Pega Smart Claims Engine for Healthcare Data Model Overview
- Application overview
- Data types
- Orchestration Configuration
- Plan
- Policy
- Accumulators - Detail (Benefits)
- Provider
- Subscriber (Policy Holder)
- Accumulators - Header (Benefits)
- Authorization details
- Claim data
- Business entity
- PTP edit
- Claim API
- ClaimHeader
- Claim Adjustment Reason Codes
- Hospital- Readmission planned diagnosis
- ClaimLine
- Code Sets
- Event Codes
- Network
- Member
- Payer
- MUE edit
- Hospital- Readmission acute diagnosis
- Case types
Application overview
Pega Smart Claims Engine (SCE) : The Pega Smart Claims Engine (SCE) is an application designed to orchestrate all of the processes required for the adjudication of healthcare claims. This application is intended to be extensible by the customer and can leverage external components as necessary.
Pega’s Smart Claims Engine for HealthCare helps you address below key tenets driving Pega Smart Claims Engine for HealthCare excellence.
- Member Selection
- Provider Selection
- Claims Processing
- Interfaces
- Coordination of Benefits
- Claims Payment
- Application Configuration
- Claims Operations
- Claims Pricing
- Authorization Pricing
- Business Edits and Audits
- Benefit Adjudication
- Episode and Related Claims
- Accumulator Management
Data types
Pega Smart Claims Engine for HealthCare uses various data types to manage different set of information in the application. Some of the data types expect data to be sourced from an external system of record. The following section provides the list of data types used in the Pega Smart Claims Engine for HealthCare and their systems of record. Along with that it also lists the relationship between various data types in Pega Smart Claims Engine for HealthCare.
Data type: Orchestration Configuration
The pegahc-data-configuration data class consist of all the system level / global level configuration information need to adjudicate Claim. Application Configuration, module configuration and claim edit configuration for duplicates and dental predetermination is captured under this class.
Class name: pegahc-data-configuration
| Systems of record: |
| No systems of record |
| Referenced by | References |
| None | None |
| Fields: | |
| No fields | |
Data type: Plan
PegaHC-Data-Plan consist of plan information related to a member. Plan information such as plan effective date and end date, plan COB eligibility, COB savings, line of business, Limits (deductible, lifetime max, annual max) etc is captured in this call which helps with benefit claim adjudication.
Class name: PegaHC-Data-Plan
| Systems of record: |
| PlanBenefits, PlanBenefits REST, Pega Database |
| Referenced by | References |
| None | • Network |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| TempSubscriberName |
| ||||
| CoverageLevel |
| ||||
| Effective date |
| ||||
| End date |
| ||||
| Medicare plan code |
| ||||
| NetworksList |
| ||||
| AdditionalLimitations |
| ||||
| COBCalculationMethod |
| ||||
| COBSavingsEligible |
| ||||
| COBSavingsMax |
| ||||
| CostShare |
| ||||
| Grandfathered |
| ||||
| Limits |
| ||||
| LineOfBusiness |
| ||||
| Logos |
| ||||
| MarketSegment |
| ||||
| OtherID |
| ||||
| Other Names |
| ||||
| ParentID |
| ||||
| PlanAttributes |
| ||||
| PlanDedProratable |
| ||||
| Plan name |
| ||||
| QHP |
| ||||
| StopLossAmount |
| ||||
| URLs |
| ||||
| Product availability |
| ||||
| BeginPrimaryCareCost-SharingAfterASetNumberOfVisits |
| ||||
| BeginPrimaryCareDeductibleOrCoinsuranceAfterASetNumberOfCopays |
| ||||
| Product benefit |
| ||||
| Product benefit group |
| ||||
| Product category |
| ||||
| Product certification condition indicator |
| ||||
| Child-Only Offering |
| ||||
| Child Only Plan ID |
| ||||
| Product claim cost per member per month |
| ||||
| Product coinsurance |
| ||||
| Product co insurance out of network |
| ||||
| CompositeRating |
| ||||
| CreateProduct |
| ||||
| Product dependent eligibility age max |
| ||||
| Disease Management Programs Offered |
| ||||
| EHB Apportionment for Pediatric Dental |
| ||||
| EHBTotalPremium |
| ||||
| Product family deductible |
| ||||
| Product family deductible multiplier |
| ||||
| Product family deductible multiplier out of network |
| ||||
| Product family deductible out of network |
| ||||
| Product family out-of-pocket maximum |
| ||||
| Product family out-of-pocket maximum multiplier |
| ||||
| Product family out-of-pocket maximum multiplier OON |
| ||||
| Product family out-of-pocket maximum out of network |
| ||||
| FormularyID |
| ||||
| Product group size high |
| ||||
| GuaranteedVsEstimated Rate |
| ||||
| HIOSProductID |
| ||||
| HPID |
| ||||
| HSA Eligible |
| ||||
| HSA/HRA Employer Contribution |
| ||||
| HSA/HRA Employer Contribution Amount |
| ||||
| Product individual deductible |
| ||||
| Product individual deductible out of network |
| ||||
| Product individual out-of-pocket maximum |
| ||||
| Product individual out-of-pocket maximum out of network |
| ||||
| Product insurance line code |
| ||||
| Is a Referral Required for Specialist |
| ||||
| Product life time max |
| ||||
| Product life time max out of network |
| ||||
| Limited Cost Sharing Plan Variation - Est Advanced Payment |
| ||||
| Product maximum group size |
| ||||
| MaxNoOfDaysForChargingAnInpatientCopay |
| ||||
| Product member out-of-pocket |
| ||||
| Metal Level |
| ||||
| National Network |
| ||||
| Product network restriction |
| ||||
| Networks |
| ||||
| NewOrExisting Plan |
| ||||
| NoticeForPregnancy |
| ||||
| Product office visit copay |
| ||||
| Office visit copay out of network |
| ||||
| Out of Country Coverage |
| ||||
| Out of Country Coverage Description |
| ||||
| Product out of network indicator |
| ||||
| Out of Service Area Coverage |
| ||||
| Out of Service Area Coverage Description |
| ||||
| Product primary care physician required |
| ||||
| Product performance flag |
| ||||
| Plan Brochure |
| ||||
| PlanCostShares |
| ||||
| Product plan coverage description |
| ||||
| Plan Level Exclusions |
| ||||
| Product plan number |
| ||||
| Product list |
| ||||
| Product plan number |
| ||||
| QHPOrNonQHP |
| ||||
| Product rate effective date |
| ||||
| Product rate term date |
| ||||
| ServiceAreas |
| ||||
| Product short description |
| ||||
| Specialist(s) Requiring a Referral |
| ||||
| Product student eligibility age maximum |
| ||||
| Tobacco Wellness Program Offered |
| ||||
| UniquePlanDesign |
| ||||
| URL for Enrollment Payment |
| ||||
| URL for Summary of BenefitsAndCoverage |
| ||||
| Product value statement |
| ||||
| Source |
| ||||
| Product name |
| ||||
| Plan ID |
| ||||
Data type: Policy
The Membership Policy Data Class holds membership data specifically related to the policies held by the member. Medical Policy is contract that defines medical benefits available to subscriber as long as premium is being paid.
Class name: PegaHC-Data-Policy
| Systems of record: |
| Member REST, Pega Database, Member |
| Referenced by | References |
• Member | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| Service insurance type code |
| |||
| Policy benefit coverage level code |
| |||
| Policy contract ID |
| |||
| Policy effective date |
| |||
| Policy plan number |
| |||
| Policy number |
| |||
| Policy term date |
| |||
| Source |
| |||
| MembersPerPolicy |
| |||
| NumberOfPlans |
| |||
| PlanKey |
| |||
Data type: Accumulators - Detail (Benefits)
The PegaHC-Data-Accumulators-Header and PegaHC-Data-Accumulators-Detail consist of all the Accumulator information for a specific member. This information is looked at (and validated against) during claim adjudication to calculate the final approved amount and member responsibility. Claim and Claim Line information which counts towards an accumulator are held under this Class.
