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SCE and ClaimsXten integration overview

Updated on October 9, 2020

When ClaimsXten is integrated with Pega Smart Claims Engine for Healthcare (SCE), claim data is exchanged between the two systems. SCE can pass professional and facility claims and corresponding claim history to ClaimsXten in real time or using a batch process. In addition to the required claim level and line item data needed by ClaimsXten, SCE can also provide other data, including but not limited to the member’s product, provider ID, hospital bill code and plan type. These data elements can be used by ClaimsXten to filter claims or apply conditional editing criteria to the claims.

  • Inbound file in this document always refer to files inbound to ClaimsXten. (send from SCE). Aka request files.
  • Outbound file in this document always refer to files outbound from ClaimsXten. (Send to SCE). Aka response files.

As seen in the flow below, ClaimsXten validates each claim based on the rules setup in ClaimsXten and return the results to SCE. SCE adjudicates the claim based on the response received. SCE also has the capability to display the full response sent by ClaimsXten. This flow shows the exchange of data between ClaimsXten and SCE for the current claim.

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