Test scenarios are built by associating one or more test claims to a scenario and defining the results expected upon execution of the scenario.
Expected results you may define include, but are not limited to:
- Triggering a specific event code
- Applying a defined copay amount
- Adjudicating against a selected benefit
- Generating a defined approved amount
- Applying a specified claim status
Like test claims, test scenarios are saved and can be re-executed.
When test scenarios include multiple test claims, they are run in a sequence you define; this provides the ability to test more complex scenarios involving more than one claim. The final test claim in the sequence is used to validate the expected result.
To view the list of test scenarios or create a new one, from the left panel, click Test suite>Test scenarios. The Test scenarios list opens and displays all the scenarios in the system, the number of claims associated with the scenario, the last run date, and the status of that run.Creating a test scenario
To create a test scenario, click Add test scenario on the upper-right of the Test scenarios list.
The Add test scenario tab opens.
Enter a Scenario ID for searching and filtering and a Description with detailed information about the goal or business case the test scenario supports.
In the Test claim ID field, use the down arrow or begin typing the name of the first test claim in the scenario. Once you have located it, click Add test claim. The test claim is added to the list. Continue to add test claims until you have added all the test claims that you want to execute in the scenario. The last claim in the list is used to validate the scenario against the expected results and claim status you will define.
The test claims added before the final test claim allow SCE to “set the stage” for the result. For example, you might add two test claims to test duplicate logic, where the first would be expected to be approved and the second would be expected to deny with a duplicate claim event code. The expected results and expected claim status are validated against the second (final) test claim in the scenario.
Next, define your expected results by clicking + Add expected result. In the Value field,use the down arrow or begin typing the value you want to define.
The value defines the field on the final claim that would need to match to be for the scenario to pass. When multiple values are selected, the claim must match all of them to pass the scenario.
Once you have selected a value, you will be prompted to enter or choose the specific value. For example, if you choose the value Event code, you are then prompted to select one or more event codes that the final test claim should report.
The table below describes all the values available in a test scenario:
|Action Code||The action code(s) must be set on the claim for the scenario to pass. Multiple action codes can be added.|
|Approved Amount||The approved amount on the claim must match the entered amount for the scenario to pass.|
|Authorization ID||The authorization(s) selected in claim processing must match the authorization(s) entered for the scenario to pass. Multiple authorizations can be added.|
|Benefit ID||The claim must match to the benefit(s) for the scenario to pass. Multiple benefits can be added to cover multiple lines on the claim.|
|Code Group||The procedure code must match the code group(s) selected for the scenario to pass.|
|Copay Amount||The copay amount must match the entered amount for the scenario to pass.|
|Event Code||The event code(s) must be set on the claim for the scenario to pass. Multiple event codes can be added.|
|Network ID||The claim must match to the network(s) for the scenario to pass. Multiple networks can be added to cover multiple lines on the claim.|
|Plan ID||The claim must match to the Plan ID(s) for the scenario to pass. Multiple Plan IDs can be added to cover multiple lines on the claim.|
|Provider contract ID||The claim must match to the Provider Contact ID(s) for the scenario to pass. Multiple contract IDs can be added to cover multiple lines on the claim.|
|Ratesheet ID||The claim must match to the Ratesheet ID(s) for the scenario to pass. Multiple Ratesheet IDs can be added to cover multiple lines on the claim.|
|Total Allowed Amount||The total allowed amount must match the entered for the scenario to pass.|
The final step in configuring the scenario is to set the Expected claim status. In this situation, there are three options as detailed below.
- Claim is approved – covers claims with a status of Pending-Approved or Resolved-Completed.
- Claim is not approved – covers claims with a status of Pending-Recycle, Resolved-Denied, or Pending-Investigation.
- All – any status is allowed.
Once the scenario is configured, select Create to move to the review screen.Executing a test scenario
To execute a scenario, in the test scenario review screen, click Execute scenario.
The results and associated test claims are displayed. If the scenario was successful, then a green banner is displayed at the top of the screen; if the scenario failed, a red banner is displayed at the top of the screen, as well as messaging indicating the number of differences between the expected results you defined and the actual results.
The Test claims section lets you open the test claims run in the scenario to view the details of each claim.
The Test scenario results section shows the expected and execution (actual) values along with the status of passed or failed for each value.
On the upper-right of the screen, you can select Execute again to run your scenario as many times as desired.Editing a test scenario
You can edit a test scenario by selecting Edit on the upper-right. The test scenario will open in edit mode, allowing you to update any of the fields. When your editing is complete, click Update to save the changes. You may also Cancel your changes if desired.