Post-adjudication

Claims finalization or post-adjudication routines in Smart Claims Engine set the final status on the claim and, if applicable, approve it for payment batch.

The primary microjourneys™ in Smart Claims Engine claims finalization are:

• Event review
• Process updates
• Finalize claim

The Event review module in Smart Claims Engine is responsible for handling open events on the claim.

First, Smart Claims Engine removes any duplicate event codes. The system also checks for any event code dependency or action code interaction and removes events as required by these configurations.

Smart Claims Engine sorts the remaining event codes as follows – first on the claim header level and then on the claim line level:

1. System event codes configured to deny
2. System event codes configured to suspend
3. Business event codes configured to deny
4. Business event codes configured to suspend

Within the sort order, event codes are ordered according to the priority set in the event code configuration; events with the same priority are reported in the order they are encountered in the orchestration.

If a header level denial is set on the claim and has the highest priority, or all the claim lines are set to deny, then the claim is denied by Smart Claims Engine.

If no header level denials are present, Smart Claims Engine determines whether any header level event codes set to suspend are raised on the claim. If so, SCE sorts these suspend events by priority. Smart Claims Engine then sorts any line level denials by priority; then line level suspends are sorted.

Finally, any informational event codes are sorted, with claim header level event informational codes prioritized higher than claim line level informational event codes.

When Smart Claims Engine does not deny the claim and event codes set to suspend are reported on the claim, Smart Claims Engine determines whether the highest priority event code is set to recycle the claim or route it to a work queue for claims examiner review and action.

When suspended claims are routed for claims examiner review, the open events are presented in the order outlined above. The claims examiner addresses them in the order presented until the claim is resolved. Once the claims examiner submits their resolution choices, the claim will flow through the orchestration again to ensure no new errors have been introduced. If there are no new errors detected, the event review module determines whether random audit logic applies to the claim. If the claim meets the defined audit criteria, an event code is raised and the claim is sent for pre-payment audit. Otherwise, the event review process is complete.

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After event review is complete, Smart Claims Engine runs the Process updates module. This module updates totals on the claim, applies event code resolution actions, and checks the claim for balancing at the claim header and line level.

If needed, Smart Claims Engine performs any claim header-level calculations required for Coordination of Benefits (COB) or Medicaid Reclamation processing. The process updates module also sets the first pass indicator.

Additionally, the module looks to see if any event codes are still open and then sets the processing time for the claims.

If any balancing routines or other checks fail during this module, event codes are reported and the claim is routed back to event review for resolution.

In the final module, denied claims are updated appropriately, the claim and work object statuses are updated, and updates of accumulators and authorizations are applied. If  required, external systems are updated with finalized claim information.