Class name: PegaHC-Data-Accumulators-Detail
| Systems of record: |
| Pega Database |
| Referenced by | References |
| • Accumulators - Header (Benefits) | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| ErrorCode |
| |||
| ErrorDescription |
| |||
| HRef |
| |||
| ResourceSettings |
| |||
| AccumulatorID |
| |||
| ClaimLine |
| |||
| CurrentValue |
| |||
| Delta |
| |||
| ExternalSystem |
| |||
| ForeignKey |
| |||
| LimitMax |
| |||
| PreviousValue |
| |||
| ServiceDate |
| |||
| Address |
| |||
| Adjudication Date |
| |||
| Allow delete |
| |||
| Payment allowed amount |
| |||
| Amount qualifier code |
| |||
| Test code |
| |||
| County |
| |||
| CustomID |
| |||
Data type: Provider
PegaHC Provider data Class holds provider data as it is utilized within the application. Provider in pega is any entity that provides medical service such as Doctor, nurse, hospitals, diagnostic labs. Information such as the provider Tax ID, provider first name and last name, Medicare and Medicaid ID, state license number, NPI etc is captured under this data type.
Class name: PegaHC-Data-Party-Provider
| Systems of record: |
| SCE, Provider REST, Pega Database, Provider |
| Referenced by | References |
| None |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| DEAList |
| ||||
| Languages |
| ||||
| Party account number |
| ||||
| Party additional name |
| ||||
| Party address line 1 |
| ||||
| Party address line 2 |
| ||||
| Party age |
| ||||
| Party bank account number |
| ||||
| Party bank identifier number |
| ||||
| Party contact |
| ||||
| Party contact function code |
| ||||
| Party entity identifier code |
| ||||
| Party flow type |
| ||||
| Party group name |
| ||||
| Party group number |
| ||||
| Party hierarchical child code |
| ||||
| Party hierarchical ID number |
| ||||
| Party hierarchical level code |
| ||||
| Hierarchical parent identifier number |
| ||||
| Party identification code |
| ||||
| Party identification code qualifier |
| ||||
| Party individual identifier |
| ||||
| Party middle name |
| ||||
| Party new taxonomy code |
| ||||
| Primary contact |
| ||||
| Board Certifications |
| ||||
| Provider credentialed specialties |
| ||||
| Provider date of birth |
| ||||
| Provider effective date |
| ||||
| Provider end date |
| ||||
| Provider federal tax ID |
| ||||
| Provider gender |
| ||||
| Provider license and state |
| ||||
| Provider maintenance reason code |
| ||||
| Provider medicaid number and state |
| ||||
| Provider medicare number |
| ||||
| Provider medicare number effective date |
| ||||
| Provider medicare number end date |
| ||||
| Military Duty |
| ||||
| Provider national provider identifier type |
| ||||
| Other Certifications |
| ||||
| OtherInformation |
| ||||
| Provider payment code |
| ||||
| Provider affiliations |
| ||||
| First Name |
| ||||
| Last Name |
| ||||
| Payer identifier |
| ||||
| Provider social security number |
| ||||
| Provider type |
| ||||
| Party receiving DFI identifier |
| ||||
| Party secondary identifier |
| ||||
| Party first name - uppercase |
| ||||
| Party last name - uppercase |
| ||||
| Source |
| ||||
| Status of the data instance |
| ||||
| EntityTypeQualifier |
| ||||
| HospitalAdmittingPrivileges |
| ||||
| Title |
| ||||
| Name Suffix |
| ||||
| Provider National Provider Identifier |
| ||||
| Party date of death |
| ||||
| Party priority note |
| ||||
| Member identifier |
| ||||
Data type: Subscriber (Policy Holder)
The subscriber Policy Data Class holds membership data specifically related to the subscriber of the policy. Subscriber is the person who pays premium for insurance. Subscriber first name, last name, subscriber selected PCP, PCP effective date, PCP end date e.t.c are captured under this data type.
Class name: PegaHC-Data-Party-Subscriber
| Systems of record: |
| SCE, Subscriber, Pega Database |
| Referenced by | References |
| None | • Member |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Party account number |
| ||||
| Party additional name |
| ||||
| Party address line 1 |
| ||||
| Party address line 2 |
| ||||
| Party age |
| ||||
| Party bank account number |
| ||||
| Party bank identifier number |
| ||||
| Party contact |
| ||||
| Party contact function code |
| ||||
| Party date of birth |
| ||||
| Party entity identifier code |
| ||||
| Party flow type |
| ||||
| Party group name |
| ||||
| Party group number |
| ||||
| Party hierarchical child code |
| ||||
| Party hierarchical ID number |
| ||||
| Party hierarchical level code |
| ||||
| Hierarchical parent identifier number |
| ||||
| Party identification code |
| ||||
| Party identification code qualifier |
| ||||
| Party individual identifier |
| ||||
| Party middle name |
| ||||
| Party national provider identifier |
| ||||
| Party new taxonomy code |
| ||||
| PaymentCode |
| ||||
| primary contact |
| ||||
| Party receiving DFI identifier |
| ||||
| Party secondary identifier |
| ||||
| Subscriber first name |
| ||||
| Subscriber individual relationship code |
| ||||
| IRCTest |
| ||||
| Subscriber last name |
| ||||
| Member |
| ||||
| Subscriber member key |
| ||||
| Subscriber member number |
| ||||
| Member reason code |
| ||||
| Subscriber member status |
| ||||
| OldPCP |
| ||||
| OldTermDate |
| ||||
| PCP |
| ||||
| PCPEffectiveDate |
| ||||
| PCPEndDate |
| ||||
| pcp reason code |
| ||||
| Subscriber plan type |
| ||||
| Subscriber policy number |
| ||||
| ProviderName |
| ||||
| TaxonomyCode |
| ||||
| Party first name - uppercase |
| ||||
| Party last name - uppercase |
| ||||
| Source |
| ||||
| EntityTypeQualifier |
| ||||
| Party date of death |
| ||||
| Party priority note |
| ||||
| Member identifier |
| ||||
Data type: Accumulators - Header (Benefits)
The PegaHC-Data-Accumulators-Header and PegaHC-Data-Accumulators-Detail consist of all the Accumulator information for a specific member. This information is looked at (and validated against) during claim adjudication to calculate the final approved amount and member responsibility. Multiple detail level accumulators’ records are associated to an Accumulator.
Class name: PegaHC-Data-Accumulators-Header
| Systems of record: |
| SCE, Pega Database |
| Referenced by | References |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
Data type: Authorization details
The Authorization Data Class holds authorization data as it is created from the Authorization flows. These could be inpatient, Outpatient, Referral or Pharmacy authorizations
Class name: PegaHC-Data-Authorization
| Systems of record: |
| MedicalManagement REST, MedicalManagement, Pega Database |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Authorization decision |
| ||||
| Service action code |
| ||||
| Authorization approved LOS |
| ||||
| Authorization attachments |
| ||||
| Denied date |
| ||||
| Authorization history |
| ||||
| Authorization list |
| ||||
| Authorized amount |
| ||||
| Authorization type |
| ||||
| Authorization certification effective date |
| ||||
| Authorization certification expiration date |
| ||||
| Authorization certification issue date |
| ||||
| Authorization certification number |
| ||||
| Authorization certification type code |
| ||||
| Authorization code category |
| ||||
| Contact Channel |
| ||||
| Create Authorization |
| ||||
| Decision Note |
| ||||
| Authorization delay reason code |
| ||||
| Authorization diagnosis code list |
| ||||
| Authorization drug code list |
| ||||
| Authorization equipment reason description |
| ||||
| Authorization estimated birth date |
| ||||
| Facility |
| ||||
| Authorization facility code qualifier |
| ||||
| Facility ID |
| ||||
| Authorization facility name |
| ||||
| Authorization home health certification period |
| ||||
| Authorization last admission period |
| ||||
| Authorization last menstrual period date |
| ||||
| Authorization last visit date |
| ||||
| Authorization length of stay |
| ||||
| Authorization level of service code |
| ||||
| Authorization requested line of business |
| ||||
| Authorization medicare coverage indicator |
| ||||
| Authorization member |
| ||||
| MemberFirstName |
| ||||
| Authorization member identifier |
| ||||
| MemberLastName |
| ||||
| Authorization member valid |
| ||||
| NegotiatedRate |
| ||||
| Negotiated Rate Frequency |
| ||||
| Authorization nursing home residential status code |
| ||||
| Authorization onset date |
| ||||
| Authorization oxygen delivery system code |
| ||||
| Authorization oxygen equipment type code |
| ||||
| Authorization oxygen use period hour count |
| ||||
| Authorization period count |
| ||||
| Authorization physician contact date |
| ||||
| Authorization physician order date |
| ||||
| Authorization policy number |
| ||||
| Authorization portable oxygen system flow rate |
| ||||
