The inquiry can originate in a customer service system or some other external system via an API or may be manually created directly in SCE.

Claims examiners with the appropriate system privileges may create a claims inquiry directly in Smart Claims Engine.

First, from the left panel, click + New>Claims inquiry. The Claims inquiry screen opens.

Select an Inquiry reason code, inquiry channel, and inquiry type from the dropdowns; other information is optional. The fields are listed below and required fields are identified by the *.

Next, enter search criteria to identify the claim(s) which should be part of the inquiry. At least one of the following data elements are required for the claims search:

• ICN
• Provider ID
• Subscriber ID
• Patient ID

From the search results, select the claim(s) you wish to associate with the inquiry.

To continue, click Next.

You may remove claims from the inquiry using the trash can icon.

If you need to include additional claims, click Add more claims. The original search and results open in a modal. You can choose additional claims from the displayed list or conduct a new search and select additional claims from the search result.

To create and route the claims inquiry, click Finish. The inquiry you created will be routed to the designated work queue.

Once you have been assigned a claims inquiry, by clicking Get next or from a direct transfer to your worklist, you can review and resolve the claims inquiry.

All the information captured during the creation of the inquiry is displayed. You can also click Original request information to see the information that was associated with the inquiry when it was created.

Claims added to the inquiry are displayed with a hyperlink to open the claim for review in another tab.

Clicking Resolve for each claim opens the Resolve inquiry modal. This modal provides a Notes field to optionally enter any research findings. The Resolution action dropdown is required – this is where you indicate the result of your research by choosing Adjustment or No action.

Once you have completed your research and adjusted the claim or determined no action is required, click Submit to return to the primary screen. Here you have the option to review additional claims (if needed), to Update any claims you previously resolved and to Submit the inquiry once it is complete.

The Actions menu provides options to Add more claims to the inquiry, to Transfer the inquiry assignment, or to Follow the inquiry.

Additionally, an audit trail is available by selecting the Audit tab on the screen.

SCE may apply any of the following statuses to a claims inquiry:

Smart Claims Engine provides a way for you to search for a claims inquiry. From the left panel, click Claims inquiry>Claims inquiry search.

The Search inquiries screen offers a variety of search criteria on the left side of the screen.