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Pega Smart Claims Engine User Guide

Updated on December 15, 2021

Pega Smart Claims Engine for Healthcare (SCE) supports medical, dental, and vision claims management, processing, and reporting, including Medicaid reclamation claims. SCE is a flexible orchestration platform with role-based end-user navigation and guidance.

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It supports a wide variety of claim processing requirements, including business rules-driven edits and processing, adjustments, claims splitting, intelligent work routing, claim status updates, balancing, and surcharges. Seamless integration within a healthcare payer's technology and existing application ecosystem in order to support true end-to-end business and system workflow is possible because:

  • The SCE architecture utilizes Pega's industry-leading technology such as business process management, case management, and workflow technologies.

  • Standards-based integration unites Pega processes with enterprise systems to maximize existing investments and reduce data inconsistencies and redundancies.

  • Standalone, modular, or cloud implementations provide the flexibility to fit within an organization's technology infrastructure.

  • Rules-driven controls define how each processing step is managed internally and called from external sources.

  • SCE incorporates the Pega Foundation for Healthcare, a rich set of standard-based healthcare data models and tools which support X12, HL7, ICD, and HIPAA compliance rules. This layer functions as the backbone of the system and simplifies integration with other systems.

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