| Authorization prescription end date |
| ||||
| Authorization previous certification identifier |
| ||||
| Authorization procedure |
| ||||
| Authorization procedure code list |
| ||||
| Authorization prognosis code |
| ||||
| Authorization proposed or actual admission date |
| ||||
| Authorization proposed or actual discharge date |
| ||||
| Authorization proposed or actual service date |
| ||||
| Authorization proposed or actual surgery date |
| ||||
| Authorization provider valid |
| ||||
| Authorization referring provider |
| ||||
| Authorization referring provider identifier |
| ||||
| Authorization release of information code |
| ||||
| Authorization request category code |
| ||||
| Authorization request date |
| ||||
| Requester |
| ||||
| Authorization requester employer |
| ||||
| Authorization requester payer |
| ||||
| Authorization requester third-party administrator |
| ||||
| Authorization respiratory therapist order text |
| ||||
| Authorization second surgical opinion indicator |
| ||||
| Service Date |
| ||||
| Authorization service provider |
| ||||
| Authorization service provider identifier |
| ||||
| Authorization service trace number |
| ||||
| Show Diagnosis Error Message |
| ||||
| Authorization skilled nursing facility indicator |
| ||||
| Authorization source file identifier |
| ||||
| Authorization state code |
| ||||
| Authorization submitter |
| ||||
| Authorization subscriber |
| ||||
| Authorization time period qualifier |
| ||||
| Authorization trace assigning entity primary identifier |
| ||||
| Authorization trace assigning entity identifier |
| ||||
| Authorization um guideline description |
| ||||
| Authorization utilization management organization |
| ||||
| Authorization units unused |
| ||||
| Authorization valid member |
| ||||
| Authorization valid request indicator |
| ||||
| Authorization valid requestor |
| ||||
| Authorization valid service provider |
| ||||
| Authorization valid subscriber |
| ||||
| Service accident date |
| ||||
| Service activities permitted code |
| ||||
| Service actual admission date |
| ||||
| Service actual discharge date |
| ||||
| Service acute manifestation date |
| ||||
| Service admission date |
| ||||
| Service admission diagnosis |
| ||||
| Service admission source code |
| ||||
| Service ambulance drop-off |
| ||||
| Service ambulance drop off city |
| ||||
| Service ambulance drop off postal code |
| ||||
| Service ambulance drop off state code |
| ||||
| Service ambulance pickup |
| ||||
| Service ambulance pick up city |
| ||||
| Service ambulance pick up postal code |
| ||||
| Service ambulance pick up state code |
| ||||
| Service ambulance transport code |
| ||||
| Service ambulance transport reason code |
| ||||
| Service ambulance trip destination address |
| ||||
| Service ambulance trip origin address |
| ||||
| Service anesthesia related surgical procedure |
| ||||
| Ambulatory payment classification details |
| ||||
| Approved Place Of Service |
| ||||
| Service arterial blood gas quantity |
| ||||
| Service assessment date |
| ||||
| Service assumed or relinquished care date |
| ||||
| Service authorization reason |
| ||||
| Service authorized service unit count |
| ||||
| Service begin therapy date |
| ||||
| Service benefit amount |
| ||||
| Service benefit begin date |
| ||||
| Service benefit coverage level code |
| ||||
| Service benefit end date |
| ||||
| Service benefit percent |
| ||||
| Service benefit quantity |
| ||||
| Service related causes code |
| ||||
| Service certification condition indicator |
| ||||
| Service certification period projected visit count |
| ||||
Data type: Claim data
The Claim Data Class holds Claims data as it is utilized within the application. Medical and Dental Claim information is captured under this data type. Information such as the Claim adjustment group code, claim adjustment quantity, claim status, claim attachment etc is captured under this data class.
Class name: PegaHC-Data-Claim
| Systems of record: |
| Claims, SCE, Pega Database |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| Country Code |
| |||
| IndividualDeathDate |
| |||
| PatientStatus |
| |||
| Payment repriced allowed amount |
| |||
| Payment repriced approved ambulatory patient group amount |
| |||
| Payment repriced saving amount |
| |||
| Payment repricing per diem or flat rate amount |
| |||
| Authorization decision |
| |||
| Adjusted repriced claim reference number |
| |||
| Claim adjudication or payment date |
| |||
| Claim adjustment quantity |
| |||
| Claim adjustment reason code |
| |||
| Claim admission date format qualifier |
| |||
| Claim admission date time |
| |||
| AdmissionHour |
| |||
| Claim admitting diagnosis |
| |||
| Claim ambulance certification |
| |||
| Claim ambulatory patient group number |
| |||
| Claim assumed or relinquished care date |
| |||
| Claim assumed or relinquished care date qualifier |
| |||
| Claim attachments |
| |||
| Claim attending physician |
| |||
| Claim auto accident state code |
| |||
| Claim benefit assignment certification indicator |
| |||
| Claim bill classification |
| |||
| Claim billing note text |
| |||
| Claim bill type |
| |||
| Claim care plan oversight number |
| |||
| ClaimStatus |
| |||
| Claim adjustment group code |
| |||
| Claim filing indicator code |
| |||
Data type: Business entity
Data Class to hold Business Entity attributes such as NPI, billing address e.t.c.
Class name: PegaHC-Data-Party-BusinessEntity
| Systems of record: |
| Provider REST, Pega Database, Provider |
| Referenced by | References |
| • Business entity |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Party account number |
| ||||
| Party additional name |
| ||||
| Party address line 1 |
| ||||
| Party address line 2 |
| ||||
| Party age |
| ||||
| Party bank account number |
| ||||
| Party bank identifier number |
| ||||
| BankAccountInformation |
| ||||
| Business entity holding contract |
| ||||
| Business entity holding contract ID |
| ||||
| Business entity contract TIN |
| ||||
| Business entity business type |
| ||||
| Business entity contract |
| ||||
| Business entity contract identifier |
| ||||
| Business entity contract name |
| ||||
| CountContracts |
| ||||
| Business entity currency code |
| ||||
| Business entity description |
| ||||
| Business entity end date |
| ||||
| Business entity federal tax identifier |
| ||||
| Business entity active affiliation? |
| ||||
| Business entity active? |
| ||||
| Business entity active contract? |
| ||||
| Business entity contract entity? |
| ||||
| Business entity only contract entity? |
| ||||
| Business entity active provider? |
| ||||
| Business entity line of business |
| ||||
| Business entity locations |
| ||||
| Business entity name |
| ||||
| Business entity national provider identifier |
| ||||
| Business entity practice address |
| ||||
| Business entity primary contact |
| ||||
| Business entity provider code |
| ||||
| ProviderContracts |
| ||||
| Business entity tax identification number |
| ||||
| Business entity tax identifier qualifier |
| ||||
| Business entity versions |
| ||||
| Party contact |
| ||||
| Party contact function code |
| ||||
| Party date of birth |
| ||||
| Party entity identifier code |
| ||||
| Party flow type |
| ||||
| Party group name |
| ||||
| Party group number |
| ||||
| Party hierarchical child code |
| ||||
| Party hierarchical ID number |
| ||||
| Party hierarchical level code |
| ||||
| Hierarchical parent identifier number |
| ||||
| Party identification code |
| ||||
| Party identification code qualifier |
| ||||
| Party individual identifier |
| ||||
| Party middle name |
| ||||
| Party new taxonomy code |
| ||||
| PaymentCode |
| ||||
| Party receiving DFI identifier |
| ||||
| Party secondary identifier |
| ||||
| Party first name - uppercase |
| ||||
| Party last name - uppercase |
| ||||
| Source |
| ||||
| EntityTypeQualifier |
| ||||
| Party date of death |
| ||||
| Business entity effective date |
| ||||
| Party priority note |
| ||||
| Member identifier |
| ||||
Data type: PTP edit
The PegaHC-Data-PPECCI consist of the NCCI procedure-to-procedure (PTP) edits which define pairs of Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes that should not be reported together for a variety of reasons. The purpose of these PTP edits is to prevent improper payments when incorrect code combinations are reported.
Class name: PegaHC-Data-PPECCI
| Systems of record: |
| Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| Source |
| |||
| Column 1 |
| |||
| Column2 |
| |||
| DeletionDate |
| |||
| ModifierIndicator |
| |||
| PTPRationale |
| |||
Data type: Claim API
This data type captures the information need for Integration Class to hold claim related data.
