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Duplicate claim edits

Suggest edit Updated on April 26, 2021

The Claim Edit Configuration screen defines the control of claims submitted to Smart Claims Engine for Healthcare for processing. This configuration screen also lets you create the logic used in the exact duplicate and suspect duplicate edit processing.

Duplicate claim checking logic is available in the ClaimIdentifier level and ClaimLineIndex level when the claim is chargeable, reporting, or a subrogating claim. Duplicate edits are available at both the claim and claim line levels.

You can configure the duplicate claim edits after configuring the claim type.

Currently, Smart Claims Engine for Healthcare processes the following four types of claims: Professional, Outpatient, Inpatient and Dental. To adjudicate these claim types, Smart Claims Engine for Healthcare uses the following three process identifiers:

  • Chargeable/Billing
  • Reporting/Encounter
  • Subrogation/Reclamation

The following table describes Duplicate Claims Edits information.

Clam edit parametersDescription
PropertyThe Field used to match against in the duplicate processing query.
Associated WeightEnter a number to define the weighing of the possible duplicate result. This can be used in a calculation to determine whether this is a Possible Duplicate Claim or Claim Line.
Total for Exact MatchEnter a number to represent the total of "Exact Match" amounts that would indicate an Exact Duplicate Claim or Claim Line.
Minimum Weight for Possible MatchEnter a number to calculate the total of "Weight" amounts that represents the minimum amount for a Possible Duplicate Claim or Claim Line.
Maximum Duplicate Claim ResultsThis is the maximum number of duplicates that will be reported with the event.
Reporting Threshold SizeIf this number is exceeded, then a work object will be created to alert due to a high number of duplicates being reported, which will indicate a system or data error.
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