Primary data entities
This section describes the data types that are used by Pega Smart Claims Engine for Healthcare, stored in external systems or, where appropriate, internally to the Pega system.
Holds information about a medical or dental plan (including
benefit information) which is needed for claims adjudication.
This information is used for adjudicating cost shares, setting
limits, applying plan rules etc. Holds all the claim and supplementary information needed to
process Dental, Institutional and Professional healthcare claims
from point of intake, to resolution and finalization. Holds information about practitioners which is used during claims
processing. Holds information about the subscriber and subscriber policy.
Name Description System of record (SOR) Accident Subrogation Case Holds information about accident cases which is further used to
avoid payments. It can be also used to seek reimbursement from a
responsible party for a claim that is associated with an accident. Pega Accumulators – (Header & Detail) Records accumulator information precisely, collecting and
calculating total claim dollar values against plan deductibles,
benefits and others. The detail is the individual line which
increments or decrements the overall accumulator Pega or External Authorization details Holds information about inpatient, outpatient, referral or
pharmacy authorizations which are used for authorization matching,
claim pricing and limit adjudication functionalities. Pega or External Benefit plan (plan) Pega or External Business Entity Holds provider business entity attributes such as Tax ID, NPI,
billing addresses, services addresses, etc. The business entity data
is the information associated with the billing provider on the
claim. Pega or External Claim Adjustment Reason Code Holds information about the codes used during claims adjustments
and claims corrections. These codes are sourced from WPC. Pega or External Claims - (Header & Detail) Pega Code Sets Holds information about code groups (including code group
definition) used for benefit matching. Pega or External Event Codes Holds Event code information which is set on a claim when the
claim is adjudicated. This includes disposition and response mapping
information Pega or External Hospital- Readmission Acute Diagnosis Holds the diagnosis codes used to determine hospital
readmissions. Pega or External Hospital- Readmission Planned Diagnosis Holds the diagnosis codes used to determine planned hospital
readmissions. Pega or External Member Holds Member/Patient demographic information. Pega or External MUE Edit Holds NCCI Medically Unlikely edit (MUE) information used during
validating a claim. Pega or External Network Holds information defining the provider networks Pega or External Payer Holds payer Information used for regular claim processing and
identifying other insurance carriers. Pega or External Policy Holds member’s policy Information. Pega or External Practitioner Pega or External Provider Holds provider demographic and other ancillary information. Pega or External Provider affiliation Holds information about the billing provider affiliations with
other providers and practitioners. Pega or External Provider contract Holds information about provider contracts which is parsed in the
rate sheet selection module, based on the member and provider
network matches. This information is used along with other claim
data for pricing calculations. Pega or External PTP Edit Holds NCCI Procedure-to-Procedure (PTP) edit information used
during validating a claim. Pega or External Rate Sheet Holds information about provider rate sheets used for pricing a
service billed on the claim. Pega or External Subscriber Pega or External
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