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Pre-adjudication

Suggest edit Updated on August 31, 2021

The SCE provides a series of pre-adjudication edits and processing to ensure that claims can be adjudicated cleanly.

These edits include ensuring that data on the claim is consistent with coding files and dates as well as performing provider and member match to ensure the providers and member on the claim are identified.

CapabilityDescription
Validation edits

The SCE performs a series of validity checks on the data on the claim to reduce the likelihood of claims failing during processing. These checks include validating data on the claim against code files, date validations, and other key data requirements.

  • Data validity checks
Member match

The SCE member match process enables the patient or subscriber on the claim to match to a member in the system and selects the appropriate policy for adjudication. Validations between the member in the system and the claim are also performed.

  • Member match
  • Member validation
  • Policy selection & eligibility
  • Member split claim
Provider match

The SCE provider match process ensures that the providers on the claim are found in the system for adjudication. Comparisons between the provider data in the system and claim are also performed to ensure the data is correct.

  • Provider match
  • Provider validation
  • Contract selection
  • Provider split claim
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