This entails the matching of certain key criteria (e.g. name and NPI) which is described in greater detail below. Second, SCE must also validate the relationship between the provider and/or practitioner and the Business entity represented on the claim.

Every provider or practitioner must be associated to a Business entity to ensure the correct adjudication of a claim. The association of a practitioner or provider to a Business entity links the Tax Identification Number (TIN) and servicing address of the billing provider to the provider or practitioner who is rendering the service. The relationship between the provider or practitioner and the Business entity is shown below.

The workflow shown below illustrates the end-to-end process followed during the execution of the Provider Eligibility module.

There are multiple pages that are used to provide information for the provider match, validations, and contract selection. These pages will need to be populated for the SCE to perform the necessary lookups and validations.

The Provider Eligibility module compares the provider data from the source of truth to the provider data found on the claim. This capability is applied to each provider found on the claim, and applies the same matching criteria to all providers encountered, which includes National Provider Identifier (NPI), first name and last name, with the exception of the Business entity (or billing provider) for which it considers tax identification number, name, and address.

The SCE utilizes a reusable ES query that assigns a weight of “1” to each search criterion to indicate that SCE is looking for an exact match for each specific property. If an exact match for each property is met, SCE then declares the provider on the claim to be a valid match to the provider in the source of truth. In the instance that an exact isn’t made, the SCE sets a “fuzzy match” criterion against the provider’s first and last name when the provider’s NPI (or TIN for billing provider) matches exactly. This enables an up-to-two-character mismatch for the provider’s first and/or last name to be submitted and still achieve a successful match.

The configuration for the validations of the Provider’s name, Taxonomy, NPI and address, is controlled by a decision table, ValidateProvidersMetadata.

This decision table enables configurations for:

• The provider and level at which the matching logic will be applied (e.g., rendering provider – claim line)
• The provider matching audit message displayed during claims adjudication
• The event codes to be set during fallout for the following events
  1. Provider not found
  2. NPI length > 10
  3. Name mismatch
  4. Taxonomy mismatch
  5. Address mismatch
  6. NPI mismatch

Provider types can be considered for matching and validation during the execution of the provider eligibility module simply by either adding or removing the appropriate when conditions on each line from the decision table.

The SCE assigns out of state indicators at the claim and line level when the servicing location (or billing address) differs from the state associated with the member on the claim. The SCE also assigns the servicing state on the claim and line to support other calculations. This is assigned, as the servicing state can be assumed from the billing provider in the absence of a servicing address on the claim.

Once SCE declares (validates) that a match exists between the provider claim data and source of truth, SCE then validates the rendering provider’s relationship to the business entity identified on the claim. If there is a valid relationship existing between the rendering provider and the Business entity on the date of service, SCE then declares the association between the two valid. However, if the relationship is declared not to be valid on the date(s) of service, SCE sets an event code.

In addition, SCE determines whether the servicing address of the rendering provider is in effect on the date of service. If the servicing facility is associated to the servicing address on the claim on the date of service, SCE then declares the association between the rendering provider and the business entity to be valid.

If there are missing providers or discrepancies, etc. between the information on the claim and the database, the event codes listed in the table below will set to the claim. Provider validation event codes will be set: