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Validating provided predetermination on billable claim

Updated on April 26, 2021
  • If a Claim is submitted with a Pre-determination identification number, then the system matches the same with existing ICN's to see if a match exists. If a match is not found, the system raises the Event code - "Claim is submitted with the Pre-determination identification number does not exist."
  • Claim received with predetermination number is further checked to see if the below information on the Claim and Predetermination matches. If not, the system raises the event code “Submitted wrong predetermination of benefit identifier”.
    • Patient id
    • billing provider
    • billed amount
    • procedure code
    • tooth number
  • If a chargeable claim is received with predetermination which is not within the configured number of days, the system sets an event "Claim is submitted with the Pre-determination identification number not in a range of configuration”

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