Interfaces
Pega Smart Claims Engine for Healthcare needs to support electronic transactions to receive medical claims and provide appropriate payment responses to the submitting entity. This chapter details the transactions that are supported and how Pega Smart Claims Engine for Healthcare processes or generated those transactions.
Pega Smart Claims Engine for Healthcare provides the capability to handle the receipt and generation of X12-compliant HIPAA transactions. The 5010 version of the HIPAA transactions is supported in Pega Smart Claims Engine for Healthcare.
The following transactions are supported:
- X12 837 Professional EDI and XML variants
These files are used to process professional medical claims through Pega Smart Claims Engine for Healthcare.
X12 837 Institutional EDI and XML variants
These files are used to process institutional medical claims through Pega Smart Claims Engine for Healthcare.
X12 837 Dental EDI and XML variants
These files are used to process dental claims through Pega Smart Claims Engine for Healthcare.
X12 276/277 Solicited Claim Status Request/Response
The 276 Claim Status request is submitted to Pega Smart Claims Engine for Healthcare and a corresponding 277 Claim Status response file is created.
X12 835 Remittance Advice
This file is used to generate the remittance information on payments to the provider for the claims that have been submitted and processed to completion through Pega Smart Claims Engine for Healthcare.
X12 277 Unsolicited Response
This file is created with the 835 Remittance Advice. It shows claims that are still in process in Pega Smart Claims Engine for Healthcare and have not yet been fully adjudicated for payment or denial.
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