Creating and extending sequences to customize adjudication

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Creating and extending sequences to customize adjudication

Description Description and use of sequences in the Smart Claims Engine application.
Version as of 8.5
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences

Definition and concept

Sequence is defined as a collection of one or more modules with a pre-defined execution order. This is the middle layer in the processing hierarchy for Smart Claims Engine. It groups logical operations and controls portions of the orchestration processing.

Sequence figure 1

Initialization and finalization processing steps can be defined within the sequence configuration. These are key extension points during the processing.

A sequence can be reused in multiple orchestrations. This can be useful in many common claims processing scenarios including:

  • Identical processing steps between types of claims like dental and professional. Specific edits can be different while membership and eligibility rules are reusable without modification.
  • Lines of business utilizing the same provider networks while benefit coverage differs significantly.
  • Progressive testing environments which have different components, data quality, and purposes. User acceptance testing, system integration testing, and development unit testing have different purposes and can be streamlined to reduce time-to-market.
  • Supporting a phased implementation of Smart Claims Engine as illustrated in figure 2.
Sequence figure 2

The sequence hierarchy is important to understanding the processing flow. It is initiated from the orchestration and in turn initiates modules. The sequence returns control to the orchestration after module processing completes.

Sequence figure 3

Key considerations

The sequence cannot be removed from Smart Claims Engine if it is included in an orchestration.

OOTB sequences can be moved, removed, or extended to meet specific processing requirements.

Sequences produce a result status that is used to determine whether to continue to the next sequence, restart the sequence, restart the orchestration or stop processing.

Reference materials on Community