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Other enhancements

Updated on June 16, 2021

The 8.7 release also contains the following enhancements:

Undo mass transfer
Users now have the capability to reverse/undo the last mass transfer they completed. Users are given the option to select claims from their most recent transfer, send them back to the original queue (when available) and download an excel report of the entire transaction. Appropriate audits are captured for the same.
Rounding off Split Amounts

In the 8.7 release, SCE enhanced its split capability by introducing system level settings giving the administrators the choice to round the billed and COB amount by $0.01. This prevents balancing issues and uneven split event codes, leading to higher auto-adjudication rates.

The screenshot above shows a claim with a $10 billed amount split into three claims. Two split claims are assigned $3.33 billed amount and the third split claim is rounded to $3.34.

Event Code resolution - Multiple "Submit" buttons

Before the SCE 8.7 release, there were two submit buttons associated with the event code resolution process. The "Resolve open events" screen had a Submit button AND the "Resolve Event" screen also had a Submit button. This has caused confusion amongst the users. The buttons were renamed to “Apply”, “Process immediately” and “Submit” with the appropriate sections of the flows, making the resolution flow more user friendly.

SCE: Assignment instructions in transferred claims

The SCE 8.7 release now has the capability to display any assignment instructions added during the transfer of claims from one queue to another. Seeing the assignment instructions in pulse allows users to see any special instructions or handling that is required for the claim.

UI updates - Claim summary and payment information

Payment related field labels within the claim screens have been renamed to comply with common industry terminology. This allows the screens to be more intuitive.

SANP References in SCE

The terms "Stand Alone Networx Pricer," and SANP have been renamed to the product name “NetworX Pricer”.

Updating event codes data model
Pega Foundation for Healthcare in its latest version of 8.7, introduced four new classes. The existing classes in event code data model were replaced to have the right inheritance and application.

Following table contains class details:

Old Class New Class
Embed-PegaHC-ClaimIdentifier Embed-PegaHealth-ClaimIdentifier
Embed-PegaHC-ClaimType Embed- PegaHealth-ClaimType
Embed-PegaHC-EventDependency Embed- PegaHealth-EventDependency
Embed-PegaHC-EventDependencyWrapper Embed- PegaHealth-EventDependencyWrapper

The old classes are moved from PegaHealthCodes ruleset to the PegaHC ruleset, and the new classes are created in PegaHealthCodes ruleset.

All the rules present in the old classes and their references are copied to the new classes. Any rules created in or using a reference old classes are required to reference the new classes (In the customer implementation layers).

Optional: Updating access groups and roles
Pega Smart Claims Engine for Healthcare comes packaged with a series of access groups that can be used to enable different capabilities across operators (users). In this release, all the access groups have been updated to use new roles, that are streamlined following the pattern of dependent roles.

Review the access groups and roles here

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