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Test claims

Updated on August 31, 2021

Test claims are entered into SCE and, once an orchestration is selected, execute the same code as “real” claims. When test claims are adjudicated, they utilize member, provider, event code configurations, and benefit data for processing.

When you create a test claim, the metadata is stored as Test Claim Data (TCD); test claims can be stored and re-executed as many times as desired. Executing a TCD creates a claim work object, which you can view to validate the use case or business scenario you are testing.

To view the list of test claims or create a new one, from the left panel, click Test suite>Test claims. The Test claims list opens and provides access to search for, view, copy, edit, or execute an existing TCD or to add a new test claim.

Creating a test claim

To create a test claim, click Add test claim on the top right of the Test claims list.

The New Claim tab opens. The steps for entering information are displayed on the right side of the screen and remain visible throughout the entry process. At any point during the process, you have the option of saving work by clicking Save for later or deleting work by clicking Discard in the top right corner of the screen.

Start by entering the metadata defined in the table below. Once the metadata is entered, including the claim form type, the remainder of the claim entry process mirrors the entry of “real” claims and is detailed in Chapter 13, Claims Operations, in the Manual claim entry section.

Required fields are noted with an asterisk (*)
Name *Name of the test claim
DescriptionDescription of test claim; this is typically used to define your expected outcome
Claim form type *Type of claim to be submitted. Values are: Professional, Institutional, and Dental
Trace numberA trace number that can be used for reporting and filtering
Submitter IDA submitter ID that can be used for reporting and filtering
Submitter nameA submitter name that can be used for reporting and filtering
Submitted date *The date for submission. Defaults to today’s date but can be edited.

Once test claim entry is complete, clicking Submit on the bottom right saves the test claim to the test claim list.

Executing a test claim

To execute a test claim, click on the TCD name in the Test claims list. On the top right, use the dropdown to choose the orchestration you wish to use and click Execute test claim. The test claim will process through the chosen orchestration and a new tab will open, displaying the claim work object for review.

If you choose the “blank” orchestration from the dropdown, as shown below, SCE will derive the appropriate orchestration based on claim data via a decision table.

Editing a test claim

You can edit any test claim by selecting Edit on the top right. The test claim will open in edit mode, allowing you to update any of the claim fields. When your editing is complete, click Done editing to save the changes. You may also Discard your changes if desired.

Actions menu

The Actions menu on the TCD provides the ability to Copy the test claim, to Delete the test claim, and to Generate XML file based on the data you have entered. The Help option displays the mapping of the test claim metadata to an X12 electronic file.

Navigating the test claims user interface

Test claims follow the same organizational structure as “real” claims. All information entered during test claim creation, as well as information auto populated by SCE during test claim entry is available, either by directly viewing it on the primary test claim screen or by opening via hyperlink.

Chapter 3, UX Navigation modules, describes the various sections of the claims screen.

Chapter 13, Claims operations, outlines the handling of event codes and the options available under the Actions menu.

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