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Claim holds and SLAs

Updated on October 9, 2020

Claim holds are used to hold claims from adjudicating for a period of time when specific business scenarios are met. Holds are applied in Smart Claims Engine using Event Code configuration. Because Event Codes configured to suspend are already performing the same function as a claim hold, what is needed is the ability to control the Disposition behavior of suspend event codes.

Service level agreements (SLAs) also define a period of time for which a claim can be held/suspended before certain kinds of penalties begin to apply to the claim (for example, interest is required to be paid after 14 days from claim receipt date).

SLAs and claim holds are closely tied to determining when a held/suspended claim should be denied or recycled after being suspended due to an Event Code. SLAs and claim holds are configured in the Disposition Information of event code configuration.

According to the following section in the event codes disposition tab Claim Hold will determine, how many days the claim should be held and whether to use SLA or Hold to hold the claim.

If a claim is executed with a high priority “Event Code” which has the above hold details configured, it will hold the claim.

The claim will be held in the “CEClaimsHoldWB” work basket for the earliest period of time, determined by the SLA and Hold configuration. An event which has an SLA or Hold configured in it will automatically select the recycle process since a claim which is held should be recycled after the hold expires.

If a claim hold is set, the following audit message will be executed in the Process History.

  • If we are going to hold the claim by taking the SLA days then the audit message “Event code xxxx has met specified SLA of xx days” will be set.
  • If we are going to hold the claim by taking the Hold days then the audit message “Event code xxxx has met specified claim hold of xx days”.

The following Audit message is for a claim which is held by taking the SLA days.

If a claim exceeded the SLA days, the following report will be generated to show that the claim has exceeded the SLA days. This functionality is only for SLA and not for Hold.

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