Implementing claims skills

The skills assignment module should be implemented in the orchestration just prior to the event review. This ensures that any logic in the system that can be used to assign skills criteria has been executed and the skills are added directly before the claim is reviewed for any events that have been assigned.

Once the module is added, skills can be seen on the claim and the module is executed when the Bypass flag for the module is Off. Enabling this flag will cause the module to be bypassed and the conditional View claim skills link on the action button will be unavailable when viewing the claim.

Configuring claims skills

The SCE provides all the tools to configure skills via the delegated rules section of the configuration menu.

The primary table controlling the skills assignment to the claim is the Skill type configuration table. This is used to define the skills available, the collection used to assign the skills in the skill assignment module, and the flag to identify if the skill is enabled or not.

This table can be updated to enable or disable the pre-configured skills or extended to add new skill types. Each type of skill on this table has a unique configuration that is detailed below. The SCE uses the models for skill types and they can be used or extended as necessary. Out of the box, the SCE enables all the skills and defines a required status of True and a rating of 1 in each of the configurations.

When configuring skills on the appropriate decision tables, guidance is to identify the highest rating or most important skill first and then configure the lower ratings or less important skills, if necessary, for each of the subsequent rows. This will ensure that if the criteria for the highest rating is met, that value will be applied to the skill. If the claim does not meet any of the configured criteria in the skills tables, then that skill will not be applied to the claim.

Authorization skill

The authorization skill adds an authorization skill on the claim. This skill is applied when either one or more of the following are true:

• Prior authorization is submitted on a claim.
• Prior authorization number is submitted on the claim line
• An adjudicated authorization is applied to the claim
• The event code “SPA-0009” is assigned to the claim.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the authorization skill on the delegated rules.

Claim type skill

The claim type skill adds a skill to the claim aligned with the claim type associated with the claim.

The table can be extended to add or remove criteria, set the ratings, and if the skill is required for work retrieval. This table is accessed through the claim type skill on the delegated rules. The SCE provides a skill for Professional, Inpatient, Dental and Outpatient.

Coordination of benefits skill

The COB type skill adds a coordination of benefits skill on the claim. This skill is applied when either one or more of the following are true:

1. COB segments are submitted on a claim.
2. An event code assigned by the COB/TPL Module (STP) is applied to the claim.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the COB skill on the delegated rules.

Group ID skill

The Group ID skill adds enables a skill associated with the member group to be applied to the claim. This skill looks for the existence of a configured Member Group ID on the claim and will then assign the associated group skill. The table can be extended to add or remove criteria, set the ratings, and if the skill is required for work retrieval. This table is accessed through the Group ID skill on the delegated rules.

High dollar

The high dollar skill will report a high dollar skill on the claim when the configured criteria are met. This skill is configured to support deviations by claim type, billed amount, calculated amount, and approved amount. These configurations enable the skill to be assigned under different circumstances for different amounts and claim types.

For example, high dollar may apply for inpatient claims with a billed amount greater than $100,000 or for professional claims with a billed amount greater than $30,000. Best practice may be to extend the table to add multiple increasing amounts, each with a higher rating. For example: A professional claim with an allowed amount of $50,000 may require a high dollar skill rating of 10, but a professional claim with an allowed amount of $10,000 may require a high dollar skill rating of 5.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval.

This table is accessed through the High dollar skill on the delegated rules. The table is provided with the ability to assign different ranges for the billed amount, allowed amount, and approved amount for each claim type.

Line of business skill

The line of business skill adds enables a skill associated with the line of business on the claim to be applied to the claim. This skill reviews the line of business assigned to the claim and will add the appropriate configured skill. The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the LOB skill on the delegated rules.

Member contract state skill

The member contract state skill enables claims that are associated with specific member states to have a skill associated with them. This ensures situations that require users with specific state skills to work on those claims. Out of the box configurations for Georgia, New York and California are enabled.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the Member contract state skill on the delegated rules.

Member specialization skill

The member specialization skill enables claims that are for VIPs or employees to have those skills applied to the claim.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the Member specialization skill on the delegated rules.

Newborn skill

The newborn specialization skill identifies claims that meet the newborn criteria and assigns the newborn skill to the claim. The table uses the newborn action code or any newborn event code to set the newborn skill.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the Newborn skill on the delegated rules.

Split claims skill

The split claims skill identifies claims have been split and assigns the split claim skill to the claim. The table uses the split claims action codes to set the split claims skill.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the Split claims skill on the delegated rules.

Transplant skill

The transplant claims skill identifies claims have meet the criteria identifying them as a transplant claim and assigns the transplant skill to the claim. The table uses the transplant action code, the transplant event codes and the appropriate patient relationship codes to set the transplant skill.

The table can be extended to add or remove criteria, set the ratings, and denote that the skill is required for work retrieval. This table is accessed through the Transplant skill on the delegated rules.

Viewing skills assigned to the claim

To view the skills assigned on a claim, select the View claims skills item on the claim Actions menu.

This will present a popup showing the skills assigned on the claim, along with the required flag and the required examiner rating.