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Claim level statuses

Updated on December 15, 2021

Claim statuses in Smart Claims Engine are displayed on the banner at the top of the claims screen. The claim status is also displayed in the claim header slot on the right side of the claim screen.

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Most claim statuses consist of two hyphenated words which, taken together, define the state of the claim. Claim statuses beginning with Pending tell you that the claim is not finalized. Claim header statuses beginning with Resolved tell you that the claim is finalized in SCE.

Claim header statuses in Smart Claims Engine:

Claim header statusDefinition
NewIndicates that the claim has been imported, parsed, and mapped to a work object and is waiting for initial processing.
Open-ProcessingThe claim has begun processing.
Open-ErrorIndicates an error during processing; the claim did not get to the end of the orchestration and process through the review rules.
Pending-InvestigationThe claim is not yet finalized; there are one or more event codes open on the claim.
Pending-RecycleThe claim has been routed to a recycle work queue based on event code configuration or other business rules.
Pending-UpdateThe claim has been assigned to a claims examiner who has opened the claim and saved it to their worklist using Save for later
Pending-ReprocessAll event codes have been resolved and at least one event code was resolved directly by a claims examiner. Once submitted, the claim status is set to Pending-Reprocess until the system reprocesses the claim.
Pending-ApprovedAll event codes have been resolved or no event codes were raised on the claim and at least one claim line has a billed service that has been allowed. The claim is ready for finalization and payment batch.
Resolved-PaidThe claim has completed adjudication and the payment batch cycle has been completed. The claim may contain both approved and denied service lines.
Resolved-DeniedThe claim has completed adjudication and includes on denied service lines and/or a denial at the claim level.
Resolved-CompletedThis status is set on Reporting (capitated) claims when the claims have completed processing.
Resolved-SplitThis status is applied to an original claim when it is split into two or more claims.
Resolved-CancelledThis status is set when the entire claim has been annulled and the prior status is not “Pending-Approved” or “Resolved-Paid”
Resolved-VoidedThis status is set when a claim is adjusted or cancel/void is applied and the prior status was “Pending-Approved” or “Resolved-Paid”. This indicates all associated accumulators have been reversed in the system.

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