Class name: PegaHC-Int-Claim
| Systems of record: |
| No systems of record |
| Referenced by | References |
| None |
| Fields: | |||||
| ClaimHeader |
| ||||
| ClaimLine |
| ||||
| claimOrEncounterIdentifier |
| ||||
| claimSubmissionType |
| ||||
| claimType |
| ||||
| claimTypeCode |
| ||||
| EDITransaction |
| ||||
| interChangeControlNumber |
| ||||
| mediaType |
| ||||
| orchestrationName |
| ||||
Data type: ClaimHeader
PegaHC-Int-ClaimHeader consist of Header Level Claim information. Medical and Dental Claim header information is captured. This class refers is associated with multiple Claim Line Level information.
Class name: PegaHC-Int-ClaimHeader
| Systems of record: |
| No systems of record |
| Referenced by | References |
| • Claim API | None |
| Fields: | |||||
| accidentCountry |
| ||||
| accidentDate |
| ||||
| acuteManifestationDate |
| ||||
| adjustedRepricedClaimID |
| ||||
| admissionDate |
| ||||
| admissionDateFormatQualifier |
| ||||
| admissionDateTime |
| ||||
| admissionHour |
| ||||
| admissionIndicator |
| ||||
| admissionSource |
| ||||
| admissionType |
| ||||
| admittingDiagnosis |
| ||||
| ambulance |
| ||||
| anesthesiaRelatedSurgicalProcedure |
| ||||
| assumedOrRelinquishedCareDate |
| ||||
| assumedOrRelinquishedCareDateQualifier |
| ||||
| Attachment Report Type Code |
| ||||
| Attachments |
| ||||
| Attachment Transmission Code |
| ||||
| attendingProvider |
| ||||
| autoAccidentState |
| ||||
| benefitAssignment |
| ||||
| billClassification |
| ||||
| billingNoteText |
| ||||
| billingProvider |
| ||||
| billType |
| ||||
| carePlanOversightID |
| ||||
| claimFrequencyCode |
| ||||
| claimID |
| ||||
| Claim Note Text |
| ||||
| claimStatus |
| ||||
| claimStatusDate |
| ||||
| claimSubmissionType |
| ||||
| claimType |
| ||||
| CLIANumber |
| ||||
| COB |
| ||||
| conditionAdditionalDescriptionPatient |
| ||||
| conditionCode |
| ||||
| conditionDescriptionPatient |
| ||||
| conditionInfo |
| ||||
| conditionInformation |
| ||||
| contractCode |
| ||||
| contractInformation |
| ||||
| costReportDayCount |
| ||||
| coveredDays |
| ||||
| dateTimePeriodFormatQualifier |
| ||||
| delayReasonCode |
| ||||
| demonstrationProjectID |
| ||||
| destinationPayer |
| ||||
| diagnosisCode |
| ||||
| diagnosisDescription |
| ||||
| diagnosisType |
| ||||
| disabilityBegin |
| ||||
| disabilityDateFormatQualifier |
| ||||
| disabilityDateQualifier |
| ||||
| disabilityToDate |
| ||||
| dischargeDateTime |
| ||||
| dischargedDate |
| ||||
| dischargeHour |
| ||||
| DRG |
| ||||
| ECode |
| ||||
| EDITransaction |
| ||||
| EPSDT |
| ||||
| facility |
| ||||
| facilityCodeQualifier |
| ||||
| facilityType |
| ||||
| facilityTypeCode |
| ||||
| firstVisitDate |
| ||||
| fixedFormatInformation |
| ||||
| gracePeriod |
| ||||
| headerStatus |
| ||||
| homeBound |
| ||||
| hospitalizationBeginDate |
| ||||
| hospitalizationEndDate |
| ||||
| ICDType |
| ||||
| imageID |
| ||||
| implementationGuideVersionName |
| ||||
| industryCode |
| ||||
| infoReleaseCode |
| ||||
| initialTreatmentDate |
| ||||
| interChangeControlNumber |
| ||||
| investDeviceExemption |
| ||||
| investDeviceExemptionID |
| ||||
| investDeviceExemptionIDQualifier |
| ||||
| isAutoAccident |
| ||||
| isEmployment |
| ||||
| isOtherAccident |
| ||||
| lastMenstrualPeriod |
| ||||
| lastSeenDate |
| ||||
| lastWorkedDate |
| ||||
| lastXRayDate |
| ||||
| LatePaymentInterestPercent |
| ||||
| lifeTimeReserveDays |
| ||||
| LPIAmount |
| ||||
| LPINumberOfDays |
| ||||
| mammographyCertID |
| ||||
| medicalRecordID |
| ||||
| medicareSection4081Indicator |
| ||||
| member |
| ||||
| Note Reference Code |
| ||||
| Notes |
| ||||
| occurrenceCode |
| ||||
| OperatingProvider |
| ||||
| originatorApplicationTransactionIdentifier |
| ||||
| otherOperatingProvider |
| ||||
| otherProcedure |
| ||||
| outOfStateIndicator |
| ||||
| patient |
| ||||
| patientDateOfBirth |
| ||||
| patientEstimatedAmountDue |
| ||||
| patientFirstName |
| ||||
| patientID |
| ||||
| patientLastName |
| ||||
| patientNumber |
| ||||
| patientSignatureCode |
| ||||
| patientStatus |
| ||||
| patientVisionCondition |
| ||||
| payer |
| ||||
| payerClaimControlID |
| ||||
| payerID |
| ||||
| payment |
| ||||
| payToPayer |
| ||||
| payToProvider |
| ||||
| peerReviewAuthorizationID |
| ||||
| pendCode |
| ||||
| placeOfService |
| ||||
| planID |
| ||||
| policyID |
| ||||
| PPSCode |
| ||||
| PPSCodeType |
| ||||
| predeterminationOfBenefitsCode |
| ||||
| predeterminationOfBenefitsIdentifier |
| ||||
| prescriptionDate |
| ||||
| pricingDetails |
| ||||
| pricingResponses |
| ||||
| primaryDiagnosis |
| ||||
| principalDiagnosis |
| ||||
| principalDiagnosisInfo |
| ||||
| principalProcedureDateFormat |
| ||||
| principalProcedureInformation |
| ||||
| principleProcedure |
| ||||
| principleProcedureDate |
| ||||
| priorAuthorization |
| ||||
| procedureCode |
| ||||
| procedureType |
| ||||
| processStatus |
| ||||
| providerAcceptsAssignment |
| ||||
| providerID |
| ||||
| providerSignature |
| ||||
| reasonForVisit |
| ||||
| receivedDate |
| ||||
| referralID |
| ||||
| referringProvider |
| ||||
| refPatientID |
| ||||
| Related Causes Code |
| ||||
| renderingProvider |
| ||||
| reprice |
| ||||
| repricedClaimNo |
| ||||
| repricerReceivedDate |
| ||||
| returnToWorkDate |
| ||||
| serviceAuthorizationException |
| ||||
| serviceDate |
| ||||
| serviceDateTimePeriodFormatQualifier |
| ||||
| serviceEndDate |
| ||||
| serviceFacility |
| ||||
| serviceFromDate |
| ||||
| similarSymptomsDate |
| ||||
| specialProgramCode |
| ||||
| spinalManipulationPatCondCode |
| ||||
| submitter |
| ||||
| submitterName |
| ||||
| submitterNumber |
| ||||
| subscriber |
| ||||
| subscriberDateOfBirth |
| ||||
| subscriberFirstName |
| ||||
| subscriberID |
| ||||
| subscriberLastName |
| ||||
| subscriberPrimaryIdentifier |
| ||||
| supervisingProvider |
| ||||
| surchargeAmount |
| ||||
| surchargeFactor |
| ||||
| termsDiscountPercentage |
| ||||
| timelyFilingDays |
| ||||
| traceNumber |
| ||||
| transactionType |
| ||||
| treatmentCode |
| ||||
| treatmentCodeInfo |
| ||||
| type |
| ||||
| valueAddedNetworkTraceID |
| ||||
| valueCode |
| ||||
| valueInformation |
| ||||
| assistantSurgeon |
| ||||
| orthodonticBandingDate |
| ||||
| orthodonticTreatmentMonthsCount |
| ||||
| orthodonticTreatmentMonthsRemainingCount |
| ||||
| toothStatus |
| ||||
| acrossProvider |
| ||||
| paidAmount |
| ||||
| submittedDate |
| ||||
| totalChargeAmount |
| ||||
Data type: Claim Adjustment Reason Codes
Claim Adjustment Reason Codes (added by wizard) is captured in this Class.
