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Implementation models

Updated on December 15, 2021

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.

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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 client needs.

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 for adjudication.
  • Fallout of claims can be managed and resolved manually, if required.
  • 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 available.
End-to-end adjudication

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 member.
  • Claim liabilities can be calculated utilizing current accumulator amounts and the benefit adjudication rules.
  • Cutbacks based on other insurance payments can be applied.

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