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Smart Claims Engine and ClaimsXten integrations

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Updated on August 31, 2021

When ClaimsXten is integrated with Smart Claims Engine (SCE), claim data is exchanged between the two systems. SCE can pass professional and facility claims and corresponding claim history to ClaimsXten in real time or using a batch process.

In addition to the required claim level and line item data needed by ClaimsXten, SCE can also provide other data, including but not limited to, the member’s product, provider ID, hospital bill code and plan type. These data elements can be used by ClaimsXten to filter claims or apply conditional editing criteria to the claims.

ClaimsXten edits each claim and returns the results to the SCE. Smart Claims Engine displays the full message of the ClaimsXten recommendation for each claim, as well as applying certain recommendations like denying lines, adding lines, or applying a pay percentage recommendation.

Note: In this document, inbound files refer to files sent from SCE to ClaimsXten. These are also referred to as request files. Outbound files refer to files sent to SCE from ClaimsXten. These are also referred to as response files.

All ClaimsXten results returned to the SCE at the claim line level are stored in Smart Claims Engine; relevant data is displayed in the user interface.

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