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Updated on November 6, 2020

Prior to the execution of the NXP adjudication module, claims first pass through the ClaimsXten adjudication module where claim review is executed, and various code edits applied on a claim line-by-line basis according to the user’s payment policies and edit configurations. If specific claim lines are denied because of the ClaimsXten edit process, those identified lines are automatically suppressed, or withheld from inclusion in the API call to NXP.

The table below represents 3 scenarios in which claim lines are suppressed following ClaimsXten denial recommendations: (a) a single line claim with single claim line denial, (b) a multiple line claim, with all lines denied, and (c) a multiple line claim with multiple, but not all lines denied. In these scenarios, the denied claim lines are suppressed and withheld from the request XML file transferred to NXP, and upon the return of pricing data from the NXP XML response file, all claim lines are merged back together before continuing in the adjudication process. The ClaimsXten denial recommendations are identified as discrete Event codes in the system, and the presence of those Event codes on the suppression configuration table enables the line to be denied. This model allows clients to add other event codes to the suppression table as well when NXP doesn’t need to be executed.

Single Line Claim: line deniedSuppress entire claim
Multiple Line Claim – all lines deniedSuppress entire claim
Multiple Line Claim – multiple, but not all lines deniedSuppress denied claim lines – do not send suppressed lines to NXP

The following work flow depicts the suppression process (as described above), beginning with the completed execution of ClaimsXten sequence module.

NXT Claim line suppression rules are configured OOTB in the decision table shown below, entitled SANPClaimLineSuppression.

Note: This decision table can also support the configuration of other attributes used for suppression, such as Claim Types (institutional vs. professional), Action Codes, NPI, Provider Taxonomy, and the presence/absence of rate sheets. In future releases, more complex suppression scenarios will be supported, such as the suppression of claim lines based on ClaimsXten denial recommendations, coupled with user-configured claim attributes (e.g., procedure code modifiers).

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