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Enhancement requirement to Smart Claims Engine 7.13



Require the below list of features for Split Claims, SANP and CXT.

Split Claims Functionality

1. Enhanced system capability to split a line based on needed triggers (for example, Multiple Rate Sheets).
2. Enhanced system capability to display Split Line Numbers and associate the same with the Original Line Number.
3. Enhanced system capability to split the following uniformly:
  • Billed Amount
  • Units
  • COB Paid Amount
  • COB Units
  • Adjustments

4. Enhanced system capabilities to associate Action Codes for each split line (Original Split Line and Newly Split Lines).
5. Enhanced Balancing Logic and Split Line Pends.

CXT Enhancements

CXT Audit Type Enhancements

1. Enhanced system capability to calculate Audit Type using a Decision Table and a Decision Tree. Audit Type would be driven by:


  • Modification to existing UI to display the Audit Type.
  • Modification to the existing mapping table (CXTResponsetoSCECode Decision table) to accommodate:

CXT Smart Claim History Enhancements

1. Extension Point (multiple iterations)
• CE_SANPClaimLine_Suppression collection are created to invoke Decision Table
• Suppressed line audits are updated to a single message
2. Extension Point (ConnectFile)
• Created CE_InvokeSANP Collection – calls Connect File Activity
3. Extension Point (demo rule)
• Created CE_HandleSANPResponse collection – invokes Demo Response Decision Table
4. Mapping Problem (NetworXerror)
• NetworXerror is mapped to SCE
5. Mapping Issues (Pricing Details in SANP Response)
• Mapping for pricing details at claim line level updated
6. Section Changes
• UI Updated to match pricing details mapping changes
7. Clean Up
• Clean up of dual call to add pend codes in response actions in Step 5 of IntegrateMultipleSANPResponse Collection


Install HFix-23798.

Published October 6, 2015 - Updated October 8, 2020

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