Pega Smart Claims Engine can identify correct claim pricing by executing a ratesheet selection process. This process parses the provider contracts, networks and associated ratesheets to find the appropriate record for pricing. This information can then be submitted to a pricing engine for the price calculations.

Pega Smart Claims Engine can integrate with the NetworX Pricer application. During claims adjudication, the Smart Claims Engine can generate and send a request, containing claim and other key information to the NetworX Pricer application, which returns the associated response. The pricing results are parsed from the response and added to the claim. Information returned from NetworX Pricer is displayed in the Claims UX for review.

Pega Smart Claims Engines can price claims using a fee-for-service approach, by executing decision tables that match procedure codes (CPT, HCPCS, Revenue, CDT) to discrete per unit pricing. Smart Claims Engines fee-for-service pricing logic accommodates par pricing, non-par pricing, and authorization pricing. Smart Claims Engine displays all the pricing sources, methods (for example, fee-for-service, percent of charges, and per diem) and discrete unit prices generated during adjudication in the claim line user interface, and then displays the final source and method in the claim line execution result.

Smart Claims Engine includes a highly flexible winning price feature where one or several pricing functions (for example, participating, non-participating, third-party pricing engine) may be executed to generate multiple prices for a single claim or claim line. The single most favorable pricing option or winning price is then automatically selected according to the user-defined criteria.