The Pega Smart Claims Engine for Healthcare application contains many configuration settings that you can modify. The settings are divided into the following categories:

• Global configuration
• Application configuration
• Module configuration
• Claim edits configuration

Global configuration

System settings

From the Business Analyst portal, click Configuration > System Settings.

Timely filing

• Timely filing: system default - The number of default days for the timely filing edit if no other configuration exists.
• Timely filing: federal contract - The number of timely filing days configured with a federal contract.
• Retrieve claim history for the last (365) - Indicates how many days to look back (based on the value of the claim Service From date) when retrieving historical claims. Use this setting for gathering claims to be compared in the system audits (Duplicate claim, Interim bill processing, and so forth).

Accumulator

• Threshold utilization (%) - The percentage of an accumulator's use that triggers the reporting of its pending exhaustion.
• Reordering period (days) - The period for claims that might require reordering based on an accumulator being exhausted.
• Allow manual ICN entry - Determines how the ICN number for a claim is created.
  • On = The user manually enters the ICN number for a claim.
  • Off = The system automatically generates the ICN number.

Hospital readmission

• Match Days - The span of time (expressed in days) that has elapsed between a hospital admission date and the hospital discharge date immediately prior to that admission date. The match days are used to define the parameters for a potential unplanned hospital readmission. For example, you can define a hospital readmission to occur within 30 days of the member’s most recent hospital discharge.
• Readmission copay look back - The span of time that has elapsed between a hospital admission date and the hospital discharge date immediately prior to that admission date. This lookback period is used as a trigger for waiving a member’s hospital copay for an unplanned hospital readmission. For example, your policy might require that if the readmission occurs within 48 hours of the most recent discharge, the member’s copay for the current readmission is waived.
• Period/Qualifier - The qualifier that is used to express the time span for the Readmission Copay Lookback. Options are Days or Hours.

Subrogation

• Subrogation dollar limit - The minimum billed amount for a claim to be identified as a Subrogation claim.
• COB cutback model - The model that the application uses for calculating COB on the claim.
  • Pay COB - Pays the remaining patient liability on the claim.
  • Reduced Allowed Amount - Reduces the allowed amount on the claim by the sum of the payments made by other payers (default setting).
• Review required for copy of old claim changes for adjustments - Defines whether a claim that was previously modified by an examiner needs to pend or ignore the updates when the provider submits an adjustment.

Events

• Default claims examiner workbasket - Defines the workbasket that is used when the one defined for the event code configuration cannot be found or does not exist.
• Claim level event resolution process - The default resolution process used for event codes set at the claim level.
• Default event resolution role - The default role of the user assigned to pend resolution.
• Default system manager workbasket - Defines the workbasket that is used when the one defined for the system configuration cannot be found or does not exist.
• Claim line level event resolution process - The default resolution process that is used for event codes that are set at the claim line level.
• Default end date - The date that is used for system configurations if the value is left empty.

Authorization

• Minimum search results - The minimum list of authorizations retrieved to validate. Should be zero.
• Authorization Match Days - Defines the period in which to search for authorizations that have been approved.
• Maximum search results - The maximum list of authorizations retrieved to validate.
• Automatic non exact authorization resolution - Defines whether the authorization should be applied or an event code set if the authorization is no exactly matched.

Claims Xten

• Allowed history claim lines - Defines the maximum number of lines that would be sent on Claims response to ClaimsXten. The maximum includes the current claim lines along with the history claim lines.
• ClaimsXten, send history - Indicates if history needs to be sent to the McKessons ClaimsXten tool on the request XML.
• Send history, max lines exceeds - Indicates whether or not to send the history when the number of history lines exceeds the allowed history count.

SLA

• Default SLA - Defines the base SLA that is used in urgency calculations.
• Claim latency % - Defines the percentage of an SLA that has passed before the claim is received by the system to trigger the Latency Action Code.
• Organization name for SLA - Defines the organization name for SLA.

Manual pricing threshold

• Pricing source reference - The payment source comparator used to establish the ceiling for a manually re-priced claim line allowed amount. The current options are: Non-par pricing or Ratesheet pricing (which are the 2 payment sources configured in Smart Claims Engine's Pricing module). For example, you can limit the manually re-priced allowed amount to a percentage of the configured fee for the same procedure listed in the Ratesheet pricing fee schedule.
• Threshold (%) - The configured percentage of the comparator used to establish the ceiling for a manually re-priced claim line allowed amount; for example, 75% of the Ratesheet pricing fee.

Security

Field level security configuration - A feature that allows you to configure data fields in the Claims adjustment and Claims correction work flows.

• ON = Enables the feature.
• OFF = Disables the feature.

Benefits

• Professional Diagnosis for benefit determination - The specific diagnosis(es), based on their position on a claim line for a professional claim, that you can configure in order to drive benefit determination during claims processing. Options are: 1^st diagnosis, 1^st and 2^nd diagnosis, 1^st, 2^nd and 3^rd diagnosis, and All 4 diagnoses.
• Dental diagnosis for benefit determination - The specific diagnosis(es), based on their position on a claim line for a dental claim, that you can configure in order to drive benefit determination during claims processing. Options are: 1^st diagnosis, 1^st and 2^nd diagnosis, 1^st, 2^nd and 3^rd diagnosis, and All 4 diagnoses.

