Configurations in BA portal
System settings in the BA portal typically manage business requirements. The system settings are accessed from the Configuration section in the left-hand navigation panel of the BA portal.
- Effective & End date – The start and end date for the system settings instance.
- Timely Filing
- Timely filing system default – The default timely filing days for the timely filing edit should no other configuration exist.
- Timely filing federal Contract – The timely filing days configured with a federal contract.
- Retrieve claim history for the last days – Indicates how many days to look back (based on the value of the claim Service From date) when retrieving historical claims. Use this for gathering claims to be compared in the system audits: Duplicate Claim, Interim Bill processing, etc.
- Accumulators
- Threshold Utilization % – The percentage of an accumulator’s use that triggers the reporting of its pending exhaustion.
- Accumulator Reordering Period – The period for claims that may require re-ordering based on an accumulator being exhausted.
- Allow manual ICN entry – Setting the Allow Manual ICN entry to “On” would allow users to enter the ICN Number manually for a Claim. Setting it to “Off” would not allow the ICN number to be entered manually. The system would generate the ICN Number automatically.
- Hospital Readmissions
- Match Days – the lookback period used to define a hospital readmission.
- Readmission co-pay lookback – the lookback period used to trigger the waiving of a co-pay for a hospital readmission. The Period Qualifier is expressed in Hours or Days.
- Subrogation
- Subrogation Dollar Limit – The Subrogation dollar limit defines the minimum billed amount for a Claim to be identified as a Subrogation Claim along with the other criteria.
- COB Cutback Model – Defines the model used in Smart Claims Engine for
calculating COB on the claim.
- Reduced Allowed Amount – Reduces the allowed amount on the claim by the sum of the payments made by other payers (default setting).
- Review required for copy of old claim changes for adjustments – 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.
- Predetermination
- Number of days for predetermination expiry – 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.
- Default System management workbasket – Defines the workbasket used when the one defined for the event code configuration cannot be found or does not exist.
- Claim level event resolution process – The default resolution process used for event codes set at the claim level.
- Claim line level event resolution process – The default resolution process used for event codes set at the claim line level.
- Default event resolution role – The default role of the user assigned to pend resolution.
- Default End Date – Definition for the default end date for system configurations if the value is left empty.
- Authorization
- Minimum search results – Minimum list of authorizations retrieved to validate – Should be zero.
- Authorization Match Days – Defines the period in which to search for authorizations that have been approved.
- Maximum search results – Maximum list of authorizations retrieved to validate.
- Automatic non exact authorization resolution – Defines whether the authorization should be applied, or an event code set if the authorization is not exactly matched.
- ClaimsXten
- Allowed History Claim Lines – The Allowed History claim lines field allows users to define the maximum number of lines which would be send on Claims response to ClaimsXten. The Maximum would include the “Current” Claim lines along with the “History” Claim lines.
- Send History – The On / Off indication allows a user to configure if history needs to be sent to the ClaimsXten tool on the request XML.
- Send History, Max Lines Exceeds – Defines whether to send the history or not when the number of history lines exceeds the allowed history count.
- Claim Status to include for paid feed – The statuses which need to be included and excluded within the current claim as history can be configured using this configuration.
- Claim line status to exclude – The line statuses which need to be excluded within the current claim and history claims can be configured using this configuration.
- SLA
- Default SLA – Defines the base SLA used in the urgency calculations.
- Claim latency % - Defines the percentage of an SLA that has passed before the claim is received by the system to trigger the Latency Action Code.
- Organization name for claim latency – indicates the name of the organizational entity/department to which the claim latency SLA and % are attributed.
- Manual pricing threshold
- Pricing source reference – 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.
- Threshold % – 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 – When turned to “on”, the user has the capability to enable the feature that facilitates the configuration of data fields in the claims adjustment and correction workflows.
- Benefits
- Professional Diagnosis for Benefit Determination – Designates the diagnosis code, when multiple exist, to be used in driving the configured benefit.
- Dental Diagnosis for Benefit Determination – Designates which diagnoses will be used to drive benefit determination in dental claims.
- Reporting
- Claim status not to be included – Allows the user to configure which claim status(es) will not be included in the Total number of claims processed report.
- X12 claim status to be included – Allows user to configured which X12 claim status(es) will be included in the Unprocessed claims report.
- Adjudication claim status not to be included – Allows user to configure which claim status(es) will not be included in the Average claim processing report.
- Member Fuzzy Search settings
- Primary and Secondary fuzzy search allow the ability to apply the defined degree of fuzziness to Primary Member search (with ID) and secondary Member Search type (without id).
- Member match tiebreaker settings
- When multiple member records are identified by SCE during the member match routines, a tiebreaker can be configured and applied. The application of the tiebreaker is controlled in the System Settings. To access the settings, navigate to Configuration>System settings and locate the Member match tiebreaker settings.
- The Address tiebreaker compares the submitted member address to the address in the system of record. If a match is found that member record is selected for adjudication.
- The Address tiebreaker may be enabled for both the primary and secondary searches or for just one or the other.
- 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. Note that this setting should be used cautiously as it may result in a “false positive”.
- The Eligibility tiebreaker may be enabled for both the primary and secondary searches or for just one or the other.
- Newborn configuration setting
- Users can choose to set an event code (Patient is Newborn, SMM-0005) for all claims meeting the criteria on the newborn state-wise days configuration decision table.
- Policy selection and eligibility
- Policy selection look back period allows the system search to for the defined number of days while matching to a policy on the Claim.
- Policy eligibility start period end period.
- Submitted vs Highest Ranked Policy: 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 SCE using the RankPolicies decision table. The decision table allows policy rankings to be defined based on Contract type and Line of Business. The decision table further allows the application of a differentiator like the birthday rule when more than one policy has the same rank.
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