Event codes and claims fallout
Claims may be suspended for claims examiner review during adjudication if they encounter business rules which require a decision and action from a claims examiner. This is process is commonly referred to as “fallout” and it negatively impacts the payers’ auto adjudication rate.
In Smart Claims Engine, the mechanism for recognizing and handling fallout claims is called an event code. One use of event codes in Smart Claims Engine is to report issues or problems during claim processing.
For example, an event code might compare the discharge date for an inpatient claim to the admission date. If the reported discharge date is earlier than the admission date, Smart Claims Engine raises an event code on the claim.
Event codes are used to verify the accuracy, validity, required presence, format, consistency, allowable values, and submitted claim data integrity.
Event codes may also be configured for more complex business rules, such as identifying and processing unplanned inpatient hospital readmissions
The presence of an event code on a claim does not always result in fallout. Smart Claims Engine event codes can be configured to automatically deny a claim or claim line in support of auto adjudication.
Event code configuration defines what happens to a claim or claim line if the event code is assigned to the claim. The event code could be configured to deny the claim or claim line. It might also be configured to suspend the claim for review. Additionally, the event code can be configured to be informational only, which allows it to be reported but does not suspend the claim or impact auto adjudication rates.
Event codes can also track system configuration and processing issues. For example, if Smart Claims Engine is integrated with third party software and that software does not provide a response to a request from Smart Claims Engine, an event code could be triggered to flag the problem.
Check your knowledge with the following interaction.