Application configuration

From Dev Studio, click Configure > Claims Engine > Claims Engine Configuration.

Module settings

• Global measurement - Indicates whether a measurement should be captured for all modules.
  • On = Overrides the measurement indicators at the module level.
  • Off = Uses the measurement indicator at the module level.
• Global audit messages - Indicates whether an audit message should be reported for all modules.
  • On = Overrides the Audit indicators at the module level.
  • Off = Uses the Audit indicator at the module level.

Subscriber lock settings

• Subscriber lock - Indicates whether to use the Subscriber Lock feature in the application.
  • On = The Subscriber Lock feature is activated, which means that you cannot process subsequent claims for a specific subscriber until the lock is released for the original claim that suspended, or requires the manual Claim Examiner review.
  • Off = The Subscriber Lock feature is deactivated, which means that claims you are processing are not subject to subscriber locking.
• Subscriber lock recycle interval - The time when claims that have set the subscriber lock are resubmitted for processing.

Configuration settings

• Config applies to - Defines the class that the application references when resolving custom rules.
• Configuration work class - Defines the class to which claims processed by the application instance are saved.
• Configuration history class - Defines the class to which the history for claims processed by the application instance is saved.
• Action code ruleset/version - Defines the open ruleset or version that Action Code Management uses to store action code rules.

Event settings

• Use client event code - When set to On, allows the client's event codes to be displayed on the user interface's reports instead of the system generated event codes. This allows clients to replace the system event codes with their own codes.
• Event code reporting interval - Defines the interval used to report pend process times.
• Event code implementation id order of resolution - Defines the order of event codes to be processed in the Smart Claims Engine by their Implementation ID. To modify, click Modify Event Code Implementation ID.

Claim processing settings

• Process new claims every - Defines the interval that is used to process incoming claims. To immediately trigger the new claims process, click Process Now.
• Process recycle claims - Allows you to immediately process claims with a status of Pending-Recycle.
• Process Pending-Reprocess claims every - Allows you to configure the time interval at which claims with a status of Pending-Reprocess are reprocessed. Current options are Minute, Hour, Day or Week.
• Initiate 835 process - Generates an 835 file considering claims that were not picked since the last 835 generations.
• Resolution flows - The list of Resolution flows to support configuration. To modify, clickModify resolution flows list.
• Create claim WO from EDI batch transactions - Creates claim work objects from EDI batch transactions. To immediately create claim work objects from EDI batch transactions, click Process now.
• Available claim identifiers - Identifiers that are used to support claim configurations. Current options include All, Chargeable, Medicaid Reclamation, and Reporting.

Module configuration

In Dev Studio, click Configure > Claims Engine > Claims Engine Configuration, then click the Module Configuration tab.

Modules are defined once in the application and are referenced in Sequences. Sequences are defined once and are referenced in Orchestrations. Modules can be referenced in more than one Sequence. An Orchestration defines a claim process from start to finish.

To build an Orchestration, complete the following steps:

1. Define Modules - Modules are self-contained collection rule processes and are defined in a unique ruleset to perform a specific function in the adjudication process. Each module includes a pre- and post-routine that can set up data or evaluate results. You can use a Pega-provided module or you can create your own.
2. Define Sequences - Sequences are collections of modules that can be reused across Orchestrations. Once you define your Sequence, you can add references to Modules in the order they are to be run. You can use a Pega-provided module or you can create your own.
3. Define Orchestrations - Orchestrations are collections of Sequences and add references to Sequences.

Claim edits configuration

In Dev Studio, click Configure > Claims Engine > Claims Engine Configuration, then click the Claim edits tab.

Claim Edits are defined by Claim Type. Only Claim Types that have available Claim Edits on this tab can be processed by the application.

Claim Edits are copied during the Configuration landing page set up to give you a starting point. You can add, modify, or delete Claim Edits in the Configuration landing page.

You define a Claim Edit for each Claim Type, Claim Identifier, and process level (Header or Claim Line) you need for your application. For each Claim Type, you can define Claim Edit parameters for:

• Duplicate claims
• Split claims
• Claim Submission

Duplicate claims

Duplicate claims can be either Exact or Possible matches, and are defined by selecting and specifying the following parameters:

• Weight - Enter a number to indicate the weight of this When rule result when true.
• Total For Exact Match - A number that represents the total of EXACT MATCH results that would indicate an exact Duplicate Claim or Claim Line.
• Minimum Weight For Possible Match - The maximum claims that the system can fetch for duplicate claim or claim line comparisons.
• Maximum Duplicate Claims Results - A number that represents the maximum claims that the system can fetch for duplicate claim or claim line comparisons.
• Reporting Size Threshold - The threshold value for the number of duplicates after which the system creates an event to inform the user.

Split claims

Split claims are identified using a selection of When rules. When all of the rules result in true, the claim is identified as a Split Claim.

When - Select a rule which will indicate a true or false result.

Claims submission

Claims must be identified as eligible for submission by this application. The following check boxes support claim submission:

• New - Indicates that New claims can be processed in this application.
• Adjustment - Indicates that Adjustments can be processed in this application.
• Void - Indicates that Voids can be processed in this application.