Pre-adjudication of a claim involves the evaluation of data submitted to ensure it can be processed correctly. The member match portion of pre-adjudication includes patient identification, policy selection, eligibility verification and associated validations.
Member matching is an important step in the claims pre-adjudication process to reduce pends, increase first pass rates, and increase overall operational efficiency. These are achieved by normalizing data disparities and inconsistencies submitted on claims.
SCE provides enhanced member search and match functionality, supporting automated and manual processing, to uniquely identify the member receiving services.
There are three modules that are used to support the member match capabilities:
- Member match (SMM) – This module performs the match to the member utilizing the information on the claim to assist in the matching
- Member validations (SMV) – This module validates key information on the claim against the matched member record and sets event codes when discrepancies arise
- Policy selection and eligibility (SMP) – This module selects the appropriate policy for adjudication and validates the eligibility
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