Skip to main content


         This documentation site is for previous versions. Visit our new documentation site for current releases.      
 

Adjudication

Updated on December 15, 2021

Adjudication in the SCE encompasses the final calculations to identify the members cost shares based on the benefit configuration and existing accumulations.

Pega Marketing User Guide

The SCE provides COB models to reduce the payment based on the other payer’s adjudication results.

CapabilityDescription
Cost share calculations

The SCE calculates the appropriate cost shares based on the rules defined in the benefit. The SCE utilizes any current accumulator balances in the calculations of the cost shares to identify the members liability.

  • Calculate copay
  • Calculate coinsurance
  • Calculate deductible
  • Calculate any member penalties
  • Apply cost share accumulators
COB deductions

The SCE uses COB models to reduce the payment based on the other payer’s adjudication results.

  • Deduct other payer amounts

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best.

Pega.com is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us