The Smart Claims Engine supports multiple implementation models and processing options. The three most common are adjudication, adjustment, and error handling. Orchestrations are not supplied with new installations beginning with 8.7. However, the options are pre-configured for easy reference.
The orchestration configuration table, Derive orchestration, can be found under Orchestration configuration in the Orchestration section of the Delegated rules menu in the portal. To view or update this table, select the edit icon.
This will present the Derive orchestration decision table which can be modified and saved utilizing the standard Pega development process. Specific return values representing the orchestrations implemented must be added for execution. This table can be extended by clients to add new fields, but is delivered with the following columns:
|This identified if the claim has been manually or mass adjusted based on a flag populated during the manual or mass adjustment process
|Claim frequency type
|The frequency code submitted on the claim. This may also be the last character of the bill type. For example: 1 (admit through discharge), 7 (replacement of prior claim)
|Claim transaction type
|The type of transaction being submitted. For example: CH (chargeable), RP (reporting), 31 (Medicaid reclamation/subrogation)
|Claim payer ID
|The payer ID submitted on the claim
|Claim form type
|The type of claim being submitted. For example: P (professional), I (institutional), D (dental).
|The name of the orchestration being selected based upon the values in the table
The Smart Claims Engine requires an error handling orchestration if no orchestration is found through the selection. This sets the event code SGB-0048 – Orchestration not found. This event code will also set if the name of the orchestration returned by the decision table is not found in the configured list of orchestrations.