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Provider match

Updated on December 15, 2021

Pega Marketing User Guide

The provider eligibility module (SPE) supporting the provider match is used in the SCE to retrieve provider information from the supporting provider source of truth and then validating the information against the provider information supplied on the claim. Populating the provider data to support the match logic

The following providers are reviewed for validation at both the claim and line levels when appropriate:

  • Billing provider
  • Referring provider
  • Rendering provider
  • Pay-to provider
  • Supervising provider
  • Service facility location
  • Purchased service provider
  • Ordering provider
  • Attending provider
  • Operating provider
  • Other operating provider
  • Assistant surgeon

The claim form type drives the types of providers that are displayed in the claim UI at the header and claim line levels. The table below illustrates how providers are displayed by claim form type.

Provider typeProfessional claim Professional claimInstitutional claim Institutional claimDental claim Dental claim
Header Line Header Line Header Line
Billing provider X X X
Referring provider X X X X X
Rendering provider X X X X X X
Service facility X X X X X
Supervising provider X X X X
Purchased service provider X
Ordering provider X
Operating provider X X
Other operating provider X X
Attending provider X
Assistant surgeon X X

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