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How the application matches benefits and accumulators to claim lines

Suggest edit Updated on April 26, 2021

Smart Claims Engine uses the following logic to match benefits and accumulators to claim lines:

  1. The application retrieves and places the member record on the clipboard in preparation for performing all the required calculations.
  2. The application establishes a temporary work page on the clipboard to enable the tracking and management of co-payments from the claim to ensure their correct application during adjudication.
  3. The application matches a benefit from the benefit list to each individual claim line.
  4. From each benefit, the application identifies which accumulators need to be retrieved from the accumulator manager for tracking and updating.
  5. The application uses the cost share data from each selected benefit to help determine the amounts that will be paid to the provider on a claim line-by-claim line basis. Then the application iterates through each accumulator step in each selected benefit to perform those cost share calculations and determine which amounts are incremented to each of the applicable financial accumulator limits.
  6. The application iterates through each claim line to identify all the co-payments associated with the entire claim.
  7. The application iterates through the benefit list to determine which network is applied to each claim line. The application looks in each network for any associated network-level accumulators and retrieves all the network-level patient and family accumulators.

    At this point in the process, Smart Claims Engine has:

    • Identified all the cost shares associated with the benefit on the individual claim line.
    • Obtained from the accumulator manager all the associated accumulators that represent any amounts that have already been incremented toward those accumulator limits from previous claims, if there are any.
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