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Application rules

Updated on April 26, 2021

Pega Smart Claims Engine for Healthcare contains application rules for the main layers. Application rules define an ordered set of rulesets and versions that together identify the parts of the layers of Pega Smart Claims Engine for Healthcare. In addition, application rules relate the application's objective, use cases, and actors to objects created as part of the Direct Capture of Objectives capabilities. The access groups (listed later) are associated with the specific application rules.

The application rules that make up the base Pega Smart Claims Engine for Healthcare are:

  • PegaClaims: 8 — provides the primary structure of Smart Claims Engine needed to adjudicate a claim.
  • SCE_SampleLayer: 01.01 — provides a top layer that allows you to demonstrate the Pega-provided application. It is only for demonstration and provides a way to save rules into an open ruleset version without having to create your own. This layer should not be included in a customer implementation. The customer can opt to include their own top layer if necessary.

The application rules for other layers (Pega Care Management, Product Composer System, and so on) configured as necessary in a customer’s application structure.

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