Standard case types
Case Type Description Claims The claim is the key case type in the SCE. This case allows the
lifecycle of a claim to be managed through the adjudication process.
Once a Claim is received in the system, via parsing claims files,
manual entry or an API, it goes through adjudication. Adjudication
allows the claim to go through a series of validations, edits and
core processing. The outcome of this processing is that the claim
approved, pended or denied. Pended claims require secondary
processing and can then be resolved via the appropriate automated or
manual actions. Test Claims Pega Smart Claims Engine for Healthcare allows users to create a test bed.
Test Analyst, Administrator and other business users can create
these test beds to adjudicate claims against existing
configurations. Multiple claims can be generated through one Test
Claim setup. Even though test claims have the same characteristics
as claims they are identified separately. Claims Inquiry The claims inquiry case is used to manage claims inquiries. An
inquiry case is a message from a member, provider, external system
and is used to request an adjustment or inquire why a claim paid
differently than expected. The claims inquiry case may contain more
than one claim. A claims inquiry can be created manually in the SCE
or received through an API. The claims inquiry case tracks the work
performed on the case and allows the user to resolve the case after
making an adjustment or identifying that the claim(s) did indeed
process correctly.
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