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How the authorization processing module works

Updated on March 12, 2022

  1. During the execution of the CE_ProcessAuthorization module, SCE queries an external benefit system (for example, Pega’s PCS) to determine whether an authorization or referral is required for the adjudication of the current claim or claim line.
  2. SCE parses the authorization requirements from the benefit configuration, and then places them onto the D_BenefitCoverage clipboard page.
  3. If an authorization or referral is not required, the claim advances along the normal path to the next step in the adjudication process.

    The following graphics represents auth requirement variations, as configured in an external (e.g., PCS) benefit system, and the display of those variations on the D_BenefitCoverage clipboard page.

    Authorization requirement displayed on D_BenefitCoverage clipboard page.

    SCE also uses the IsAuthorizationRequired decision table for determining whether an auth is required. This decision table is used as a proxy in lieu of integrating directly with a benefit system that would normally specify the authorization requirements. This decision table allows the user to test SCE’s authorization processing functionality, and identifies the need for an authorization based on the procedure code supplied on the claim line.

  4. Following the determination of the auth requirements, SCE then initiates the ES process by first identifying the authorization type that will drive the ES query. This decision table pairs each claim type (Professional, Outpatient, Inpatient, Dental, Referral) with a discrete authorization type (authorization or referral) in order to inform SCE which ES query to execute.

  5. Once SCE determines which ES query will be used, the identified query is then executed in order to fetch authorization instances, or “candidates” onto the data page, according to the auth matching criteria.

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