Class name: PegaHealth-Codes-Data-ClaimAdjustmentReason
| Systems of record: |
| Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| CodeSetType |
| |||
| Description from |
| |||
| Description to |
| |||
| Normalized National drug codes package code |
| |||
| Active ingred unit |
| |||
| Active numerator strength |
| |||
| Annotation |
| |||
| Application number |
| |||
| Approximate flag |
| |||
| Category |
| |||
| Category 1 |
| |||
| Category 2 |
| |||
| Category 3 |
| |||
| Category 4 |
| |||
| Category 5 |
| |||
| Choice lists flag |
| |||
| Claim adjustment reason deactivation date |
| |||
| Code |
| |||
| Combination flag |
| |||
| Dea schedule |
| |||
| Description |
| |||
| Disorder |
| |||
| Dosage form name |
| |||
| Effective date |
| |||
| Effective date string |
| |||
| End marketing date |
| |||
| Expiration date |
| |||
| Expiration date string |
| |||
| Full description1 |
| |||
| Full description |
| |||
| Instruction description |
| |||
| Labeler name |
| |||
| Last modified date |
| |||
| Last modified date string |
| |||
| Listing sequence number |
| |||
| Long description |
| |||
| Long description |
| |||
| Marketing category name |
| |||
| Name |
| |||
| National drug codes package code |
| |||
| No map flag |
| |||
| Non proprietary name |
| |||
| Notes |
| |||
| OrderNumber |
| |||
| Package description |
| |||
| Pharm classes |
| |||
| Product id |
| |||
| Product national drug codes |
| |||
| Product type name |
| |||
| Proprietary name |
| |||
| Proprietary name suffix |
| |||
| Route name |
| |||
| Scenario flag |
| |||
| Short description |
| |||
| Source description |
| |||
| Start marketing date |
| |||
| Status |
| |||
| Substance name |
| |||
| Target code |
| |||
| Target description |
| |||
| Type |
| |||
| Validity |
| |||
Data type: Hospital- Readmission planned diagnosis
Readmission-Planned-Daignosis
Class name: PegaHC-Data-ReadmissionPlannedDaignosis
| Systems of record: |
| Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| ErrorCode |
| |||
| ErrorDescription |
| |||
| HRef |
| |||
| ResourceSettings |
| |||
| Address |
| |||
| Adjudication Date |
| |||
| Allow delete |
| |||
| Payment allowed amount |
| |||
| Amount qualifier code |
| |||
| County |
| |||
| CustomID |
| |||
Data type: ClaimLine
PegaHC-Int-ClaimHeader consist of Header Level Claim information. Medical and Dental Claim header information is captured. This class refers is associated with multiple Claim Line Level information. (PegaHC-Int-ClaimLine). It captures of all the fields at the Claim Line Level.
Class name: PegaHC-Int-ClaimLine
| Systems of record: |
| No systems of record |
| Referenced by | References |
| • Claim API | None |
| Fields: | |||||
| adjudicationDate |
| ||||
| adjustedRepricedClaimID |
| ||||
| allowedBasis |
| ||||
| ambulance |
| ||||
| attachments |
| ||||
| attendingProvider |
| ||||
| calculatedAllowedAmount |
| ||||
| capitationFlag |
| ||||
| certificationRevisionDate |
| ||||
| chargeAmount |
| ||||
| claimFeedback |
| ||||
| CLIAFacilityID |
| ||||
| CLIANo |
| ||||
| COB_OtherPayerID |
| ||||
| compositeMedicalProcedureCode |
| ||||
| compositeMedicalProductOrServiceIDQualifier |
| ||||
| contract |
| ||||
| contractInformation |
| ||||
| contractPercentage |
| ||||
| contractVersionIdentifier |
| ||||
| CoPayStatus |
| ||||
| dateTimePeriodFormatQualifier |
| ||||
| DetailStatus |
| ||||
| diagnosisCodes |
| ||||
| DMEAttachmentTransmissionCode |
| ||||
| DMECertificationType |
| ||||
| DMEDuration |
| ||||
| DMEPurchasePrice |
| ||||
| DMERCConditionCod |
| ||||
| DMERCConditionCode |
| ||||
| DMERCConditionIndicator |
| ||||
| DMERentalPrice |
| ||||
| DMEUnitorBasisforMeasurementCode |
| ||||
| drug |
| ||||
| emergencyIndicator |
| ||||
| EPSDTIndicator |
| ||||
| facilityProvider |
| ||||
| facilityTax |
| ||||
| FamilyPlanningIndicator |
| ||||
| fixedFormatInformation |
| ||||
| formIdentification |
| ||||
| hospiceEmployerCondIndicator |
| ||||
| immunizationBatchNo |
| ||||
| initialTreatmentDate |
| ||||
| isNetworkPricingSupressed |
| ||||
| isParticipatingNetwork |
| ||||
| lastCertificationDate |
| ||||
| lastSeenDate |
| ||||
| lastXRayDate |
| ||||
| lengthOfMedicalNecessity |
| ||||
| Line Adjudication |
| ||||
| lineItemControlNumber |
| ||||
| lineNumber |
| ||||
| mammographyCertNo |
| ||||
| measurement |
| ||||
| medicalProductOrServiceIDQualifier |
| ||||
| modifier |
| ||||
| monetaryPayment |
| ||||
| network |
| ||||
| nonCovered |
| ||||
| noteReferenceCode |
| ||||
| notes |
| ||||
| obstetricAnesthsiaAdditionalUnits |
| ||||
| operatingProvider |
| ||||
| orderingProvider |
| ||||
| OtherOperatingProvider |
| ||||
| OtherPayer1ID |
| ||||
| OtherPayer1Paid |
| ||||
| otherPayerpriorAuthNoQualifier |
| ||||
| otherProvider |
| ||||
| outOfStateIndicator |
| ||||
| patientCalculatedAmount |
| ||||
| payment |
| ||||
| placeOfProfessionalServiceCode |
| ||||
| placeOfService |
| ||||
| PostageClaimedAmount |
| ||||
| prescriptionDate |
| ||||
| priAuthReference |
| ||||
| pricingDetails |
| ||||
| primaryCareProvider |
| ||||
| procedureCode |
| ||||
| procedureCodeDescription |
| ||||
| professionalServiceUnitCode |
| ||||
| PurchasedServiceChargeAmount |
| ||||
| purchasedServiceProvider |
| ||||
| PurchasedServiceProviderIdentifier |
| ||||
| quantity |
| ||||
| RARCodes |
| ||||
| RateSheetID |
| ||||
| referralIDQualifier |
| ||||
| referralNo |
| ||||
| referralNoOtherPayerID |
| ||||
| referralNumberList |
| ||||
| referringProvider |
| ||||
| RemainingPatientLiability |
| ||||
| renderingProvider |
| ||||
| rentalUnitPriceIndicator |
| ||||
| repricedClaimLineNumber |
| ||||
| Repricing |
| ||||
| revenueCode |
| ||||
| SalesTax |
| ||||
| serviceDate |
| ||||
| serviceDateTimePeriodFormatQualifier |
| ||||
| serviceEndDate |
| ||||
| serviceFacility |
| ||||
| serviceFromDate |
| ||||
| serviceTax |
| ||||
| serviceToDate |
| ||||
| serviceUnitCount |
| ||||
| servicingState |
| ||||
| shippedDate |
| ||||
| Status |
| ||||
| statusReason |
| ||||
| Supervising Provider |
| ||||
| surchargeAmount |
| ||||
| surchargeFactor |
| ||||
| termsDiscountPercentage |
| ||||
| testDate |
| ||||
| therapyStartDate |
| ||||
| thirdPartyOrganizationNotes |
| ||||
| unit |
| ||||
| Assistant Surgeon |
| ||||
| oralCavityDesignationCode |
| ||||
| orthodonticBandingDate |
| ||||
| priorPlacementDate |
| ||||
| priorPlacementDateTimeQualifier |
| ||||
| prosthesisCrownOrInlayCode |
| ||||
| replacementDate |
| ||||
| servicePredeterminationIdentification |
| ||||
| toothInformation |
| ||||
| treatmentCompletionDate |
| ||||
| treatmentStartDate |
| ||||
Data type: Code Sets
Holds a record in HealthCare_COGP_CodeSet Table
Class name: PegaHealth-Codes-Data-CodeSet
| Systems of record: |
| Pega, Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| BETOSCategory |
| |||
| BETOSID |
| |||
| Code set category |
| |||
| Code set code |
| |||
| Code set code key |
| |||
| Code set code key list |
| |||
| Code set code set type |
| |||
| Code set cogp description |
| |||
| Code set cogp name |
| |||
| Code set end date |
| |||
| Code set mark delete |
| |||
| Code set range key |
| |||
| Code set start date |
| |||
| Description from |
| |||
| Description to |
| |||
| Normalized National drug codes package code |
| |||
| Active ingred unit |
| |||
| Active numerator strength |
| |||
| Annotation |
| |||
| Application number |
| |||
| Approximate flag |
| |||
| Category 1 |
| |||
| Category 2 |
| |||
| Category 3 |
| |||
| Category 4 |
| |||
| Category 5 |
| |||
| Choice lists flag |
| |||
| Combination flag |
| |||
| Dea schedule |
| |||
| Description |
| |||
| Disorder |
| |||
| Dosage form name |
| |||
| Effective date |
| |||
| Effective date string |
| |||
| End marketing date |
| |||
| Expiration date |
| |||
| Expiration date string |
| |||
| Full description1 |
| |||
| Full description |
| |||
| Instruction description |
| |||
| Labeler name |
| |||
| Last modified date |
| |||
| Last modified date string |
| |||
| Listing sequence number |
| |||
| Long description |
| |||
| Long description |
| |||
| Marketing category name |
| |||
| Name |
| |||
| National drug codes package code |
| |||
| No map flag |
| |||
| Non proprietary name |
| |||
| Notes |
| |||
| OrderNumber |
| |||
| Package description |
| |||
| Pharm classes |
| |||
| Product id |
| |||
| Product national drug codes |
| |||
| Product type name |
| |||
| Proprietary name |
| |||
| Proprietary name suffix |
| |||
| Route name |
| |||
| Scenario flag |
| |||
| Short description |
| |||
| Source description |
| |||
| Start marketing date |
| |||
| Status |
| |||
| Substance name |
| |||
| Target code |
| |||
| Target description |
| |||
| Type |
| |||
| Validity |
| |||
Data type: Event Codes
This data type consist of all the information need to capture Event codes / event code edits.
