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Action codes

Updated on October 9, 2020

Smart Claims Engine action codes allow business policy to alter processing. Action codes are rules that you define to override events, assign work to a specific work queue, change the urgency on an event, and bypass modules. You can report an action code anywhere in Smart Claims Engine to support the appropriate claims processing scenario. Smart Claims Engine is delivered with action codes that support several specific scenarios, such as the following:

  • Identification of a natural catastrophe
  • Claim latency
  • Priority handling
  • Module bypass (e.g., Claims Xten, Authorization pricing)
  • Waive member co-pay (for unplanned hospital readmissions)

Using the Business Analyst Portal, you configure action codes and apply them using the appropriate rules in the processing engine.

Business user information

As a business user, you need to:

  • Access the list of action codes.
  • Create an action code.
  • Update an action code.
  • Get approval for an action code.
  • Delete an action code.

You can also access some sample action codes.

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