Modules in Smart Claims Engine
Modules represent the most basic component of the orchestration in Smart Claims Engine – they apply specific business rules or logic used in distinct steps of the claim adjudication process. The modularity is purposeful – it allows you to design an orchestration layer or layers meeting your specific needs.
Examples
The following are examples of a few of the modules delivered with Smart Claims Engine and a brief description of their functionality:
Module bypass
The module bypass function in Smart Claims Engine enables the claim to skip specific modules during processing. Module bypass may be applied to create efficiencies in the system when specific issues need to be resolved before the claim can process further. For example, when a unique member record is not identified during member match, Smart Claims Engine is configured to skip additional processing modules and present the issue to a claims examiner for resolution before continuing. The member must be known to apply additional processing steps, such as benefit determination.
Module bypass might also be applied in order to skip a module based on a client contract, external integration rules, and so on.
Each module in the Smart Claims Engine is associated with a discrete decision table which contains the specific conditions that drive the bypass functionality; there is also a global module bypass table. Each table offers multiple conditions (for example, event code, claim type, payer ID), which can be configured to trigger a bypass.
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