Why Are Business Rules So Critically Important? When a claim is submitted to EmblemHealth, the proper determination of benefits and payment is based on highly complex business rules embedded in the claims adjudication systems (QCare, HCS, MCS). The rules are based on multiple data from the claim forms (member, plan, provider, affiliation, diagnosis, procedure, preauthorization, etc.), and many rules include ICD-9 codes. These rules all need to be updated to accommodate the new ICD-10 codes. Over…
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