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Updated on December 10, 2021

The final step of the SCE is to create the appropriate payment files and mark the claim as paid.

Payment calculation

The payment calculation identifies the final amounts on the claim lines and uses these to identify the total amounts at the claim level. These include any patient liabilities as well as the approved and allowed charges.

LPI / Prompt pay

The SCE identifies claims that meet late payment interest (LPI) requirements and calculates the associated interest daily. The interest calculations utilize an extensible table with each State’s LPI rules.

Payment info

Claims that are approved to be paid can be extracted and submitted to a financial processing system. The extract contains both claims that are approved to be paid, and negative financial transactions from adjustments or voids. A response file with the check or EFT numbers can be posted to the claim along with the final amount and paid date.

Claim payment response

Pega Smart Claims Engine can generate an 835 remittance advice and 277 claim status to identify the amount paid and any adjustments that have been added to the claim.

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