Once you have clicked Resolve, the Resolve event screen displays. Resolution action buttons are available based on the application of the event code at claim header or line level and the configuration of the event code.
The basic resolution actions which may be presented are:
|Header and Line||Override event||Applies an override to the event in SCE, meaning it has been reviewed and is allowed without changes. Once overridden, the event will not be reported on the claim during reprocessing.|
|Header and Line||No action required||Similar to override but the event will recur if the logic which originally raised the event is encountered during the reprocessing of the claim. This is sometimes used when a claims examiner fixes the issue while addressing another event on the claim.|
|Header and Line||Replace event code||Allows the user to select from a pre-defined list of replacement event codes; SCE will apply the configuration of the selected replacement when the claim is reprocessed.|
|Header||Cancel claim||Cancels the claim entirely; use with extreme caution.|
|Header||Update claim||“Opens” pre-defined fields of the claim to allow correction of claim data.|
|Header||Deny claim||Denies the entire claim.|
|Line||Deny claim line||Denies the specific claim line on which the event code was reported.|
|Line||Manually price claim line||Allows the claims examiner to set the allowed amount and/or the number of approved units. The user may also choose to edit the winning price and select from all the pricing options offered on the claim line.|
|Line||Update claim line||“Opens” pre-defined fields of the claim line to allow correction of claim line data.|
Note:Additional resolution actions may be offered when a custom guided event resolution is associated with the event code. Custom guided event resolutions are addressed throughout this user guide in the corresponding section.
Under the resolution action buttons, the View actions history hyperlink is available. When selected, a pop-up window displays all the actions and resolution comments previously entered for the event code, as well as the user and date.
Once you have selected the resolution action and made updates or changes as required, you can optionally enter a resolution comment and click Submit. This returns you to the Resolve open events screen. The resolution action you chose is displayed under the Resolution heading on the list. If you wish to change the resolution action you chose, you may click the Update button and make another choice.
The Closed events and associated action codes hyperlink displays under the list of open events. When selected, a pop-up window opens, displaying any events closed by SCE as well as any action codes raised on the claim.
Once you have resolved all the events you have access to, selecting Submit will apply the resolution actions you chose and send the claim for reprocess and finalization. If there are open events your role does not allow you to resolve, the claim will be routed to a work queue so it can be finalized.