The Pega ClaimsXten Adaptor provides for the integration of ClaimsXten, a full-service claim editing and auditing solution with Pega claim processing functionality. Increasingly complex plans, plus more and varied lines of business, can push healthcare payers' claims payment systems beyond their ability to deliver the necessary speed and accuracy. ClaimsXten is a durable, flexible solution for clinically-based claims auditing that offers flexible rules creation and firing that enable payers to process each claim under the specific terms and conditions of each benefit plan.

Healthcare ClaimsXten combines the strength and flexibility of the Healthcare Total Payment™ platform, a comprehensive library of Healthcare clinical rule content, and a services team of medical claims experts to provide payers with more medical and administrative savings opportunities. With full-service, technologically advanced ClaimsXten, you can do much more than standard fee-for-service claim code editing.

With ClaimXten, you can:

• Increase auto-adjudication rates
• Adjudicate ICD-10 claims with rules that look at historical claims coded in ICD-9
• Consistently and accurately apply policies - across plans, regions and claims processing systems
• Pay claims more accurately while reducing administrative costs
• Shift processing burdens to extend the useful life of your claims processing system(s)

The ClaimsXten solution contains KnowledgePacks consisting of individual claims management rules. Each of these rules is associated with specific edits. KnowledgePacks are currently available for auditing professional (provider) and outpatient facility claims. This includes but is not limited to:

• CPT-to-CPT procedures, Diagnosis-to-procedure options
• Medicare and Medicaid-related auditing logic found in the Correct Coding Initiative (CCI)
• Other centers for Medicare and Medicaid Services (CMS) carrier directives (for example, National Coverage Determinations for medical devices and other complex procedures)
• Outpatient Code Editor (OCE) rules

A ClaimsXten rule is the logic necessary to execute a specific payment policy or guideline. Each rule has an associated set of clinical data contained in Dictionary Category tables that, when applied to the rule logic, results in an edit. The edit is a recommendation made by ClaimsXten to deny, review, modify, or allow a specific claim line.