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Updated on December 10, 2021

Healthcare payers are confronting ever-changing business challenges and opportunities amid an unpredictable regulatory landscape. Payers are expected to:

  • Address employer demands to reduce costs for themselves and their employees
  • Respond to legislation and mandates
  • Encourage and reward good health habits by providing effective incentives & integrated benefits
  • Contend with a complex marketplace

All the while, “keeping the lights on” is eating up large portions of IT budgets.

Pega Smart Claims Engine for Healthcare (SCE) gives payers full transparency and control over medical, vision, and dental claims processing across all claims systems and lines of business. This maximizes auto-adjudication and automation, optimizes productivity for any fall out exceptions, and manages work across the full life cycle. Pega SCE is the only solution that has a flexible orchestration platform to deliver a composable phased solution, enabling out-of-the-box capabilities and/or customer-specific components at any point in the claim processing lifecycle.

Unique to SCE, Guided Pend Resolution provides a curated navigation path and related information tailored to the claim being resolved – providing contextually appropriate actions to examiners. This increases accuracy, productivity, and reduces training time for new hires. Dynamic events and action codes, created and managed by business users, streamline everyday work such as holding claims for specific providers until new contract rates are finalized, avoiding re-work, and enabling business continuity within minutes, e.g., adding a rule for local disaster tornado recovery during a period of existing special instructions for COVID related claims.

OOTB support for Claims Inquiry that enables timely review and resolution of disputed claims submitted by providers and members.

Payers can leverage SCE processing to provide context-aware claims adjudication while implementing value-based reimbursement models that align with consumer value.

The Pega Smart Claims Engine for Healthcare processes medical and dental claims from intake through finalization. The claims engine supports the processing of chargeable, reporting and Medicaid reclamation claims. The claims engine also supports adjustments, manual or automatic splitting of claims and claim lines, work queue routing for pended claims, claim status updates, balancing and surcharges all on a flexible adjudication platform.

The claim-processing engine can integrate seamlessly within the healthcare payer’s technology and existing application environment due to the following capabilities:

  • Smart Claims Engine architecture is built on industry-standard databases; the platform leverages industry leading business process management, case management, and workflow technologies.
  • Standards-based integration unites Pega processes with enterprise systems to maximize existing investments and reduce data inconsistencies and replication.
  • Stand-alone, modular, or cloud implementations provide the flexibility to fit an implementation within your organization’s technology infrastructure.
  • Rules-driven controls define how each processing step is managed internally and called from external resources.
  • Modular architecture supports phased implementations – providing quick wins today while laying the foundation for future gains.

Pega’s Smart Claims Engine (SCE) provides a rich set of features which are designed to enhance the customer experience, improve user productivity and increase customer satisfaction. The SCE is an application designed to orchestrate all processes required for the complete adjudication of healthcare claims. Features of the SCE can be implemented as-is, removed or extended based on your business needs. The orchestration platform can also be used to implement client-specific features as part of the claims processing lifecycle.

The SCE supports two distinct implementation models to support a wide variety of client needs.

Implementation Model

Implementation Mod
Smart Claims Management

This enables clients to use the SCE to edit and “repair” claims and manage claims pended in the core claim adjudication platform. In this instance:

  • The claim can be validated for compliance, ensuring key data on the claim is present and valid.
  • The member and policy can be retrieved and validated ensuring the correct member and policy are used for adjudication.
  • The provider and appropriate cross-provider relationships can be retrieved and validated ensuring the correct provider is used for adjudication.
  • Fallout of claims can be managed and resolved manually if required.
  • Pended claims can be prioritized utilizing the Get next work algorithms of the SCE to ensure that the highest priority claims are presented to examiners.
  • Claim data can be modified for adjudication; for example, splitting claims based on various scenarios.
  • The guided event resolution models can be implemented to support examiner workflow and provide the right information to the examiner at the right time.

Reporting on claims operations and claim resolution is available.

Smart Claims Adjudication

This enables clients to utilize the SCE to support the end-to-end adjudication of claims from intake and pre-adjudication editing to benefit matching and liability calculations. In this instance:

  • The claim can match to the benefit configured for the member.
  • Claim liabilities can be calculated utilizing current accumulator amounts and the benefit adjudication rules.
  • Pricing rules and integrations can be applied to identify the appropriate allowable charges for the service
  • Surcharges and Late Payment Interest can be calculated and applied to the claim

Cutbacks based on other insurance payments can be applied.

The SCE incorporates multiple groups of capabilities that can be implemented. These are:

  • Claims operations, inventory management & payment integrity – Responsible for managing the end-to-end claims lifecycle and support claims operations.
  • Intake – Responsible for parsing claims and claim files from a variety of input mechanisms
  • Pre-adjudication - Perform pre-editing to validate fields and select the appropriate member and provider.
  • Business rules & edits – Responsible for setting up the claim to adjudicate cleanly, applying key business edits, performing COB edits, and integrating to third party applications.
  • Coverage determination – Matches the claim lines to the appropriate benefit and applies benefit limit rules and authorization processing.
  • Pricing – Prices the service lines by selecting the appropriate rate sheet, integrating to 3rd party pricers and performs winning price calculations.
  • Benefit adjudication – Responsible for calculating the appropriate member cost shares associated with the benefit and applies any COB deductions.
  • Finalization – Applies any COB savings or surcharges, calculates the final member liability, and updates the accumulators
  • Payment – Performs the final payment calculations applying any late payment interest or prompt pay savings, updates the payment information on the claim and generates the 835-remittance advice.
  • Process control & configuration – Responsible for managing the SCE processing environment, configures the orchestration, event codes, action codes, manages SLA’s, etc.
  • Accumulator management – Stores all the accumulators associated with the claims and provides tools to update or manage accumulators as necessary.

Information on these capabilities is detailed in the sections below.

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