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Claim pre-adjudication

Suggest edit Updated on August 31, 2021

The Smart Claims Engine performs a series of tasks as part of the pre-adjudication of claims during processing. These tasks include validating codes, system configurations, and key data on the claim; performing a member match, retrieving the appropriate policy and validating eligibility, and validating provider information.

This chapter will detail those processes and provide information on appropriate configurations and extensions.

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