The Claim Policies tab of the contract is evaluated before the Service Components tab.

• A. Not sure
• B. True
• C. False
• D. It depends

Answer: (B)

The main idea is the processing order in contract evaluation: policy rules are applied before breaking down the claim into its individual service components. Claim policies set the overarching constraints—eligibility, coverage, limits, and patient responsibility—for the claim as a whole. Once those policy determinations are in place, the system evaluates each service component within that policy context to determine how each item is covered, what portion is payable, and how cost sharing is allocated. This sequence ensures that service-level calculations align with the contract’s terms and avoid applying service rules in a vacuum. If a policy restricts or denies coverage, the impact cascades to the service components accordingly, so evaluating policies first is the correct approach. Therefore, the statement is true.