Claim processing reports
Pega Marketing User Guide
Smart Claims Engine provides baseline reporting on claims processing. These reports are available by selecting the Claims processing category from the dropdown on the reports screen.
The reports listed with denoted by an asterisk (*) are also displayed in the Claims manager portal and provide weekly, monthly, and yearly breakdowns.
Available claims processing reports include:
| Report name | Type | Description |
| Average Claim Processing Count | Chart | Count of claims processed since yesterday, broken down by status. |
| *Average Claim Processing Count - Month | Chart | Count of claims processed this month, broken down by status. |
| *Average Claim Processing Count - Week | List | Count of claims processed in the past 7 days, broken down by status. |
| *Average Claim Processing Count - Year | Chart | Count of claims processed this year, broken down by status. |
| Average Claim Processing Time | Chart | Displays average processing time of claims resolved in the last 7 days. |
| Average Claim Processing Time - 3 Hour Increments | List | Displays resolution time in minutes, status, claim type, billing provider ID, payer ID, and contract ID; broken down into 3 hour increments. |
| Average Claim Processing Time -1 Hour Increments | Chart | Displays average processing time of claims resolved in the last 7 days, broken down by hour |
| Average Claim Processing Time -1 Hour Increments | List | Displays resolution time in minutes, status, claim type, billing provider ID, payer ID, and contract ID; broken down into 1 hour increments. |
| Backlog Counter | Summary | Displays all unresolved claims by status, as well as a count of those claims. |
| Claims - By Status Last 7 days | List | Lists all claims processed in the last 7 days by status. |
| Claims - Last 7 Days | List | Lists claims that have been updated in the last 7 days |
| *Claims Backlog | Chart | Displays all unresolved claims from the last 7 days, with claim counts per day. |
| Claims exceeded SLA days | List | Lists claims on hold with a hold SLA assigned |
| Claims Test - Last 7 Days | List | List of test claims processed in the last 7 days |
| Claims to be Paid | List | Lists claims approved for payment or cancelled |
| Encounter process - Member contract | Summary | Total number of encounters processed per member |
| Event Code/ Module Fallout Details Report | List | Suspended claims received today and in the last 7 days |
| Event Code/Module Fallout Summary Report | Summary | All suspended claims broken down by age and module |
| Event Group Claims | List | List of claims associated to event groups |
| *First Pass Rate | Chart | Displays first pass indicator for claims resolved in the last 7 days, broken down by claim type |
| *First Pass Rate - By Month | Chart | Displays first pass indicator for the month, broken down by claim type |
| *First Pass Rate - By Year | Chart | Displays first pass indicator for claims resolved this calendar year. |
| First Pass Rate - Overall Last 60 days | Summary | Displays first pass indicator (Y/N) for claims resolved in the last 60 days. |
| IBNR | Summary | Displays Pending-Approved claims broken down by status |
| IBNR - Provider | Summary | Displays IBNR by billing provider tax identification number |
| LPI Report | Summary | Lists claims incurring late payment interest by claim type |
| Mass Adjustment Process - By Provider | List | List of sequenced mass adjustment jobs with breakdown by provider |
| Mass Adjustment Process - By Subscriber | List | List of sequenced mass adjustment jobs with breakdown by subscriber |
| Operator Performance | Summary | Summary of tasks by operator, including processing time and duration |
| Operator Statistics Manager | Chart | Summary of operator resolved work for the current week |
| Operator Statistics Manager | Summary | Daily summary of operator resolved work |
| Process Time | Chart | Process time per claim type for the past 7 days |
| Provider Claim Analysis | Summary | Summary of claims approved in the last 7 days by provider tax identification number |
| Test claims | List | Test claims updated in the last 7 days |
| Turn Around Time | Summary | Claim turnaround time for the last 7 days by provider |
| Turn around time | Chart | Claim turnaround time for yesterday by claim type |
Additionally, the Claims manager portal displays the following reports:
| Report name | Type | Description |
| Average days on hand | List | Displays the average days on hand and the average productivity (average number of claims per day per examiner) of claims examiners. |
| Average resolution time in days | Chart | Displays the average resolution time in days for the time period selected. |
Previous topic Report actions Next topic Healthcare IT operations reports