Creating a new event code
Selecting the Add event code button on the Event codes screen will open the New event code screen.
There are six steps that are shown in the right panel of the New event code screen to walk through the creation of the new event code. These steps are:
- Event information – This section contains key metadata for the event code. For example: event code number, name, version start and end.
- Event configuration – This section provides the core configurations for the event code. For example: dates of service, claim type, clean claim indicator, along with the configurations needed for a dynamic event code.
- Disposition configuration – This section contains the information needed by the system on how to handle the event code when it is set. For example: action, processing dates, SLA, event resolution flow.
- Response configuration – This section contains the information needed by the system to map the outcome of the event to a response code and supplementary information. For example: claims adjustment reason codes, claim status codes, explanation of benefits text.
- Claims transfer configuration – This section contains the settings that can limit where the claim with this event code assigned can be transferred to by an operator. For example: work queues and work lists.
- Review and submit – This step will enable the user to review the entered information, perform any necessary modifications and then submit it for approval. Once the event code is approved, it is available for use.
The fields used in the creation of an event code are listed in the table below. Fields with an asterisk (*) are required.
| Step | Section | Field | Description |
| 1 | Information | Version | Version number based on previous existing versions of the same event code. Auto populated by the system. |
| 1 | Information | Version start* | The date the event code becomes active in the system; must be today or a date in the future. If version start date is set as the current day, an information alert is displayed stating that this might be changed on approval. |
| 1 | Information | Version end* | The date the event code becomes inactive in the system; must be today or a date in the future and must be greater than or equal to the version start date. |
| 1 | Information | Is Dynamic event? | Yes / No. This option allows the user to configure the criteria based on which the dynamic event code would be triggered. |
| 1 | Information | Module Source* | Module that sets the event code. This is defaulted when the is Dynamic event box is checked. |
| 1 | Information | Event code number* | Numeric field that contains the internal code used to identify the business event rule that was applied during claims execution. Event code number must be in the correct range for the implementation ID chosen. |
| 1 | Information | Event name* | Name of the event code. |
| 1 | Information | Description* | Description of the event code. |
| 1 | Information | Category* | Identifies whether the event code applies to business or system rules. This drives the priority routing of claim work objects. |
| 1 | Information | Applies to* | Differentiate between claim header and claim line level event codes. This drives the disposition configuration. |
| 1 | Information | Client ID | Capability for client to add their own mapping for their own event or pend code numbering. |
| 1 | Information | Event code documents or links | Allows the user to attach documentation that is associated to the event code. For example, knowledge articles, business policies and resolution workbooks. |
| 2 | Configuration | Event group | The event group to which the event code is associated. |
| 2 | Configuration | Implementation ID* | The application to which the event code is associated. This field is auto populated. |
| 2 | Configuration | Clean Claim Indicator | Yes / No. Identifies if the event code would cause the claim to be “clean” or “unclean”. |
| 2 | Configuration | DOS start* | The first date of service (DOS) on the claim which the configuration applies to; can be any date in the past or future. |
| 2 | Configuration | DOS end* | The last date of service (DOS) on the claim which the configuration applies to; can be any date in the past or future and must be greater than or equal to the DOS start date. |
| 2 | Configuration | Event source rule type | Allows you to select the actual flow, collection, decision tree, activity, decision table, or data transform that creates the event code. |
| 2 | Configuration | Event source rule name | Allows you to add event source rule from drop down selection of rules. This provides transparency between the Pega rule assigning the event code and the event code configuration. This field is displayed once the event source rule type is populated. |
| 2 | Configuration | Claim type* | Different claim types use different outcomes and descriptions for the event code, Drop Down Box - multiple can be selected. For example: All, Dental, Inpatient, Outpatient, Professional. |
| 2 | Configuration | Claim identifier* | Different claim identifiers use different outcomes and descriptions for the event code. Drop Down Box - multiple can be selected. For example: All, Chargeable, Reporting, Medicaid Reclamation. |
| 2 | Dynamic event criteria | Label, Condition & Logic string | This defines the criteria for the dynamic user created events. More information on this is detailed in the section below. |
| 2 | Dependencies | Dependency event code | This is the list of event codes that will cause this event code to be disregarded in event review. Use the + Add event codes option to add more entries to this list. This is used to remove event codes from the claim that are related to another event code. For example, if a claim set a procedure code not found event, then the benefit not found would also set. Adding the procedure code not found event code as a dependency of the benefit not found event code will remove the benefit not found event code from being reported. |
| 3 | Disposition Configuration | Claim type, Claim identifier, Submission type, Media type, Processing start, Processing end & Action | The configuration of dispositions is detailed in the section below. This will detail the use of the fields based on the disposition action selected. |
| 4 | Suspend response configuration & Deny response configuration | Claim status category Code* | Code indicating the general category of the status (accepted, rejected, additional information requested, etc.). Maps to an X12 claim status category code. Required when a suspend or deny disposition exists. |
| 4 | Suspend response configuration & Deny response configuration | Claim status code* | Code conveying the status of an entire claim or a specific service line. Maps to an X12 claim status code. Required when a suspend or deny disposition exists. |
| 4 | Suspend response configuration & Deny response configuration | Entity identifier code | Code identifying an organizational entity, a physical location, property or an individual and is associated with a status code. Maps to an X12 entity identifier code. |
| 4 | Deny response configuration | Claim adjustment group code* | Code identifying the grouping for the financial adjustment associated with the adjustment reason code. Maps to an X12 claim adjustment group code. |
| 4 | Deny response configuration | Claim adjustment reason codes* | Code identifying why the claim or service line was paid differently than billed. Maps to an X12 claim adjustment reason code (CARC). Required when a suspend or deny disposition exists. |
| 4 | Deny response configuration | Remittance advice code* | Code used to provide additional explanation for an adjustment already described by a claim adjustment reason code or to convey information about remittance processing. Maps to an X12 remittance advice remark code (RARC). |
| 4 | Deny response configuration | Liability assignment: Provider or Member | Identifies the party, liable for the remainder of the claim. If the selection is Member, then the liability calculation can be either the Billed or Allowed amounts. |
| 4 | Correspondence configuration | EOB description | Explanation of Benefits - Description of the event code assigned for external communications to the member. |
| 4 | Correspondence configuration | EOP description | Explanation of Payment - Description of the event code for external communications to the provider. |
| 4 | Correspondence configuration | Correspondence | Enables the selection of a correspondence rule that can be attached to the event code |
| 4 | Disposition document and links | Enables the ability to attach documents or links that is associated with the event code. These could be link to external document management systems. | |
| 5 | Claim transfer configuration | Work group | Restricts the transfer of claims with the event code assigned to only the selected work groups. If none are selected, then all work groups will be available for transfer. To add a work group, select Add work groups, and then select the appropriate work groups from the list by selecting Add and then Submit. |
| 5 | Claim transfer configuration | Work queues | Restricts the transfer of claims with the event code assigned to only the selected work queues. If none are selected, then all work queues will be available for transfer. To add a work queue, select Add work queues, and then select the appropriate work queues from the list by selecting Add and then Submit. |
| 5 | Claim transfer configuration | Work lists | Restricts the transfer of claims with the event code assigned to only the selected users work lists. If none are selected, then all work lists will be available for transfer. To add a work list, select Add work lists, and then select the appropriate users from the list by selecting Add and then Submit. |
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