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Audit type

Updated on October 9, 2020

To determine the Audit type:

  1. The system would parse the outbound XML response. Based on the fields received on the response, SCE would determine the audit type using the DetermineAuditType decision table.
  2. Once the audit type is determined the system would refer to the CXTResponsetoSCECode table. The event code would be a mapped based on certainty, current claim line action, rule acronym, rule type, case action, audit type and customer adjustment code.
  3. DetermineAuditType Collection added to ProcessClaimLineAction collection helps identify audit type based on the response received from ClaimsXten.

  4. DetermineAudit Type collection has DetermineAuditType data transform which holds case line action on current claim and another to hold the case line action for history claims.
  5. DetermineAuditType decision table will be configured to calculate the audit type based on below parameters:
    1. Rule Acronym.
    2. Rule Type.
    3. Case Action.
    4. Claim Line Action
    5. Any Other SUPPORT action (Current Claim Line)
    6. Any Other DENY action (Current Claim Line)
    7. Any Other ADD action (Current Claim Line)
    8. Any Other SUPPORT action (History Claim Line)
    9. Any Other DENY action (History Claim Line)
    10. Any Other ADD action (History Claim Line)

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