Pega Smart Claims Engine for Healthcare processes medical and dental claims from intake through finalization, and supports processing chargeable, reporting, and Medicaid reclamation claims. Pega Smart Claims Engine for Healthcare also supports adjustments, splitting claim lines, workbasket routing, claim status updates, balancing, and surcharges, all on a flexible orchestration platform. The following capabilities allow the claims processing engine to integrate seamlessly within the healthcare payer's technology and existing application environment:

• Fully ICD-10 compliant, Pega Smart Claims Engine for Healthcare architecture is built on industry standard databases. The platform uses business process management, case management, and workflow technologies.
• Standards-based integration unites Pega processes with enterprise systems to maximize existing investments and reduce data inconsistencies and replication.
• Standalone, modular, or cloud implementations provide the flexibility to fit an implementation within your organization's technology infrastructure.
• Rules-driven controls define how each processing step is managed internally and called from external sources.

Pega Smart Claims Engine for Healthcare uses Pega Foundation for Healthcare, which contains a rich set of standard-based healthcare data models such as x12, HL7, ICD, and HIPAA compliance rules. This layer functions as the backbone of the system and enables integration with other systems.

• Purpose of this guide
• Prerequisites
• What is already set up
• Basics of the application
• Core Configuration
• Security
• Transactions
• Interfaces
• Pega Healthcare API
• Queue processor
• Action codes
• Random audit configuration
• Event code management
• Modules, Sequences, and Orchestrations
• Benefit determination
• Business edits
• Claims business audits
• Incentives and payments
• Coverages, accumulators, and payment
• Process Authorizations
• Third-party Liability (TPL) edits
• Claims finalization
• Late Payment Interest
• User experience hot keys in Smart Claims Engine
• Benefit Limit Accumulator Processing
• Claims Inquiry
• Manual split claim processing