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Claim holds and SLA disposition configurations

Updated on April 26, 2021

The SCE provides the ability to perform claim holds or apply specific SLA’s for an event code.

The claim hold scenario enables the claims that meet specific business scenarios be held from adjudicating for period instead of being submitted to a work queue for resolution. An example of a situation where a hold may be applied is where a claim pended for a missing authorization. Authorization approvals may be externally managed and uploaded to the system every 10 days. In which case, the claim would be held for 10 days and then reprocessed. Claims that are held are stored in the claims hold work queue.

Service level agreements (SLAs) define a period for which a claim can be suspended before certain kinds of penalties begin to apply to the claim. For example, interest is required to be paid after 14 days from claim receipt date. The SLAs in the event code configuration enable task level SLAs to be assigned to the resolution instead of the global claim SLA. The SLAs will increase in urgency based on the SLA rule associated with the event code.

The claim audit trail is updated when the SLA or hold time is met, along with the time configured for the hold or SLA.

The Claim exceeded SLA days report showing all claims that have exceeded the SLA is also available for review.

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