Pega’s Smart Claims Engine (SCE) provides a rich set of features which are designed
to enhance the customer experience, improve user productivity, and increase customer
satisfaction. The SCE is an application designed to orchestrate all processes required for
the complete adjudication of healthcare claims. Features of the SCE can be implemented
as-is, removed, or extended based on your business needs.
The orchestration platform can also be used to implement client-specific features as part
of the claims processing lifecycle. This flexible platform enables the SCE to support
four distinct implementation models which can be used to support a wide variety of
|Pre-adjudication processing and editing
This enables clients to use the SCE to edit and “repair” claims prior
to core adjudication. In this instance:
- The claim can be validated for compliance ensuring key data on
the claim is present and valid.
- The member and policy can be retrieved and validated ensuring
the correct member and policy are used for adjudication.
- The provider and appropriate cross-provider relationships can be
retrieved and validated ensuring the correct provider is used
- Fallout of claims can be managed and resolved manually, if
- Claim data can be modified for adjudication; for example,
splitting claims based on various scenarios.
|Post-adjudication processing and review
This enables clients to use the SCE to review claims that are
approved to pay before payments are made. Secondary edits and audits
can be implemented to validate payment accuracy, including
integration with 3rd party editors. In this instance:
- The claim can be reviewed for random or plan compliance audits
ensuring the payment calculations are valid.
- Clinical or pre-payment edits can be implemented to review the
claim against other previously paid claims.
- Post adjudication duplication validations can be performed to
find similar matching claims.
|External pend management
This enables clients to use the SCE to manage claims that have been
pended in external systems. In this instance:
- Pended claims can be prioritized utilizing the Get Next work
algorithms of the SCE to ensure that the highest priority claims
are presented to examiners.
- The guided event resolution models can be implemented to support
examiner workflow and provide the right information to the
examiner at the right time.
- Reporting on claims operations and claim resolution is
This enables clients to utilize the SCE to support the end to end
adjudication of claims from intake and pre-adjudication editing to
benefit matching and liability calculations. In this instance:
- Both the pre-adjudication processing and editing and smart
claims workstation are supported.
- The claim can match to the benefit configured for the
- Claim liabilities can be calculated utilizing current
accumulator amounts and the benefit adjudication rules.
- Cutbacks based on other insurance payments can be applied.