The D_CE_PatientHistoryDetails Data page is the primary source in duplicate edits processing for whenever we need to fetch data from elastic search. The data page takes two parameters the Query and TypeOfData. TypeOfData param, which identifies the repository the connect rest has to hit and whether it should be work or data. The Query holds the request created for all the scenarios.

1. Request building

   These are the data transforms, which build the queries for dupe check.

   Data transform Name	Description
   PrepareESStandardQuery	Standard Query which includes PatientID, ClaimType, Status, Service From Date and Service To Date
   PrepareESQueryForSelfDupeCheck	Prepares the query for self-dupe check
   PrepareESHeaderQuery	Prepares the query for header dupe check
   PrepareESClaimLineQuery	Prepares the query for claim line dupe check

   All the queries prepared are put on the temp page DuplicateEditsTempPage which is referred to during processing. All the queries use a data transform ApplyReplaceToQueryToSupES which use the Regex function to embed the wild character and make sure that the query is in the format elastic search requires. An extension, ApplyReplaceToQueryToSupES_Ext, is provided to enable clients ease in extending this rule based on a client’s requirements.

   

2. Response Mapping

   The MapESResponseToPage handles the response to enable it to be mapped to the page ESResponse of type PegaHC-Int-ElasticSearch-Response. This enables the process to iterate over it to find the dupe data. An extension MapESResponseToPage_Ext is available to support extensions needed by a client.

   

3. Connect Rest

   The data page is sourced by two connect-rests processes, HitDataRepository and HitWorkRepository. The DataIndex parameter TypeOfData is used to identify which process is utilized. HitWorkRepository is configured to hit the work elastic search and HitDataRepository is configured to hit the data elastic search as mentioned in the elastic search configuration.

   

   Duplicate claim edits logic for Professional Chargeable claim type.

   

   Duplicate claim edits logic for Inpatient Chargeable claim.

   

   Duplicate claim edits logic for Outpatient Chargeable claim.

   

   Smart Claims Engine for Healthcare application uses an elastic search query against the member’s claims to identify if either an exact or a suspect duplicate claim is identified.

   Currently Smart Claims Engine for Healthcare sets six types of pends for duplicate claim edit:

   • Exact Duplicate Claim Edit – Event code SBA-0006

     (When an Exact Duplicate claim is found in the system)

   • Possible Duplicate Claim Edit – Event code SBA-0007

     (When a Possible Duplicate claim is found in the system)

   • Exact Duplicate Claim Line History Edit – Event code SBA-0008

     (When an Exact Duplicate Claim Line is found against historical claims)

   • Possible Duplicate Claim Line History Edit – Event code SBA-0009

     (When a Possible Duplicate Claim Line is found against historical claims)

   • Exact Duplicate within Claim Lines Edit – Event code SBA-0010

     (When an Exact Duplicate line is found within the current claim lines)

   • Possible Duplicate within Claim Lines Edit – Event code SBA-0011

     (When a Possible Duplicate line is found within the current claim lines)

• Claims business audits