The Smart Claims Engine coverage determination features are responsible for identifying the appropriate benefit and applying any rules to identify the coverage for the claim.
The Pega Smart Claims Engine for Healthcare incorporates a benefit determination and adjudication capability utilizing the benefit definitions and structures residing in the Pega Foundation for Healthcare (PFHC). The benefit information can be provided natively by the Pega Product Composer (PCS) application or from another source.
The benefit determination logic utilizes Elasticsearch algorithms coupled with information from the member, provider, and claim records to match to the most appropriate benefit. After a benefit has been matched, claims are evaluated to determine if the submitted services have been provided in accordance with the available benefits in the member's plan. If the service is not covered based on the configuration, then the claim will set an appropriate event code. The SCE will also apply benefit limit calculations using the current limit accumulators defined at the plan or benefit level. If a unit limit has been met, then the Smart Claims Engine automatically adjusts the claim based on the available approved units.
The SCE will also apply benefit limit calculations using the current limit accumulators defined at the plan or benefit level. If a unit limit has been met, then the Smart Claims Engine automatically adjusts the claim based on the available approved units.Auth match / application
The Smart Claims Engine provides the capability to process authorizations against claims. Authorization requirements can come from the benefit configuration or from an authorization required table in the Smart Claims Engine.
Authorizations are matched to the claim based on information associated with the provider and claim. Different matching queries are available for inpatient, outpatient, dental, professional and referral authorizations. If the authorization cannot be matched exactly, an event code is raised, and guided event resolution can be implemented to assist the claims examiner in selecting the appropriate authorization.
Smart Claims Engine provides the capability to adjudicate referrals and authorizations at the claim and line levels. Smart Claims Engine first determines whether an authorization or referral is active, then determines whether there are units available for processing. Smart Claims Engine adjudicates referrals, service authorizations, and pricing authorizations.