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SCE integration point

Updated on October 9, 2020

Clients configure the point in the SCE orchestration when ClaimsXten is called; it is typically at the point where clinical edits are required. For example, during daily claim processing, claim information would be entered into SCE. SCE would process the member’s eligibility, and if the member is eligible, SCE would determine the provider’s network affiliation. At this point of time the system could be configured to send the claim to ClaimsXten. Based on the response from ClaimsXten the system could continue further processing such as duplicate checking, referral matching, pre-authorization requirements, pricing etc. As seen in the diagram below, SCE can integrate with ClaimsXten at different processing points. The configuration would be client specific.

SCE’s ClaimsXten adapter can be invoked at any time depending upon the client requirements. ClaimsXten returns the recommendations to SCE along with the ClaimsXten processing results fields. SCE receives the updated claim information and makes any changes necessary to record, store, and display the ClaimsXten results.

A user can customize the point at which ClaimsXten can be called by following the steps below:

  1. Go to Designer Studio > Claims Engine > Claims Engine Configuration.
  2. Change the order of the ClaimsXten module as required. Click on Edit. The sequence of the modules can be changed by pressing the button (next to each module) and dragging the module up or down as needed.

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