The Smart Claims Engine provides a model that enables modules to be bypassed based on specific criteria. For example: event code, action code, payer ID, and claim type. In the module configuration a bypass decision table is identified, which is then referenced at the beginning of the execution of each module. A claim that matches the fields on the module bypass table will subsequently cause that module to be skipped. The return value or row on the module bypass table will be listed in the audit trail for the module being bypassed.

A global bypass table is also available for configurations that need to be used to skip all modules. This global bypass table is useful to manage situations where executing subsequent modules maybe problematic or not required. For example: member not found, provider not found, system configuration events.

The module bypass creates efficiencies in the system when specific event codes have set that need to be resolved before the claim can adjudicate further, or can be applied to skip based on a client contract, external integration rules, etc. The configurations for module bypass are managed through the business analyst portal by selecting module bypass in the configuration menu.

To access or modify the decision table controlling each module select the associated gear icon. The displays the decision table which can then be viewed or modified. To modify the decision table, use the check-out button and then follow the Pega development process for modifying, saving, and checking in rules.

The following properties are included as columns in the conditions section of the supplied module decision tables:

• Payer ID
• Plan/Product ID
• Claim Media Type
• Claim Type
• Claim Submission Type
• Claims Identifier
• Action Code
• Event Code

Modules that are bypassed during the processing of the claim will appear in grey on the visualization screen and the row causing the bypass logged in the claim process log and module audit text.

• Overview