Skip to main content

         This documentation site is for previous versions. Visit our new documentation site for current releases.      


Updated on December 10, 2021

The SCE provides two key features to support the calculation of the members’ base liability for the claim. These are the ability to perform cost share calculations and deductions from another payer.

Cost share calculations

The Smart Claims Engine provides the following benefit adjudication rules based on configurations on the benefit:

  • Benefit cost share calculations - Cost shares for each line on a claim are determined based on the matched benefit, current accumulator status and its associated terms. Accumulators are automatically updated based on the matched benefit. Adjustments are applied to the claim based on the cost share applied. Multiple different types of copay rules can also be calculated based on the benefit configuration:
    • Per day
    • Per visit
    • Per day/per provider
    • Per unit
  • Cross network accumulators – “Counts towards” flags can be configured to indicate whether a cost share (copay, coinsurance and/or deductible) counts towards the following accumulators:
    • Network and benefit level individual deductible.
    • Network and benefit level family deductible.
    • Network and benefit level out of pocket.
    • Network level family out of pocket.
COB deductions

SCE uses the other payer payments, along with the Smart Claims Engine pricing calculations to identify the amount that would be paid for the claim. Either the other payer payments or members out of pocket expenses from that payer can be used to calculate the final payment.

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best. is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us