Skip to main content


         This documentation site is for previous versions. Visit our new documentation site for current releases.      
 

About processing Subrogation Demand claims

Updated on April 26, 2021

For the Medicaid Subrogation Demand claims, Pega Smart Claims Engine for Healthcare checks if the value of Medicaid Paid Amount is less than the value of Calculated Allowed Amount. If it is, the application performs the tasks in the table below.

Is Medicaid Paid Amount at the Line Level Greater than 0?Then Pega Smart Claims Engine for Healthcare does the following:
Yes
  • Zeroes out all the adjustments at the header and line level.
  • Sets the value of Calculated Allowed Amount at the line level equal to the value of Medicaid Paid at the line level.
  • Sets the value of Calculated Allowed Amount at the header level equal to the value of Sum of Calculated Amounts at the line level.
  • Adds the new adjustment code 215 Billed Amount equals the Approved Amount
No
  • Zeroes out all the adjustments at the header and line level.
  • Sets the value of Calculated Allowed Amount at the header level equal to the value of Medicaid Paid at the header level.
  • Adds the new adjustment code 215 Billed Amount equals the Approved Amount
  • Previous topic Identifying Subrogation Demand claims
  • Next topic About voiding or cancelling Medicaid Subrogation Demand claims

Tags

Pega Smart Claims Engine for Healthcare 8.6

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Visit the Support Center

Did you find this content helpful?

Yes
No

Want to help us improve this content?
Suggest an edit

We'd prefer it if you saw us at our best.

Pega.com is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us