Skip to main content


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

Claim edits tab

Updated on April 26, 2021

The claim edits tab controls the key information needed for specific claim types, as well as the configurations for the duplicate claim rules. The duplicate claim rules are detailed in the section for duplicate claim edits. This section will cover the key fields used to configure claim types in the system.

The claim type is defined based on a series of parameters. The Claim Type Identification link below the parameters displays the configuration for the claim type. The Type indicates the form type (Institutional, Professional, Pharmacy and Dental). The facility type and bill classification come from the fields on the institutional form to classify institutional claims into different claim types. Changes may be made to the configuration on the IdentifyClaimType decision table.

The claim transaction type is also broken down into three types based on the claim frequency code. You can access this table through the Claim Submission Type Mapping link on the Claim Edits tab. Changes may be made to the configuration on the ClaimSubmissionType decision table.

To configure the system to support or un-support the specific claim type, you can select +Add item, or X Delete. You can also copy an existing claim type configuration by selecting Copy claim type. To edit an existing type, double click on the claim type to be modified.

FieldDescription
Claim typeThe type of claim this configuration is for. If a claim is received and maps to an unconfigured type through the IdentifyClaimType decision table, SVE-0024 will set.
Claim BillingIndicates whether claims are processed for billing purposes. (claim identifier CH). If this identifier is not configured in the system, a claim possessing it will set SVE-0013.
Claim ReportingIndicates whether claims are processed for reporting purposes. (claim identifier RP). If this identifier is not configured in the system, a claim possessing it will set SVE-0013.
Claim SubrogationIndicates whether claims are processed for Medicaid subrogation purposes (claim identifier 31). If this identifier is not configured in the system, a claim possessing it will set SVE-0013.
Processing Level

If the processing level is Header, the payment is made at the claim level once all claim lines (Detail) have been completed and approved.

If the processing level is Detail, payment is made at the claim line level as it is completed and approved.

If the processing level is not configured, SVE-0010 will set on the claim.

Each claim identifier selected for processing will create a separate configuration for the history retrieval, the claim submission types and the duplicate edit configuration.

History retrieval – This allows the system to consider multiple claim types when retrieving history for the purposes of system audits. Clicking on a claim type will add it to the selected section. Clicking it in the selected section will remove it from consideration.

Duplicate claim edits – This provides the ability to select the fields and appropriate weights for exact and suspect duplicate edits. More information can be found in the section on Duplicate Edit section of Business edits.

Submission type – This defines the submission types that can be processed for this claim type and claim identifier. If a submission type is not configured and a claim meeting that criteria as defined in the ClaimSubmissionType decision table, SVE-0011 will be set.

The configuration settings can be changed easily in the developer studio. Once the changes have been performed, press Save Configuration, enter comments in the popup box and press Submit. Selecting Cancel will return to the configuration screen. Selecting Close on the main screen will close the configuration screen without saving the changes.

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.

Pega.com is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us