Class name: PegaHealth-Codes-Data-Event
| Systems of record: |
| SCE, Pega, Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| CodeSetType |
| |||
| Description from |
| |||
| Description to |
| |||
| Normalized National drug codes package code |
| |||
| Active ingred unit |
| |||
| Active numerator strength |
| |||
| Annotation |
| |||
| Application number |
| |||
| Approximate flag |
| |||
| Category |
| |||
| Category 1 |
| |||
| Category 2 |
| |||
| Category 3 |
| |||
| Category 4 |
| |||
| Category 5 |
| |||
| Choice lists flag |
| |||
| Code |
| |||
| Combination flag |
| |||
| Dea schedule |
| |||
| Disorder |
| |||
| Dosage form name |
| |||
| Effective date string |
| |||
| End marketing date |
| |||
| Description |
| |||
| ImplementationID |
| |||
| Expiration date |
| |||
| Expiration date string |
| |||
| Full description1 |
| |||
| Full description |
| |||
| Instruction description |
| |||
| Labeler name |
| |||
| Last modified date |
| |||
| Last modified date string |
| |||
| Listing sequence number |
| |||
| Long description |
| |||
| Long description |
| |||
| Marketing category name |
| |||
| Name |
| |||
| National drug codes package code |
| |||
| No map flag |
| |||
| Non proprietary name |
| |||
| Notes |
| |||
| OrderNumber |
| |||
| Package description |
| |||
| Pharm classes |
| |||
| Product id |
| |||
| Product national drug codes |
| |||
| Product type name |
| |||
| Proprietary name |
| |||
| Proprietary name suffix |
| |||
| Route name |
| |||
| Scenario flag |
| |||
| Short description |
| |||
| Source description |
| |||
| Start marketing date |
| |||
| Status |
| |||
| Substance name |
| |||
| Target code |
| |||
| Target description |
| |||
| Type |
| |||
| Validity |
| |||
| Effective date |
| |||
Data type: Network
This class captures all the information Network information.
Class name: PegaHC-Data-Network
| Systems of record: |
| SCE, Provider REST, Pega Database, Provider |
| Referenced by | References |
| • Plan | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| Effective date |
| |||
| End date |
| |||
| Network name |
| |||
| Network identifier |
| |||
| NetworkURL |
| |||
| NWTaxonomy |
| |||
| Network practitioner type |
| |||
| Products |
| |||
| ServiceArea |
| |||
| Network status |
| |||
| Network type of network |
| |||
| Source |
| |||
Data type: Member
This class records granular member and patient information such as name, address, age, citizenship code, communication preference, diability, vip flag indicators and contact information. This class is used in conjunction with the Contact class in healthcare implementations.
Class name: PegaHC-Data-Party-Member
| Systems of record: |
| Member REST, Pega Database, Member |
| Referenced by | References |
| • Policy |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Employee |
| ||||
| VIP |
| ||||
| Payer identifier |
| ||||
| Party address line 1 |
| ||||
| Party address line 2 |
| ||||
| Party bank account number |
| ||||
| Party bank identifier number |
| ||||
| Party contact |
| ||||
| Party contact function code |
| ||||
| Party date of birth |
| ||||
| Party entity identifier code |
| ||||
| Party flow type |
| ||||
| Party group name |
| ||||
| Party hierarchical child code |
| ||||
| Party hierarchical ID number |
| ||||
| Party hierarchical level code |
| ||||
| Hierarchical parent identifier number |
| ||||
| Party identification code |
| ||||
| Party identification code qualifier |
| ||||
| Party individual identifier |
| ||||
| Member account number |
| ||||
| Member additional name |
| ||||
| Member address |
| ||||
| Member age |
| ||||
| Member birth sequence number |
| ||||
| Member citizenship status code |
| ||||
| Member communication |
| ||||
| Member disability |
| ||||
| Employment |
| ||||
| Member gender code |
| ||||
| Member group number |
| ||||
| Guardian |
| ||||
| Guardian List |
| ||||
| Member height |
| ||||
| Languages |
| ||||
| Member identifier |
| ||||
| Member policy |
| ||||
| Member middle name |
| ||||
| Member name prefix |
| ||||
| Number Of Children |
| ||||
| Member pregnancy indicator |
| ||||
| Member previous names |
| ||||
| Member privacy restricted |
| ||||
| pyFirstName |
| ||||
| pyLastName |
| ||||
| Member race or ethnicity code |
| ||||
| School |
| ||||
Data type: Payer
This Claim captures the Payer information.
Class name: PegaHC-Data-Party-Payer
| Systems of record: |
| Operations REST, Pega Database, Operations |
| Referenced by | References |
| None |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Payer identifier |
| ||||
| Languages |
| ||||
| Party account number |
| ||||
| Party address line 1 |
| ||||
| Party address line 2 |
| ||||
| Party age |
| ||||
| Party bank account number |
| ||||
| Party bank identifier number |
| ||||
| Party contact |
| ||||
| Party contact function code |
| ||||
| Party date of birth |
| ||||
| Party entity identifier code |
| ||||
| Party flow type |
| ||||
| Party group name |
| ||||
| Party group number |
| ||||
| Party hierarchical child code |
| ||||
| Party hierarchical ID number |
| ||||
| Party hierarchical level code |
| ||||
| Hierarchical parent identifier number |
| ||||
| Party identification code |
| ||||
| Party identification code qualifier |
| ||||
| Party individual identifier |
| ||||
| Party middle name |
| ||||
| Party national provider identifier |
| ||||
| Party new taxonomy code |
| ||||
| Payer additional name |
| ||||
| Payer address |
| ||||
| Payer federal tax identifier |
| ||||
| Payer national plan identifier |
| ||||
| Payer name |
| ||||
| PaymentCode |
| ||||
| primary contact |
| ||||
| Party receiving DFI identifier |
| ||||
| Party secondary identifier |
| ||||
| Party first name - uppercase |
| ||||
| Party last name - uppercase |
| ||||
| Source |
| ||||
| EntityTypeQualifier |
| ||||
| Party date of death |
| ||||
| Party priority note |
| ||||
| Member identifier |
| ||||
Data type: MUE edit
PegaHC-Data-PPEMUE consist of the MUE edit information which help reduce the paid claims error rate for Part B claims. MUE edits for a HCPCS / CPT code also help detect the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.
