Claims Adjudication Rules Definition

Define rules for use by nightly adjudication and manual batch adjudication to update the claim status for any matching services.

1. Go to: Avatar MSO > System Maintenance > Claims Adjudication Rules Definition
2. In the Action field:
   • Select Add to define a new rule.
   • Select Edit to revise an existing rule definition. If Edit is selected, then in the Select Existing Rule field, select a rule to edit from the drop-down list.
3. In the Rule ID field, enter the ID for the rule.
4. In the Rule Description field, enter a description for the rule.
5. The Rule Version field displays the current version number, which increments each time the rule is edited. This number is system-generated and cannot be edited.
6. In the Inactive field, select Yes to deactivate a rule definition.
7. In the Rule Type field, select the type of rule to define.
   • Comparison rules compare two numerical values.
   • Existence rules check for the existence of certain properties.
   • Limit rules measure when a value for a service exceeds the amount defined on this form.
     Note: Only one rule type may be selected. Changing the selected rule type will erase any rules already defined in the Business Rule Viewer field.
8. In the Status field, designate whether the claim is Denied or Pending.
9. In the Status Reason field, select the reason code to apply to the claim decision.
10. In the Funding Source field, select the funding source from the drop-down list.
11. Enter the date range where the rule is effective in the From Date and Through Date fields.
12. Click the Add Rule button to add the rule defined below.
13. The Business Rule Viewer field displays the currently defined rule criteria.
14. Click the Remove Selected Rule button to launch the Select Rule(s) to Remove window. Select the rules to be removed, then click OK.
15. Click the Run Report Button to launch a report of the currently selected claims adjudication rule(s).