Auto-Adjudication Rules
Configure and manage automated claim adjudication rules, priorities, and actions
10
Active Rules
84.2%
Auto-Pay Rate
11.4%
Pend Rate
4.4%
Auto-Deny Rate
Adjudication Rules
10 Active| Priority | Rule Name | Type | Criteria | Action | Status | Hits (30d) | |
|---|---|---|---|---|---|---|---|
| 1 | Duplicate Claim Block | Duplicate | CLM within 30 days, same provider+patient+CPT | Auto-Deny | 1,247 | ||
| 2 | Clean Professional Low-Value | Auto-Pay | 837P, valid NPI, eligible member, charge <$500 | Auto-Pay | 8,341 | ||
| 3 | Prior Auth Required | Auth Check | CPT in auth-required list, no REF*G1 present | Pend | 412 | ||
| 4 | Non-Covered Service | Benefit | CPT/revenue code in plan exclusion list | Auto-Deny | 329 | ||
| 5 | Member Eligibility Gap | Eligibility | Service date outside enrollment span | Auto-Deny | 188 | ||
| 6 | High-Dollar Institutional | Threshold | 837I, total charges >$25,000 | Pend | 67 | ||
| 7 | COB Primary Payer Check | COB | Member has secondary payer on file, COB not calculated | Pend | 203 | ||
| 8 | Network Provider Validation | Network | Billing NPI not in current contracted network | Pend | 91 | ||
| 9 | Timely Filing — 365 Day | Timely Filing | Claim received >365 days from DOS | Auto-Deny | 44 | ||
| 10 | Experimental Procedure | Coverage | CPT code on experimental/investigational list | Auto-Deny | 0 |