Skip to main content


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

Event code groups

Updated on April 26, 2021

The Smart Claims Engine provides a feature to support the automatic grouping and subsequent reprocessing of pended claims with common shared attributes. This enables claims to be grouped together that can be resolved via a single action creating operational efficiencies. This may be used as an alternative to mass adjustments for claims that have a smaller population to resolve.

The event group function is one of several tools available for claims reprocessing and offers certain advantages over mass reprocessing and event code recycling under specific circumstances. Consider the following use case:

Use Case

  • A recently negotiated provider contract will not be configured in the payer’s claim system in time for the first date of the new contract year; consequently, all future claims associated to the provider are in jeopardy of paying incorrectly.

Solution

  • Payer and provider agree that to avoid the incorrect payment of future claims, all claims with dates of service on or after the first date of the new contract year will be suspended until the new contract has been configured. Payer will create a dynamic event code to hold those claims, and then create an event group configuration and associate it to the dynamic event code.
  • As a result, all claims associated with the provider beginning on the first day of the new contract year are suspended and captured in a single event group. When the contract is configured the payer will manually resolve that event on a single claim belonging to the event group. When that single event is manually resolved, SCE will automatically reprocess the same event for all the remaining claims in the event group.

Information on the use of event groups to perform event resolution is detailed in the section on Claims Operations.

  • Previous topic Importing and configuring the event codes for Smart Claims Engine modules
  • Next topic Viewing event groups

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