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.

• Overview