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Claim inquiry

Suggest edit Updated on August 31, 2021

A claims inquiry is a case that allows you to manage the work related to:

  • Requests to adjust or reprocess a claim or claims
  • Information regarding claims status

The inquiry can originate in a customer service system or some other external system via an API or may be manually created directly in SCE.

Manually creating a claims inquiry

Claims examiners with the appropriate system privileges may create a claims inquiry directly in Smart Claims Engine.

First, from the left panel, click + New>Claims inquiry. The Claims inquiry screen opens.

Select an Inquiry reason code, inquiry channel, and inquiry type from the dropdowns; other information is optional. The fields are listed below and required fields are identified by the *.

Claims inquiry field Description
Inquiry reason code*The inquiry reason code is chosen to indicate the basis for the inquiry. Choose from the dropdown.
Inquiry channel*The inquiry channel captures by what means the inquiry was received. Choose from the dropdown.
Inquiry type*The inquiry type simply indicates who initiated the inquiry. Choose from the dropdown.
Group numberThe group number field captures the group number of the impacted member.
Exchange indicatorThe exchange indicator field captures the exchange indicator of the impacted member.
Claims inquiry notesThis is a free-form text field allowing the entry of notes pertaining to the entire inquiry. There is also a notes field associated with each claim included in the inquiry.

Next, enter search criteria to identify the claim(s) which should be part of the inquiry. At least one of the following data elements are required for the claims search:

  • ICN
  • Provider ID
  • Subscriber ID
  • Patient ID
Claims search criteriaDescription
ICNEnter a full 18 digit ICN.
Billing providerEnter a wild card (*) to return ALL results or begin entering the provider name, internal ID, or tax identification number. SCE will display possible matches as they are identified.
SubscriberEnter a wild card (*) to return ALL results or begin entering the subscriber name or ID. SCE will display possible matches as they are identified.
PatientEnter a wild card (*) to return ALL results or begin entering the patient name or ID. SCE will display possible matches as they are identified.
TypeChoose one or more claim types (Professional, Institutional, Dental).
Claim total charge amountEnter the total charge for the claim.
Claim total paid amountEnter the total paid amount for the claim.
StatusSelect a claim status from the dropdown. If left unpopulated, claims of all statuses will be returned.
Service fromEnter or use the date picker to select a Service from date.
Service toEnter or use the date picker to select a Service to date.
Submission dateEnter or use the date picker to select a Submission date.
Rendering provider NPIEnter a wild card (*) to return ALL results or begin entering the provider name or NPI. SCE will display possible matches as they are identified.
Plan IDEnter a wild card (*) to return ALL results or begin entering the Plan ID. SCE will display possible matches as they are identified.
Contract IDEnter a wild card (*) to return ALL results or begin entering the Contract ID. SCE will display possible matches as they are identified.

From the search results, select the claim(s) you wish to associate with the inquiry.

To continue, click Next.

You may remove claims from the inquiry using the trash can icon.

If you need to include additional claims, click Add more claims. The original search and results open in a modal. You can choose additional claims from the displayed list or conduct a new search and select additional claims from the search result.

To create and route the claims inquiry, click Finish. The inquiry you created will be routed to the designated work queue.

Resolving a claims inquiry

Once you have been assigned a claims inquiry, by clicking Get next or from a direct transfer to your worklist, you can review and resolve the claims inquiry.

All the information captured during the creation of the inquiry is displayed. You can also click Original request information to see the information that was associated with the inquiry when it was created.

Claims added to the inquiry are displayed with a hyperlink to open the claim for review in another tab.

Clicking Resolve for each claim opens the Resolve inquiry modal. This modal provides a Notes field to optionally enter any research findings. The Resolution action dropdown is required – this is where you indicate the result of your research by choosing Adjustment or No action.

Once you have completed your research and adjusted the claim or determined no action is required, click Submit to return to the primary screen. Here you have the option to review additional claims (if needed), to Update any claims you previously resolved and to Submit the inquiry once it is complete.

The Actions menu provides options to Add more claims to the inquiry, to Transfer the inquiry assignment, or to Follow the inquiry.

Additionally, an audit trail is available by selecting the Audit tab on the screen.

Claims inquiry status

SCE may apply any of the following statuses to a claims inquiry:

Claims inquiry statusDefinition
Pending-ReviewThis status is assigned to new claims inquiry cases when no resolution action has been chosen for any claim that is included in the claims inquiry.
Pending-InProcessThis status is assigned to the claims inquiry when at least one claim included in the claims inquiry has a selected resolution action, but the claims inquiry has not yet been submitted/finalized.
Resolved-ActionTakenWhen the claims inquiry is submitted, SCE reviews the resolution action chosen for each claim included in the claims inquiry. If the user chooses Adjustment for at least one claim, the inquiry status is set to Resolved-ActionTaken.
Resolved-NoActionWhen the claims inquiry is submitted, SCE reviews the resolution action chosen for each claim included in the claims inquiry. If the user chooses No Action for all the claims, the inquiry status is set to Resolved-NoAction.
Claims inquiry search

Smart Claims Engine provides a way for you to search for a claims inquiry. From the left panel, click Claims inquiry>Claims inquiry search.

The Search inquiries screen offers a variety of search criteria on the left side of the screen.

Search criteriaDescription
ICNEnter a full ICN
Inquiry IDEnter a specific claims inquiry ID, beginning with CI-
Inquiry typeChoose the claims inquiry type (who initiated the inquiry) from the dropdown.
Inquiry reason codeChoose the claims inquiry reason (the basis for the inquiry) from the dropdown.
Inquiry channelChoose the claims inquiry channel (how the inquiry was received) from the dropdown.
Inquiry start dateEnter or use the date picker to select an inquiry start date.
Due dateEnter or use the date picker to select the due date.
Provider IDEnter a wild card (*) to return ALL results or begin entering the provider name, internal ID, or tax identification number. SCE will display possible matches as they are identified.
Subscriber IDEnter a wild card (*) to return ALL results or begin entering the subscriber name or ID. SCE will display possible matches as they are identified.
Patient IDEnter a wild card (*) to return ALL results or begin entering the patient name or ID. SCE will display possible matches as they are identified.
Show resolved casesSelecting this checkbox returns results from resolved as well as open claims inquiry cases.
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