Pega Smart Claims Engine for Healthcare does price validations at the line level, using the CE_FinalizationPricing module. This module contains multiple collections.

The CE_PriceLines collection validates the pricing on a given claim.

The CE_Pricelines collection begins by checking if the billed amount is less than the calculated amount. If it is true, then the calculated allowed amount is added to the total billed amount charged at the line level. The system then checks if the claim is COB or Medicaid, after which it checks for an encounter claim.

The CE_PriceLines collection is shown below.

The CE_COBOrMedicaidReclaimation collection checks if the claim is a COB claim by checking if the payment is received from the other payer at the line level. If the payment is received, Smart Claims Engine for Healthcare checks if the claim is Medicaid Reclamation claim (Claim Identifier 31). If it is, Smart Claims Engine for Healthcare enters the reclamation process. Otherwise, Smart Claims Engine for Healthcare enters the COB process.

The CE_COBOrMedicaidReclamation and CE_MedicaidReclamationProcess collections are shown below.

The CE_MedicaidReclamationProcess flow is shown below.

The CE_SetAllowed Adjustments sets the calculated allowed amount to the other payer paid amount. A Claim Adjustment Reason Code (CARC) code 23 with the difference of the billed amount and the original allowed amount is displayed on the claim as well.

The CE_COBProcess supports two COB payment models. The Member Liability COB method pays only the remaining member liability for the claim, reducing the calculated allowed amount to the amount not covered by the other payer. The Reduced by Other Payer COB method takes the other payer paid amount into consideration, reducing the calculated allowed amount by this amount, which was already paid by the other payer.

The CE_COBProcess_Pay calls the CE_MemberLiabilityLineLevelAdjustment Data Transform, which sets the calculated allowed amount equal to the member liability on the claim, assuming that the patient liability is less than the calculated allowed amount. A CARC Code of 22 with the adjustment amount is displayed on the claim.

The CE_MemberLiabilityLineLevelAdjustment Data Transform is shown below.

The CE_COBProcess_Reduce calls the CE_COBLineLevelAdjustments.

The CE_COBLineLevelAdjustment checks if the other payer payment was greater than the calculated allowed amount in Smart Claims Engine for Healthcare. If this is true, Smart Claims Engine for Healthcare allows nothing or sets the calculated allowed amount to 0. If the other payment is less than what was calculated by Smart Claims Engine for Healthcare, then Smart Claims Engine for Healthcare pays the difference. The calculated allowed amount is set to the calculated allowed amount – other payer paid amount.

The CE_COBLineLevelAdjustment is shown below.

• Pega Smart Claims Engine Implementation Guide