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About processing Reporting claims

Updated on April 26, 2021

After Pega Smart Claims Engine for Healthcare processes a reporting claim, it edits the claim just as it does for a chargeable claim, except that it sets these values:

  • Paid Amount = 0

    The reporting claim goes through the adjudication process, calculates values for the Allowed amount, Copay, and Coinsurance, similar to a chargeable claim. However, it sets the Paid Amount to 0.

  • Paid Date = Claim Process Date
  • Final status of the Reporting claim = Resolved - Completed, assuming that the Reporting claim did not meet any event code criteria.

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