Introduction

Event codes are mechanisms used by Smart Claims Engine modules to report issues or problems that arise during the processing of a claim. The event code function verifies the accuracy, validity, required presence, format, consistency, allowable values, and integrity of data submitted. Event codes are also used to track system configuration and processing issues.

Pega Smart Claims Engine for Healthcare can set an event code to suspend or deny a claim or claim line, or to flag a claim or claim line for informational purposes. Smart Claims Engine determines which event codes to report and takes the defined response action based on the configuration of each event code.

Event code management has four rule types:

• Event code configuration
• Grouping Event codes
• Module bypass
• Holds and SLAs

These top-level rules define the parameters for processes and dependencies associated with them. They contain high-level information about the Event code that is used in audit reporting as well as codes and descriptions that are used by ancillary processing functions.

The rules for holds and SLAs define how the system manages claims that have set events that have holds and SLAs associated with them.