External pend management

Pega Smart Claims Engine™ for Healthcare allows clients to resolve claim edits generated in an external system by leveraging the granular disposition options, user interface, and guided resolution flows of Smart Claims Engine.

You can map a claim edit generated in an external system to an event code in Smart Claims Engine. When a claim file including the claim edit is transmitted to Smart Claims Engine, Smart Claims Engine will report the appropriate event code on the claim.

The event code resolution path is configured in Smart Claims Engine. Smart Claims Engine can be configured to automatically deny the claim or claim line generating the claim edit, it can report the edit as informational only, or it can be configured to suspend the claim.

If the claim is suspended, the event code can be configured to apply a specific recycle option to the claim or the claim can be immediately presented to a claims examiner. Event codes presented to a claims examiner may be resolved using Smart Claims Engine’s standard or guided event code resolution process. You can leverage existing standard event code resolution options or existing guided event resolution flows, or you may create guided event resolution flows customized to your specific business processes.

You can also use Smart Claims Engine to manage workflow and suspended claim inventory.

Smart Claims Engine prioritizes and queues suspended claims automatically according to customized criteria and configurable SLA management rules. Once the issues are resolved, the claim is resubmitted for reprocessing in the primary adjudication system.

The following image is a high-level flow of how external pends are typically managed in Smart Claims Engine.

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