Processing control and configuration
The SCE provides a series of post adjudication tools to finalize the claim, calculate the amount to be paid to a Medicaid agency through reclamation, the ability to manage a subrogation case and support for reporting transactions.
Additional SLA’s can also be associated with the event codes on claims to ensure suspended claims are resolved in the appropriate time frame to avoid late payment interest.Orchestration
Pega Smart Claims Engine includes an orchestration layer that calls discrete modules for claims processing. Each module provides the business logic needed to successfully, accurately, and completely adjudicate a claim. Claims orchestration allows you to change the sequence of existing module processing, introduce more edits, or bypass validations if needed. Orchestrations are broken down into sequences and then modules to support re-use of capabilities. Multiple orchestrations can be created in the SCE and selected based on claim processing parameters.Event management
Pega Smart Claims Engine reports issues that arise during the adjudication of a claim via the use of event codes. These codes could be business policy issues, for example timely filing or authorization required, or technical issues, for example an invalid configuration. The SCE provides configuration on these event codes to identify how they are to be handled when they are set. The management of event code enables the modification of existing event codes and the creation of new ones. There are 3 key features in event code configuration.
- Event code information – This identifies the key information for the event code, the active/inactive dates, claim dates of service along with any EOB information. If creating dynamic events, the criteria to assign it is identified.
- Dispositions – This is how the SCE will handle the event code when it sets. Dispositions incorporate the ability to deny, pend or raise an informational status, along with any SLA’s or routing rules for when the configuration is to pend.
- Event groups – This is a capability that groups like events so that they can be resolved together once the resolution has been identified.
Smart Claims Engine provides the ability to create and associate action codes with the claim. These action codes can alter processing, override event codes or provide information on actions taken on the claim. Action codes are added to the claim in multiple places of processing to support specific business rules. The SCE also provides three default action codes to support some key operational scenarios:
- Catastrophe – A catastrophe action code can be configured based on core geographic data and timelines. This action code can be used to switch off event codes to enable business rules, such as authorization requirements, to be bypassed in the case of a natural catastrophe.
- Priority Handling – a priority handling action code enables specific claims to be routed to specially designated examiner.
- Claim Latency – a latency action code allows you to alter the urgency of claims in the system, so that an increased priority for resolution can be applied to suspended claims.
SLA rules can be added to the processing in the SCE and modified for specific business outcomes. Along with the core SLA for claim processing, more discrete SLAs can be created, for example to manage the resolution of a pend assigned due to an authorization issue.Testing
To ensure that claims are adjudicated correctly, Pega Smart Claims Engine has a series of testing tools that can be used to test configurations and processing.
- Test claims – a user can create single test claims for professional, institutional, and dental services.
- Test scenarios – a user can create a test scenario (set of test cases) to ensure that the test claim has the expected outcome.
- Test sets – to verify the success of the system, a user can group test scenarios so that multiple scenarios can be executed.
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