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Standard case types

Updated on December 10, 2021

Case TypeDescription
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 ClaimsPega 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 InquiryThe 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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