The Smart Claims Engine performs a series of tasks as part of the pre-adjudication of claims during processing. These tasks include validating codes, system configurations, and key data on the claim; performing a member match, retrieving the appropriate policy and validating eligibility, and validating provider information.

This chapter will detail those processes and provide information on appropriate configurations and extensions.

• Validation edits
• Member match
• Provider match

• Pega Smart Claims Engine User Guide