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Updated on December 10, 2021

The SCE performs a series of tasks on the claim to prepare it for pre-adjudication. These include performing detailed claim validations, matching the claim to the appropriate member and providers, and selecting the members policy or provider contract.

Validation edits

Smart Claims Engine provides a series of validation edits that verify that key information submitted on the claim is correct and valid and that the claim can be processed correctly in the system. This includes procedure code validations, diagnosis code validations, and future date detection, among others.

Member match

Member match is made up of three core capabilities, with the goal of identifying the correct member in the system and finding the appropriate policies to support adjudication.

  • Match the subscriber and/or patient to a member in the system.
  • Validate the matched member(s) demographics against the data submitted on the claim.
  • Retrieve the correct policy and validate eligibility.

The member match process retrieves and validates the patient and/or subscriber information on the claim to ensure that the claim can be processed. The member match model provides a high level of configurability to identify the minimum number and which fields are used in the matching along with the level of variability in those fields. The SCE also provides capabilities to match newborn patients and transplant recipients so that the claims can be adjudicated against the appropriate policy.

Validations against the membership record ensures that after the match is found, key data is reviewed to make sure it is accurate; if differences are found, event codes detailing those differences will be raised.

The final step of the member match process is to retrieve the appropriate policy and validate eligibility. The SCE can utilize a configuration to rank policies based on their type or use forced ranking from the membership system to select the policy for adjudication. Eligibility is then verified against that policy and the dates of service on the claim. The SCE can be configured to split the claims should multiple policy periods cover the claim.

Provider match

Provider selection and match compares the provider information submitted on the claim to the provider records in the system. The provider match capability uses key data on the claim to identify the correct provider, including: National Provider Identifier, Tax Identification Number, and Provider Taxonomy. Once a match has been successfully made, the provider information is validated. The provider information validated is based on the type of claim being submitted and the information held within. If the match is close, but not exact, an event code will be raised.

Validations of the provider record include:

  • Business Entity Relationship – Ensuring the rendering or servicing provider and address have a valid relationship with the business entity.
  • Unsolicited Providers – Ensuring that in the instance a primary care physician (PCP) is required, a colleague in the same practice as the members’ PCP can successfully bill for the claim.

Information on the contract and network are also retrieved to support the adjudication once the provider has been correctly matched. If the claim spans multiple provider contracts, the claim or line can be split if necessary.

The SCE also validates the dates of service on the claim against the providers contract(s) to ensure that the provider can be paid for the services billed. If the claim is outside of the contract dates, event codes can be raised on the claim.

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