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Result handling logic

Updated on October 9, 2020

  1. Pega Smart Claims Engine for Healthcare receives the outbound ClaimsXten XML, validates it and loads the ClaimsXten recommendation received.

  2. If changes are received on a historic claim, the system creates a work object and places the request in a work basket. An examiner could then review the changes and manually adjust the historic claim.
  3. If changes are received for a historic claim, the system also automatically pends or suspends the current claim with event code SCX0016 - Current claim pended because historic claim might need changes.

  4. The Work item created would show all the recommendations received for the history claim.

  5. If the recommendation is received for the current claim, the system would check the “Claim Line Action” field received on the response for each line. For each line action on the response, SCE would map it to an event code and/or action code. Mapping can be found in table CXTResponsetoSCECodes. Expected claim line actions received on the response are:
    • DENY – Disallow a payment for the referenced claim line.
    • ADD – Create net-new line, associated with other DENY line(s) in the same case.
    • SUPPORT – Support other case lines only, not an actionable case line.
    • PAYPERCENT – Lines with a multiplier to be considered in the determination of reimbursement on the claim line.
  6. If the Claim Line Action = Deny:
    1. The system would map the response received (based on the client configuration in the CXTClaimsXtenSCE Table) with the appropriate SCE Event Code and or Action Code.
    2. The SCE Line Status would be set as Denied.
    3. The Line would go through the Regular denial SCE process and update the Process History.

  7. Similarly, if the claim line action = Add or Support, the system would map the claim line to an appropriate event code and/or action code based on the client configuration in the table CXTClaimsXtenSCE.

  8. Based on the event code and action code assigned the system would go through the rest of adjudication modules.
  9. If the claim line pay percent applies, the system would map the claim line to an event code and/or action code based on the client configuration in table CXTClaimsXtenSCE. It would also recalculate the calculated allowed amount. A negative adjustment would be added to the claim balance for add line recommendations.

Note: SCE does not generate line numbers but does accommodate new lines when the “add” recommendation is received from ClaimsXten. ClaimsXten would give a new line number for each line it adds in the response.

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