Creating new event codes for claim adjudication

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Creating new event codes for claim adjudication

Description Describes the pattern behind adding new event codes
Version as of 8.5
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences

Definition and concept

Event codes are used to control processing or report information on claims. Usage can range from data validation and business defined edits to guided resolution and allowable actions. They are stored as data instances. See the Claim Engine Configuration page for additional information on event code rulesets.


Event code configuration determines actions from either the system or a processor that may be applied to a claim. Basic information about the event code is defined during the initial creation. Example details include descriptors, triggering logic, and dispositions.

System rules created to assign event codes to claims are referred to as triggering logic. This criteria exists for OOTB event codes but can be added for dynamic or new event codes during implementation.

Disposition refers to how a claim is treated by the system when the event code is applied. The options are properties of the event code. Additional criteria can be added so multiple dispositions may be applied at a granular level if desired. Resolution actions represent the options made available to finalize the claim.

Many event codes are available for import during implementation to get started. It is a good practice to determine the needs based on how the system is being utilized.

Key considerations

Triggering logic to raise the event code is critical for processing. OOTB codes have triggering logic built into the SCE rules. New event code triggers should be added in the module extension points when available. The AddEventCode function called from a Response action should be used for triggering custom event codes.

A code is specific to a module. Proper assignment of the event code based on processing logic is important. For example, event codes related to membership edits should occur early in the process flow.

The expected outcome of the event code drives the flow and available actions. This encompasses both disposition and resolution actions.  

Additional automation can be added to the processing flow through Action codes.

General guidelines

Review and familiarize yourself with the claims and reference data models for the appropriate release as a starting point.

The event code level assignment is critical to ensure correct processing. The options are claim level and claim line level.

Always create and execute unit tests for new event codes. Automate testing when possible to improve scalability.

Reference materials on Community

Event code management

Action codes