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Logical deletion of claims

Updated on April 26, 2021

In certain situations, the user may want to delete a set of claims, considering them to be invalid. In these cases, instead of the Claims examiner deleting them, Pega Smart Claims Engine for Healthcare provides an option to delete a significant number of claims in one step.

How it works: There is a logic delete CSV file, in which the user provides all the claim ICN’s that need to be deleted in a sequential manner. That CSV file is then saved, and the same CSV file dropped into the file listener folder. This CSV file will then be picked up by the system. After being picked. all the claims will be randomly deleted, and their status updated to Resolved-cancelled.

After a logical delete, all the ICN’s which have been moved to Resolved-cancelled status will display an audit message stating the claim has been logically deleted.

When any claim has been logically deleted the X12 status will be updated as -3.

Only claims which are in New, Pending-Investigation, Pending-Recycle, Open-Error, Open-Processing can be logically deleted. Claims having statuses other than those specified above cannot be logically deleted.

Locked claims cannot be deleted. For example, if anyone is performing any action on a claim, such as an adjustment or correction, the claim which is opened by an examiner will be locked until the operation is completed. During this time when the claim is being handled by a user and is in locked status it shouldn’t get logically deleted even though the ICN has been included in the CSV file.

Once logically deleted, the claims that were in work baskets earlier, should be removed from those work baskets as per the status.

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