Pre-adjudication

A microjourney™ is a discrete unit of work that results in a particular outcome. The pre-adjudication microjourneys in Smart Claims Engine are designed to detect and resolve basic claim data issues before the claim enters a downstream adjudication solution.

Health plans may use Smart Claims Engine for pre-adjudication to ensure that data submitted on claims is valid, ensure the correct member is selected, and match the correct provider record. These selections and validations ensure that downstream processes, such as determining benefits and applying pricing, can be performed accurately.

Smart Claims Engine can be used to split claims during pre-adjudication in order to address downstream system limitations, like the number of service lines on a claim. Configurable split claim or split claim line logic may also be applied when there is a change in the member or provider contract during the dates of service reported on the claim. If a claim or claim line is split when encountering the logic, the updated claim or claims may be sent to a downstream adjudication system.

The primary microjourneys addressed by using the Smart Claims Engine for pre-adjudication tasks include:

• Claims data validation
• Claims data update
• Insertion of adjudication triggers or overrides
• Integrating Smart Claims Engine results in the claims system of record

Health plan payers typically validate data submitted on a claim immediately after claim intake. For example, payers ensure that any procedure and diagnosis codes are valid on the date of service billed by the provider. Suppose Smart Claims Engine finds the submission is invalid. In that case, it can automatically generate a denial for the claim line or allow a claims examiner to investigate and correct the issue or deny the claim or claim line. Smart Claims Engine can capture the chosen option and transmitted to the adjudicating platform in an outbound file or API.

Data validation and comparison routines can also be used to detect duplicate claims submissions, identify interim bills, and apply Coordination of Benefits (COB) rules.

Pre-adjudication routines commonly apply member and provider match logic and validation. Payers must ensure the member information submitted on the claim matches a member in their system of record; if it does not, payers will typically deny or reject the claim before it enters adjudication. Providers also need to be matched against a system of record and provider data validated prior to adjudication. Smart Claims Engine supports these tasks by providing configurable member and provider match logic and validation.

When member and provider match logic is applied as part of pre-adjudication processing in Smart Claims Engine, Smart Claims Engine can update claim data based on the positive match. For example, when policy selection logic in Smart Claims Engine is applied to a claim, the claim can be updated with the selected policy and member ID and other policy information before being sent to the primary adjudication system.

Smart Claims Engine can also add a provider taxonomy code or demographic information to the claim before it is submitted for adjudication; this helps drive increased auto adjudication rates.

Smart Claims Engine can also be used in pre-adjudication to proactively address issues or limitations in an external adjudication platform. For example, Smart Claims Engine can be configured to recognize a disaster, parse through other configurations, and generate an action code or override on claims that meet the defined criteria.

The adjudicating platform can leverage the action code or another trigger to apply exception processing, such as waiving authorization requirements or cost shares.

Information updated or modified in Smart Claims Engine can be integrated into a claims adjudication system via APIs or an enhanced claim extract. Doing so enables the adjudicating platform to adjudicate the claim based on information manipulated or updated in the Smart Claims Engine. The result is an improved auto-adjudication rate and assurance that the correct rules are applied during adjudication.

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