What is the recommended context to use when building rules for claims?

• A. Payer Values
• B. Service Values
• C. Claim Values
• D. Fee Values

Answer: (C)

Rules for claims are most effective when built against claim values because the claim is the unit of adjudication, and many important checks involve the entire submission rather than individual lines. Using claim values lets you enforce cross-line and aggregate validations—such as making sure the total billed amount matches the sum of all line items, applying deductible and patient responsibility across the whole claim, and verifying policy-wide requirements like a prior authorization status that affects the entire submission. Service values are tailored to each line item, so they miss interactions between lines; payer values and fee values have their own specialized uses (payer-specific rules or price data) but don’t address the holistic integrity of the claim. Focusing on claim values ensures consistency and compliance across the entire claim before addressing line-level details.