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Claims operations, inventory management and payment integrity

Updated on December 10, 2021

The SCE provides a series of tools and capabilities to manage operations, inventory management and payment integrity.

These include:

Inventory management

The SCE provides as series of tools to manage claims inventory and SLA’s. This includes the ability to configure the appropriate prioritization and routing rules to ensure that the right work is presented to the end users. The SCE uses the Pega OOTB models for routing work to the appropriate end users. Routing rules and work queues can be extended or configured based on your specific business needs and organizational structure. The SCE also provides configurations for skill-based routing where work items can only be retrieved by users with the appropriate skills. Work queues can also be configured for event codes to ensure that the suspended claims are routed to the appropriate users for resolution.

The claims manager has tools available through the SCE to perform a single or mass transfer of work from one operator or queue to another.

Pend management

The SCE provides a series of portals for the claims examiners and managers to resolve and manage pended claims. In the examiner portal, pends are resolved through the guided event resolution process that provides options to assist examiners in correctly resolving issues. Examiners can also search for claims, view full claim and supporting information as part of the resolution process. Some of the other features available to the claim examiners include:

  • Claim view - A robust claims view capability showing processing history, claim data and ancillary processing data.
  • Manual cost share calculations – Modifying the copay, coinsurance, or deductible on the claim.
  • Adjustments and voids – Claim adjustments and void processing
  • Claims corrections – Modifying the data on the claim to support adjudication.
  • Transfer assignment – Assigning the claim to another operator
  • Split claim and claim line – Ability to manually split the claim or line.

Adjustments & voids

The SCE provides tools for the operations and systems management team to search and identify claims, preview outcomes, schedule, and adjust or recycle a population of claims. Manual adjustments and voids can also be performed through the Claims Examiner portal.

Dashboards & reporting

Reporting is provided in all the SCE portals. The claims manager and system manager portals include dashboard views reporting key processing and claims metrics. New reports and dashboards can be created as appropriate.

Claim inquiry

Claim inquiry is another capability enabled for the claim examiner in the SCE. A claim inquiry is a request for claim adjustment or for other information regarding claims resolution. Claims examiners can review and resolve claim inquiries.


Smart Claims Engine provides the capability to set random audits within the system. This information is used for auditing and can be configured on various fields on the claim, including billing provider, member, claims examiner, billed amount, and approved amount.

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