Creating guided event flows using UI patterns
Creating guided event flows using UI patterns
| Description | Learning about the Smart Claims Engine (SCE) guided event resolution flow |
|---|---|
| Version as of | 8.5 |
| Application | Pega Smart Claims Engine for Healthcare |
| Capability/Industry Area | Healthcare and Life Sciences |
Definition
The Smart Claims Engine (SCE) guided event resolution flow is a sequence of steps that presents users with the user Interfaces, data, decision models, and validations needed to manually resolve an event code on a claim.
Concept
When SCE adjudicates a claim, it goes through initial validation processes to check for erroneous, missing, or duplicate information. If a claim fails to comply with the configured business policy rules, SCE sets event codes on that claim. The SCE guided event code resolution feature supports claim examiners' manual resolution of event codes that have been automatically set on the claim by the system. Based on issues found in the claims (along with other criteria), claims associated with the event code are routed to a common workbasket, or to the individual worklists, so that claims examiners can take actions and resolve the issues.
Key considerations
A guided event resolution is used when:
- Information within the system is not sufficient enough to determine the resolution of the claim.
- Information outside the actual claim or system is needed to decide the resolution of the claim.
- When decisions made outside the adjudication result in manual changes to the claim.
Use case examples
Possible duplicate claim
When SCE adjudicates a claim, it checks whether the claim being processed is a duplicate claim. SCE compares the processed claim against historic claims in the system. If the claim is identified as a duplicate, an event code is raised on the claim. A guided event code resolution is provided to the claims examiner with the possible duplicate claim ID, for the claim examiner to investigate further.
Subscriber address mismatch
When SCE adjudicates a claim, the address of the subscriber on the claim is compared with the address of the subscriber in the system. If the addresses do not match, an event code is raised on the claim. A guided event code resolution is provided to the claims examiner, with the option to correct the address on the claim or in the system.
General guidelines
- Review and familiarize yourself with the event code data models for the appropriate release as a starting point.
- The event code assignment is critical to ensuring the availability of the correct guided event code resolution.
- Show all the information that examiners need to make a quick decision during an event code resolution.
Reference materials on Community
- Event code management
- For more information, see Chapter 13 in the SCE User Guide