Pega Smart Claims Engine for Healthcare can import specific claim files in XML format and process them through the adjudication flow. The types of files that can be processed are:
- Professional Healthcare Claims (837P)
- Institutional Healthcare Claims (837I)
- Dental Healthcare Claims (837D)
Claims for import must be complete and well-formed XML that conforms to the ACS X12 XML format.
You can drop claims for import into a specified file location at any time of the day. A file listener recognizes the arrival of the file, reads it, and processes it into a claim work object, which is placed into the backlog with a status of New. A scheduled agent processes the new claims at a defined interval, usually daily, off-hours, so as not to impact normal activity in the application.