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Business rules and edits

Updated on December 15, 2021

Business rules and edits enable the SCE to perform more complex editing on the SCE using contextual information.

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The SCE performs specific processing to enable claims to be split and to integrate to external clinical editing tools.

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.

  • Dynamic edits
  • Timely filing
  • Duplicate check
  • Interim bill
  • PCP validation
  • FWA Flags
  • Hospital readmission
  • Dental predetermination
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.

  • Subrogation edits
  • COB priority edits
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.

  • Split claim/line rules
Clinical edits

The SCE provides integration to clinical editing software and handles the responses performing updates to the claim as necessary.

  • ClaimsXten™ integration

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