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Primary data entities

Updated on December 10, 2021

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.

NameDescriptionSystem 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 accumulatorPega 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)

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.

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)

Holds all the claim and supplementary information needed to process Dental, Institutional and Professional healthcare claims from point of intake, to resolution and finalization.

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

Holds information about practitioners which is used during claims processing.

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

Holds information about the subscriber and subscriber policy.

Pega or External

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