Business rules and edits
Business rules and edits enable the SCE to perform more complex editing on the SCE using contextual information.
The SCE performs specific processing to enable claims to be split and to integrate to external clinical editing tools.
| Capability | Description |
| Administrative edits | Administrative edits cover key editing on the current claim along with historical claim and in-claim edits to ensure that the claim is billed according to business rules.
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| TPL edits | Third party liability and subrogation edits enable validation of the SCE against rules to identify where the claim should be adjudicated by another payer prior to adjudication.
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| Split claims | The SCE provides tools to split claims and claim lines based on key processing requirements. These can include situations where the number of lines needs to be limited or if the claim crosses a calendar year.
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| Clinical edits | The SCE provides integration to clinical editing software and handles the responses performing updates to the claim as necessary.
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