Modules
The modules are the smallest element of the orchestration flow. These are the key pieces of functionality that organizes a key business capability. For example, benefit determination and third-party liability editing. The Smart Claims Engine provides a series of modules for specific out-of-the-box functionality that can be implemented. The modules provided by the Smart Claims Engine are all prefixed with an “S” identifier. Proprietary modules can also be created in the application for use in the Smart Claims Engine. The list of supplied modules is defined below. Each of these can be added as necessary to sequences to support orchestrations:
| Module | Identifier | Description |
| Claim adjustments | SAD | Claim adjustment processing and validation |
| Authorization processing | SAP | Authorization matching and adjudication |
| Claim business audits | SBA | Multiple claim or multi-line editing against historical claims or the current claim |
| Benefit determination | SBD | Matches the claim to an appropriate benefit |
| Claim business edits | SBE | Single claim or line business edits and core action codes |
| Benefit limit accumulator processing | SBL | Benefit limit calculations and accumulator processing |
| Coverages, accumulators and payments | SCA | Liability calculations based on benefit coverage and accumulator use. |
| COB reductions | SCB | Payment reductions based on claim submitted COB |
| ClaimsXten | SCX | SCE adaptor for ClaimsXten integration and processing |
| Episode processing | SEP | Episode of care identification and linking |
| Event code review | SER | Reviews event codes assigned on the claim for disposition, routing, and next steps |
| Finalization claim | SFC | Finalizes the claim and performs any remaining calculations |
| Finalization pricing | SFP | Finalizes the pricing on the claim and applies any COB adjustments |
| Incentives and surcharges | SIS | Applies any provider incentives or regulatory surcharges |
| Member eligibility | SME | Legacy member match and eligibility module. Performs member lookup, checks eligibility, and validates member related data |
| Member match | SMM | Matches the subscriber and/or patient on the claim to a member in the system |
| Policy selection and eligibility | SMP | Selects the appropriate policy for adjudication and validates member eligibility |
| Member validations | SMV | Validates patient and/or subscriber information on the claim against the matched member record |
| Process authorizations | SPA | Identifies if an authorization is required, matches, and processes the claim against an authorization |
| Provider eligibility | SPE | Matches the provider on the claim to the provider records and validates the provider details |
| Price calculation | SPC | Prices the lines on the claim based on the submitted codes |
| Process updates | SPU | Updates the claim and any supporting accumulators based on the final status |
| Random audits | SRA | Applies random audit event codes to the claim based on the audit configuration |
| Ratesheet selection | SRS | Selects the appropriate ratesheet ID based on the provider’s contract |
| Split claim | SSC | Applies the generic system configured automatic split claims logic. |
| Subscriber lock | SSL | Locks the claims from subscribers from processing in parallel to ensure accumulators are in sync |
| NetworX pricer | SSP | SCE adaptor to integrate to NetworX pricer |
| TPL edits | STP | Applies COB / TPL edits to the claim |
| Process validation edits | SVE | Performs key field validations to the claim |
| Winning price | SWP | Performs the winning price logic to select the appropriate price for adjudication |
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