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Coverage determination

Updated on August 31, 2021

Coverage determination in the SCE supports multiple adjudication processes, including the matching of a claim to a benefit or authorization, ensuring any limits or authorization accumulators are applied, and then setting any adjustments to the claim if necessary.

Benefit match

Benefit matching enables the SCE to match a claim to a benefit utilizing elastic search on the benefit matching fields configured in the benefit.

  • Match claim/claim line to benefit
Benefit limits

The SCE finds and reviews any limit accumulators for the benefit and applies them to the claim. Units are adjusted if required.

  • Apply limit accumulators
  • Adjust claim units
Auth match / application

When authorizations are required, the SCE matches the claim to any authorizations, applies accumulators, and makes unit adjustments when required. Event codes are applied when no matching authorizations are available.

  • Match auth to claim
  • Apply auth accumulators
  • Adjust claim units

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