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NXP Manual pricing

Updated on November 6, 2020

Manual pricing functions are not available through the NXP REST API; consequently, the manual pricing of certain identified claim lines is handled through the application’s guided event resolution process, in concert with direct input into the NXP application, then re-pricing through the SCE-NXP REST API.

Note: The functionality that enables the user to access the NXP database directly from the event resolution UI, and to retrieve manually priced claim lines to update the claim work object, is currently under development at Cigna currently. As such, the user selects the alternate workflow to Option 1 in the manual pricing pend resolution UI as described below.

The application provides 2 options for resolving claims requiring manual pricing:

Option 1: You resolve manual pricing event in NXP. After you determine that manual pricing intervention is not necessary, you can return the claim to the Smart Claims Engine adjudication flow where the application processes the claim using a standard NXP call. To do so:

  1. Claim is returned with pended claim lines displaying in Resolve open events screen. Event code is SANP-0009; SANP –Claim Needs Allowed Amount in Allowed Field.

  2. Click Resolve, which opens the Resolve Event screen.

  3. Upon determining that manual intervention in the NXP application is not required, click Through SANP (you can also add a comment in the Resolution comment screen), then click Submit.
  4. The status of the claim line in the Resolve open events screen changes to “Resolve in SANP,” and the pend is resolved via the normal adjudication flow (as indicated in the event resolution Actions Taken). When selecting option 1, all claim lines associated with a single rate sheet will be resolved in the same manner.

Option 2: You can manually price the claim. This option enables you to (a) resolve claim lines pended for manual pricing by by-passing the normal adjudication process (and NXP call), (b) manually editing the allowed amount fields in each pended claim line, and (c) automatically updating the claim object with those manual edits. To do so:

  1. Execute steps 1 and 2 described in Option 1.
  2. Upon determining that manual pricing intervention is required, click Through SANP, and then select the Manual pricing required? check box.

When you select the manual pricing option (option 2) and close the event, the UI triggers the Action code SANP-101; Claim requires manual pricing in SANP.

This action enables the by-passing of the normal adjudication process, allowing the user to affix a manual price to each claim line associated with the rate sheet, and to update the claim work object with the new price.

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