Process and Manage pre-determination processing of claims: A request for predetermination of benefits (or predetermination) is a pre-service request for a statement of the exact benefits that would have been paid had the predetermination request been an actual claim. The predetermination request would include all data necessary to fully adjudicate a claim except for date(s) of service.

As part of business rules, New field for Claim Submission Reason Code (CLM19) is introduced.

• The mandatory check for service dates if Claim Submission Reason Code is checked (Yes) is removed.
• Claim Submission Reason Code and Predetermination of benefit identifier properties are mutually exclusive on header screen.
• New property on system configuration page was introduced to mention the no of days of Predetermination expiry.

• Duplicate logic for predetermination