Class name: PegaHC-Data-PPEMUE
| Systems of record: |
| Pega Database |
| Fields: | |||||
| Commit DateTime |
| ||||
| Create Date/Time |
| ||||
| Create Operator |
| ||||
| Create System ID |
| ||||
| Save DateTime |
| ||||
| Update Time |
| ||||
| Update Operator |
| ||||
| Update operator name |
| ||||
| Update System ID |
| ||||
| Create operator name |
| ||||
| Source |
| ||||
| AdjudicationIndicator |
| ||||
| Code |
| ||||
| MUECodes |
| ||||
| MUERationale |
| ||||
| NumberOfUnits |
| ||||
| SourceUploadFile |
| ||||
Data type: Hospital- Readmission acute diagnosis
Readmission-Acute-Diagnosis
Class name: PegaHC-Data-ReadmissionAcuteDiagnosis
| Systems of record: |
| Pega Database |
| Referenced by | References |
| None | None |
| Fields: | ||||
| Commit DateTime |
| |||
| Create Date/Time |
| |||
| Create Operator |
| |||
| Create System ID |
| |||
| Save DateTime |
| |||
| Update Time |
| |||
| Update Operator |
| |||
| Update operator name |
| |||
| Update System ID |
| |||
| Create operator name |
| |||
| ErrorCode |
| |||
| ErrorDescription |
| |||
| HRef |
| |||
| ResourceSettings |
| |||
| Address |
| |||
| Adjudication Date |
| |||
| Allow delete |
| |||
| Payment allowed amount |
| |||
| Amount qualifier code |
| |||
| County |
| |||
| CustomID |
| |||
Case types
3 Case types
This section lists the standard Case Types available with Pega Smart Claims Engine for HealthCare.
Case type: Claims Work Object
This is the data structure associated with a healthcare claim that is processed within the application. The data structure incorporates healthcare service information, for example member, provider and diagnosis information, as well as other ancillary data associated with the claim header.
Class name: PegaHC-CLM-Work-Claims
| Referenced by | References |
| • Test Claim | • Accumulators - Header (Benefits) • Member • Policy • Provider |
| Fields: | ||||||
| Commit DateTime |
| |||||
| Save DateTime |
| |||||
| Update operator name |
| |||||
| Create operator name |
| |||||
| Case ID |
| |||||
| Create date/time |
| |||||
| Update date/time |
| |||||
| Urgency |
| |||||
| Label |
| |||||
| Active channel |
| |||||
| AdjudicationDate |
| |||||
| AuthAccumsToCommit |
| |||||
| BenefitAccumsToCommit |
| |||||
| Claims category |
| |||||
| Claims claim |
| |||||
| Claims claim types |
| |||||
| FinancialAccumsToCommit |
| |||||
| Claims interchange control number (from X12 ISA segment) |
| |||||
| OldReferenceClaimID |
| |||||
| Payer Claim Control Number |
| |||||
| Claims received as X12 |
| |||||
| Claims route group |
| |||||
| Claims workbasket org name |
| |||||
| Claims xml buffer |
| |||||
| ClaimsXtenEvents |
| |||||
| ClaimsXtenPends |
| |||||
| CXTEnableFlag |
| |||||
| CXTHistoryClaims |
| |||||
| CXTPaidFeed |
| |||||
| CXTRequest |
| |||||
| HistoryClaimsData |
| |||||
| IsHistoryQualified |
| |||||
| CE_TimelyFilingFunction |
| |||||
| CE_TimelyFilingOrder |
| |||||
| temp |
| |||||
| TimelyFilingDays |
| |||||
| TimelyFilingLevel |
| |||||
| PricingExecutionSequence |
| |||||
| Action Code WorkBasket |
| |||||
| AdjustmentNote |
| |||||
| AM_Catastrophe |
| |||||
| AM_CatastropheDescription |
| |||||
| AM_CatastropheEffDt |
| |||||
| AM_CatastropheExpDt |
| |||||
| AM_CatastropheID |
| |||||
| AmountAfterInterest |
| |||||
| AdmissionDate |
| |||||
| Claim Frequency Code |
| |||||
| CE_CostShareFlag |
| |||||
| CE_OrchestrationID |
| |||||
| CE_RefContractID |
| |||||
| CE_RefPatientID |
| |||||
| CE_RefPayerID |
| |||||
| CE_RefPolicyID |
| |||||
| CE_RefSubscriberID |
| |||||
| ChangeLogExists |
| |||||
| ClaimComparisonData |
| |||||
| ClaimCondition |
| |||||
| ClaimHeld |
| |||||
| ClaimHoldData |
| |||||
| ClaimHoldDeadLine |
| |||||
| ClaimHoldExpireDate |
| |||||
| ClaimInstInpatient |
| |||||
| ClaimlineAuthInstESList |
| |||||
| ClaimPageList |
| |||||
| ClaimSearchCriteria |
| |||||
| ClaimSearchRole |
| |||||
| ClaimSearchType |
| |||||
| Critical Error Adjustment |
| |||||
| CurrentClaimAge |
| |||||
| DayRangeDifference |
| |||||
| DaysSinceFinalizedPayment |
| |||||
| EntityTypeQualifier |
| |||||
| Next Action |
| |||||
| EventCode |
| |||||
| EventFutureDate |
| |||||
| Event Interval |
| |||||
| Workstation Process |
| |||||
| Event Recycle Indicator |
| |||||
| Event Recycle SLA Date |
| |||||
| Event Workbasket |
| |||||
| ExecutionSequenceBy |
| |||||
| FinalizedDate |
| |||||
| FinalTransactionType |
| |||||
| Generation835Flag |
| |||||
| HoldRecycleWBName |
| |||||
| HoldSLA |
| |||||
| InitialClaimAge |
| |||||
| InterestRateType |
| |||||
| IsAllEventsResolved |
| |||||
| IsAllPendsResolved |
| |||||
| IsCE |
| |||||
| IsChargeableClaim |
| |||||
| IsGridVisible |
| |||||
| IsMemberConfiguration |
| |||||
| IsProviderConfiguration |
| |||||
| IsReportingClaim |
| |||||
| IsReviewHarness |
| |||||
| IsSubrogationClaim |
| |||||
| IsSubscriberConfiguration |
| |||||
| IsTCDInstance |
| |||||
| IsVoidCancelAdjustment |
| |||||
| NumberOfTransactions |
| |||||
| LockErrorMessage |
| |||||
| LPIAmount |
| |||||
| LPIDecisioning |
| |||||
| LPINumberOfDays |
| |||||
| LPIRateOfInterest |
| |||||
| LPIStaggeredDecisioning |
| |||||
| LPITotalAmount |
| |||||
| MassAdj_SearchClaimFor |
| |||||
| MassAdjustmentEG |
| |||||
| Measure |
| |||||
| Measure History Sequence |
| |||||
| MemberPageList |
| |||||
| MemberReplicas |
| |||||
| MemberYesNo |
| |||||
| NoOfClaimsToBeGenerated |
| |||||
| NoOfDaysSinceFinalizedPayment |
| |||||
| NumberOfEvents |
| |||||
| NumberOfPends |
| |||||
| OldClaimID |
| |||||
| OverAllSLADeadLine |
| |||||
| OverAllSLAGoal |
| |||||
| PaymentExtract |
| |||||
| Next Action |
| |||||
| PendCode |
| |||||
| Pend Interval |
| |||||
| Workstation Process |
| |||||
| Pend Recycle Indicator |
| |||||
| Pend Recycle SLA |
| |||||
| Pend Recycle SLA Date |
| |||||
| Pend Workbasket |
| |||||
| PerformanceFlag |
| |||||
| PerfTestElements |
| |||||
| MemberPageList |
| |||||
| PolicyPageList |
| |||||
| ProcessClaim |
| |||||
| ProcessCount |
| |||||
| ProcessImmediately |
| |||||
| ProviderPageList |
| |||||
| ProviderReplicas |
| |||||
| RemainingOopMax |
| |||||
| ResendForAdjudicate |
| |||||
| SearchValue |
| |||||
| SelectClaimForMassAdj |
| |||||
| ShowExportButton |
| |||||
| SkipBalancing |
| |||||
| SubmittedDate |
| |||||
| SubscriberPageList |
| |||||
| SubscriberReplicas |
