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Updated on December 10, 2021

The finalization routines of the SCE provide the ability to calculate the final amount to be paid to the provider incorporating any interest calculations and apply any adjustments based on the claim or line having been denied.

COB savings account

SCE can determine if savings from other payer payments can be utilized by the application to reduce or eliminate eligible member out of pocket expenses. Pega Smart Claims Engine supports Coordination of Benefits (COB) savings accounts, where money saved by having multiple insurance policies can be applied to applicable member expenses (copay, coinsurance or deductible).

Member liability

The final member liability can then be calculated. If applicable, penalty rules are identified on the benefit, these are used to calculate and assign penalties at the claim and claim line level.

Surcharge calculation

Pega Smart Claims Engine assigns surcharges to providers, based on provider location. In addition, the system includes logic to calculate and assign provider surcharges (including GME surcharges) on a claim-by-claim basis, according to the New York State HCRA regulations. The NY surcharges are generally applied to eligible facilities whose service locations are in New York, and who deliver inpatient and outpatient services. The NY state surcharge logic is driven by configurable eligible plans, providers, and services, and executes calculations for all the various regulatory scenarios (deductible only, coinsurance only, deductible and coinsurance).

Accumulator updates Once the claim has been identified as approved to pay, all accumulators on the claim updated in the accumulator manager. This will enable subsequent claims to utilize the latest values in their processing.

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