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Planned admission types

Updated on April 26, 2021

When determining whether the current claim represents a planned admission, Smart Claims Engine for Healthcare directs the claim into 1 of 3 categories, or branches, for further review based on the diagnoses found on the claim. The 3 categories of planned admissions are:

  • Total hip and total knee arthroplasty
  • Stroke
  • General population

Smart Claims Engine for Healthcare executes the following workflow leveraging the Ce_PlannedAdmissionCriteria decision table to drive the claim into the correct category or branch for review.

From the selected category, a discrete algorithm is executed in order to determine whether the claim will ultimately be excluded from further consideration as an unplanned readmission.

Note: Smart Claims Engine for Healthcare supports the General Population workflow using a discrete algorithm discussed below. The algorithms required to support the execution of the THA/TKA, and Stroke workflows may be developed on extension.

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