| |||||
| SuscriberReplicas |
| |||||
| TempClaimLinePage |
| |||||
| TempEventListPage |
| |||||
| TempManualSplitList |
| |||||
| TempPendListPage |
| |||||
| Test ClaimID |
| |||||
| TestLinkProperty |
| |||||
| TotalElapsedTime |
| |||||
| ServiceTypeCode |
| |||||
| XMLFileName |
| |||||
| Case status |
| |||||
Case type: Test Claim
class to produce testclaims from scenarios
Class name: PegaHC-CLM-Work-Claims-Test
| Referenced by | References |
| None | • Accumulators - Header (Benefits) • Member • Policy • Provider |
| Fields: | ||||||
| Commit DateTime |
| |||||
| Save DateTime |
| |||||
| Update operator name |
| |||||
| Create operator name |
| |||||
| Case ID |
| |||||
| Create date/time |
| |||||
| Update date/time |
| |||||
| Urgency |
| |||||
| Label |
| |||||
| Active channel |
| |||||
| AdjudicationDate |
| |||||
| AuthAccumsToCommit |
| |||||
| BenefitAccumsToCommit |
| |||||
| Claims category |
| |||||
| Claims claim |
| |||||
| Claims claim types |
| |||||
| FinancialAccumsToCommit |
| |||||
| Claims interchange control number (from X12 ISA segment) |
| |||||
| OldReferenceClaimID |
| |||||
| Payer Claim Control Number |
| |||||
| Claims received as X12 |
| |||||
| Claims route group |
| |||||
| Claims workbasket org name |
| |||||
| Claims xml buffer |
| |||||
| ClaimsXtenEvents |
| |||||
| ClaimsXtenPends |
| |||||
| CXTEnableFlag |
| |||||
| CXTHistoryClaims |
| |||||
| CXTPaidFeed |
| |||||
| CXTRequest |
| |||||
| HistoryClaimsData |
| |||||
| IsHistoryQualified |
| |||||
| Test Page |
| |||||
| CE_TimelyFilingFunction |
| |||||
| CE_TimelyFilingOrder |
| |||||
| temp |
| |||||
| CE_ServiceEndDate |
| |||||
| CE_ServiceStartDate |
| |||||
| TimelyFilingDays |
| |||||
| TimelyFilingLevel |
| |||||
| PricingExecutionSequence |
| |||||
| Action Code WorkBasket |
| |||||
| AdjustmentNote |
| |||||
| AM_Catastrophe |
| |||||
| AM_CatastropheDescription |
| |||||
| AM_CatastropheEffDt |
| |||||
| AM_CatastropheExpDt |
| |||||
| AM_CatastropheID |
| |||||
| AmountAfterInterest |
| |||||
| AdmissionDate |
| |||||
| Claim Frequency Code |
| |||||
| CE_CostShareFlag |
| |||||
| CE_OrchestrationID |
| |||||
| CE_RefContractID |
| |||||
| CE_RefPatientID |
| |||||
| CE_RefPayerID |
| |||||
| CE_RefPolicyID |
| |||||
| CE_RefSubscriberID |
| |||||
| ChangeLogExists |
| |||||
| ClaimComparisonData |
| |||||
| ClaimCondition |
| |||||
| ClaimHeld |
| |||||
| ClaimHoldData |
| |||||
| ClaimHoldDeadLine |
| |||||
| ClaimHoldExpireDate |
| |||||
| ClaimInstInpatient |
| |||||
| ClaimlineAuthInstESList |
| |||||
| ClaimPageList |
| |||||
| ClaimSearchCriteria |
| |||||
| ClaimSearchRole |
| |||||
| ClaimSearchType |
| |||||
| Critical Error Adjustment |
| |||||
| CurrentClaimAge |
| |||||
| DayRangeDifference |
| |||||
| DaysSinceFinalizedPayment |
| |||||
| EntityTypeQualifier |
| |||||
| Next Action |
| |||||
| EventCode |
| |||||
| EventFutureDate |
| |||||
| Event Interval |
| |||||
| Workstation Process |
| |||||
| Event Recycle Indicator |
| |||||
| Event Recycle SLA Date |
| |||||
| Event Workbasket |
| |||||
| ExecutionSequenceBy |
| |||||
| FinalizedDate |
| |||||
| FinalTransactionType |
| |||||
| Generation835Flag |
| |||||
| HoldRecycleWBName |
| |||||
| HoldSLA |
| |||||
| InitialClaimAge |
| |||||
| InterestRateType |
| |||||
| IsAllEventsResolved |
| |||||
| IsAllPendsResolved |
| |||||
| IsCE |
| |||||
| IsChargeableClaim |
| |||||
| IsGridVisible |
| |||||
| IsMemberConfiguration |
| |||||
| IsProviderConfiguration |
| |||||
| IsReportingClaim |
| |||||
| IsReviewHarness |
| |||||
| IsSubrogationClaim |
| |||||
| IsSubscriberConfiguration |
| |||||
| IsTCDInstance |
| |||||
| IsVoidCancelAdjustment |
| |||||
| NumberOfTransactions |
| |||||
| LockErrorMessage |
| |||||
| LPIAmount |
| |||||
| LPIDecisioning |
| |||||
| LPINumberOfDays |
| |||||
| LPIRateOfInterest |
| |||||
| LPIStaggeredDecisioning |
| |||||
| LPITotalAmount |
| |||||
| MassAdj_SearchClaimFor |
| |||||
| MassAdjustmentEG |
| |||||
| Measure |
| |||||
| Measure History Sequence |
| |||||
| MemberPageList |
| |||||
| MemberReplicas |
| |||||
| MemberYesNo |
| |||||
| NoOfClaimsToBeGenerated |
| |||||
| NoOfDaysSinceFinalizedPayment |
| |||||
| NumberOfEvents |
| |||||
| NumberOfPends |
| |||||
| OldClaimID |
| |||||
| OverAllSLADeadLine |
| |||||
| OverAllSLAGoal |
| |||||
| PaymentExtract |
| |||||
| Next Action |
| |||||
| PendCode |
| |||||
| Pend Interval |
| |||||
| Workstation Process |
| |||||
| Pend Recycle Indicator |
| |||||
| Pend Recycle SLA |
| |||||
| Pend Recycle SLA Date |
| |||||
| Pend Workbasket |
| |||||
| PerformanceFlag |
| |||||
| PerfTestElements |
| |||||
| MemberPageList |
| |||||
| PolicyPageList |
| |||||
| ProcessClaim |
| |||||
| ProcessCount |
| |||||
| ProcessImmediately |
| |||||
| ProviderPageList |
| |||||
| ProviderReplicas |
| |||||
| RemainingOopMax |
| |||||
| ResendForAdjudicate |
| |||||
| SelectClaimForMassAdj |
| |||||
| ShowExportButton |
| |||||
| SkipBalancing |
| |||||
| SubmittedDate |
| |||||
| SubscriberPageList |
| |||||
| SubscriberReplicas |
| |||||
| SuscriberReplicas |
| |||||
| TempClaimLinePage |
| |||||
| TempEventListPage |
| |||||
| TempManualSplitList |
| |||||
| TempPendListPage |
| |||||
| Test ClaimID |
| |||||
| Flag |
| |||||
| TestLinkProperty |
| |||||
| Name |
| |||||
| PM_PPLinkText |
| |||||
| Processed |
| |||||
| RunClaim |
| |||||
| ScenarioClaim |
| |||||
| ScenarioDescription |
| |||||
| ScenarioID |
| |||||
| ScenarioName |
| |||||
| SearchParameters |
| |||||
| SearchValue |
| |||||
| TestClaimName |
| |||||
| TestClaimsID |
| |||||
| TotalElapsedTime |
| |||||
| ServiceTypeCode |
| |||||
| XMLFileName |
| |||||
| Case status |
| |||||
Case type: Claims inquiry
Work object for claims inquiry
Class name: PegaHC-CLM-Work-ClaimsInquiry
| Referenced by | References |
| None | • Claim data |
| Fields: | ||||||
| Commit DateTime |
| |||||
| Save DateTime |
| |||||
| Update operator name |
| |||||
| Create operator name |
| |||||
| Case ID |
| |||||
| Create date/time |
| |||||
| Update date/time |
| |||||
| Urgency |
| |||||
| Label |
| |||||
| Active channel |
| |||||
| Case status |
| |||||
| Claim |
| |||||
| ClaimsInquiryNotes |
| |||||
| ClaimsList |
| |||||
| Correspondence |
| |||||
| CorrespondenceDescription |
| |||||
| ExchangeIndicator |
| |||||
| ICNList |
| |||||