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.

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.