In addition to performing validation edits on the claim, this module also retrieves all the code groups associated with the matched HCPCS/CPT/CDT procedure on each claim line. The code groups and supporting tables are managed in the Pega Foundation for Healthcare.

The procedure code groups mapped including custom made groups and the Berenson-Eggers Type of Service (BETOS) Categories. BETOS categories are typically used to group similar services and help analyze Medicare costs. All HCPCS procedure codes are assigned to a BETOS category. There are seven BETOS clinical categories:

• Evaluation and Management
• Procedures
• Imaging
• Tests
• Durable Medical Equipment
• Other
• Exceptions/Unclassified

Berenson-Eggers Type of Service (BETOS) codes are assigned for each Health Care Financing Administration Common Procedure Coding System (HCPCS) procedure code.

The matched code groups are visible in the UX by selecting the appropriate procedure code.

These matched code groups are all stored in the BETOS_CodeGroupList in the clipboard.

• Validation edits