Skip to main content

         This documentation site is for previous versions. Visit our new documentation site for current releases.      

SCE ClaimsXten history

Updated on October 9, 2020

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:

  1. Service code groups or service code categories mapped on the claim line
  2. Claim form type
  3. Type of bill (2nd and 3rd Character)
  4. Frequency code (4th Character)
  5. Place of service
  6. Claim status

Based on the factors above, history claims would be selected for:

  1. X number of days ahead or behind.
  2. Historic claims with X service group code would be considered.
  3. 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 consideredHistory for the individual claim would be send for
NoService Code GroupClaim Form Type Type of BillFrequency CodePlace of ServiceClaim StatusDays AheadDays behindService Code Groups
2MATI233-Approved and Denied322322MAT,EPV

Note: The Max Number of Claim lines allowed to be sent to the ClaimsXten can be configured in the System Configuration page. The name of the field on the UI is “Allowed history Claim lines”.

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”.

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best. is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us