The member co-pay for an unplanned readmission may be waived, based on a user-defined look-back period configured in the Application configuration page (the Pega-provided default is 48 hours).

The intent of the WPC action code is to trigger the waiving of member co-payment for the claim determined to represent a hospital readmission. This should be a default action, so that when a user completes the line-level pricing for a readmission, the member’s co-pay for that claim is automatically waived. However, if the user elects not to reprice the claim (e.g., selects override, no action required, etc.), the waiver will be removed, and the co-pay will be applied.

When the co-pay is waived, Smart Claims Engine for Healthcare sets a $0.00 in the member co-pay field in the claim line Execution results UI, and displays a note in the Claims history.

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