SCE ClaimsXten history
Pega Smart Claims Engine for Healthcare has the capability of sending history (previously adjudicated) claim information as a part of the input to ClaimsXten. During adjudication, SCE maps each claim line with a service group code (sometimes referred to as service category or benefit category). The service group code definition can be configured in Pega Foundation for Healthcare (PFHC). Once the service group code is mapped for each line on the claim, the system would send claim history Information based on the “ClaimsXten History Configuration” configured in the CXT history configuration decision table (CXTHistoryConf).
If the ClaimsXten send history option is selected as “On”, claims history would be sent considering the following factors on the claim:
- Service code groups or service code categories mapped on the claim line
- Claim form type
- Type of bill (2nd and 3rd Character)
- Frequency code (4th Character)
- Place of service
- Claim status
Based on the factors above, history claims would be selected for:
- X number of days ahead or behind.
- Historic claims with X service group code would be considered.
- Other conditions such as rendering provider and claim status.
Example: Users would be able to manage a decision table with many factors. As seen in row one, for all professional claims with service code group IPV, claim history which have service code group NPV and EPV only, 90 days old and 10 days ahead from the service date would be sent to ClaimsXten.
| Factors Based on which history, for an Individual Claim would be considered | History for the individual claim would be send for | ||||||||
| No | Service Code Group | Claim Form Type | Type of Bill | Frequency Code | Place of Service | Claim Status | Days Ahead | Days behind | Service Code Groups |
| 1 | IPV | P | - | - | - | All | 10 | 90 | NPV,EPV |
| 2 | MAT | I | 23 | 3 | - | Approved and Denied | 322 | 322 | MAT,EPV |
Within the configuration page, the users are also given an option to send the claim to ClaimsXten even if the maximum lines exceed. The name of the field on the UI is “Send history, max lines exceeds”.
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