Coverage determination
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.
| Capability | Description |
| 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.
|
| Benefit limits | The SCE finds and reviews any limit accumulators for the benefit and applies them to the claim. Units are adjusted if required.
|
| 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.
|
Previous topic Process control and configuration Next topic Pricing