten in the request XML. More information is available in the section on ClaimsXten integration. |
| ClaimsXten | Send history, max lines exceeds | This setting defines whether to send the history or not when the number of history lines exceeds the allowed history count. More information is available in the section on ClaimsXten integration. |
| SLA | Default SLA | Defines the base SLA used in the urgency calculations. |
| SLA | Claim latency % | Defines the percentage of an SLA that has passed before the system triggers the latency action code |
| SLA | Organization name for SLA | Identifies who in the organization the SLA is configured for. This can be an internal department or external organization. This is used in event code configuration. |
| Manual pricing threshold | Pricing source reference | This setting allows the user to select the comparator (either non-par pricing table, or par pricing table) for limiting the allowed amount which can be entered manually during claim line re-pricing. |
| Manual pricing threshold | Threshold (%) | This setting allows the user to select the percentage of the existing price on the comparator as a threshold when manually pricing a claim line. |
| Security | Field level security configuration | This indicator determines whether field level security can be configured. |
| Benefits | Professional diagnosis for benefit determination | Identifies how many of the submitted diagnosis codes on a professional claim should be considered for benefit determination |
| Benefits | Dental diagnosis for benefit determination | Identifies how many of the submitted diagnosis codes on a dental claim should be considered for benefit determination |
| Reporting | Claim status not to be included | Defines the claim statuses which should not be included in the total number of claims processed report |
| Reporting | X12 Claim status to be included | Defines the claim statuses which should be included in the unprocessed claims report |
| Reporting | Adjudication claim status not to be included | Defines the claim statuses which should not be included in the average claim processing report |
| Policy selection and eligibility | Policy selection look back period (days) | When member search results are returned, the system retrieves all policies pertinent to the claim type (medical, dental) associated with the member record that fall within the Policy selection lookback period. The lookback is based on the earliest date of service on the claim. More information is available in the member match section. |
| Policy selection and eligibility | Policy eligibility start period (days) | This setting applies when the eligibility tie breaker is enabled. The system parses the "Service from" date on the claim and "looks back" the defined number of days for a policy with active eligibility. More information is available in the member match section. |
| Policy selection and eligibility | Policy eligibility end period (days) | This setting applies when the eligibility tie breaker is enabled. The system parses the "Service to" date on the claim and "looks forward" the defined number of days for a policy with active eligibility. More information is available in the member match section. |
| Policy selection and eligibility | Select policy category | If “Submitted policy” is enabled, SCE will adjudicate the claim against the policy submitted on the claim. If “Highest ranked policy” is enabled, the multiple policies are ranked by the SCE. More information is available in the member match section. |
| Member fuzzy search settings | Primary fuzzy search | Controls the application of the fuzziness defined in the fuzzy search configuration table. Turns the fuzziness On or Off for the primary fuzzy search. More information is available in the member match section. |
| Member fuzzy search settings | Secondary fuzzy search | Controls the application of the fuzziness defined in the fuzzy search configuration table. Turns the fuzziness On or Off for the secondary fuzzy search. More information is available in the member match section. |
| Newborn configuration settings | Newborn configuration | When set to "On", SCE will set an event code for all claims meeting the criteria on the newborn state-wise days configuration decision table. All claims for unenrolled newborns will be suspended without further attempt by SCE to determine the policy to process the claim against. More information is available in the member match section. |
| Member match tie breaker settings | Address tie breaker | When enabled, the address tiebreaker compares the submitted member address to the address in the system of record. If a match is found, the member record is selected for adjudication. This tiebreaker, if enabled, is only applied if SCE cannot determine which member record to select when there are multiple matches. More information is available in the member match section. |
| Member match tie breaker settings | Eligibility tie breaker | When enabled, the eligibility tiebreaker compares the earliest date of service on the claim to the eligibility spans of the matching member records. If a single active policy is found, SCE will select the member associated with that policy for adjudication. This tiebreaker, if enabled, is only applied if SCE cannot determine which member record to select when there are multiple matches. More information is available in the member match section. |
| Transplant configuration | Transplant claims configuration | When set to "On", SCE will set an event code for all claims submitted with an individual relationship code of 39 or 40. All claims for transplant donors will be suspended without further attempt by SCE to determine the policy to process the claim against. More information is available in the member match section. |
| Standalone member search settings | Member search results limit | This limits the number of search results returned when a member search is performed. More information is available in the member match section. |
| Standalone member search settings | Member search look back period | Defines the lookback period (in days) for member policies returned as part of the search results. More information is available in the member match section. |
| Member notification setting | Generate system notification | When a no member found or multiple members found event code is raised on a claim and a member is selected by the claims examiner, users can choose to have SCE create a system notification. More information is available in the member match section. |
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