Creating orchestrations to control claim processing

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Creating orchestrations to control claim processing

Description Describes the role of orchestrations and how they can be used for complex processing scenarios
Version as of 8.5
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences

Definition and concept

An orchestration is the top level organizational element of the Smart Claims Engine modular design. It is comprised of one or more sequences. Sequence is defined as a collection of modules with a defined execution order. Modules are self-contained rulesets designed to perform specific processing functions. They are assigned a pre-defined collection rule as their process. Figure 1 illustrates the components and associated hierarchy.

Figure 1

The orchestration defines end-to-end processing for a claim. It guides the transaction through the defined logic but does not have to end with a finalized claim. Figure 2 represents the logical flow inside a single orchestration. Exit points may be added within modules to stop processing if needed.

Figure 2

Key considerations

Specific orchestrations may be assigned for processing directly through input or programmatically. Direct assignment would be expected when using an API. Programmatic selection can be driven from data or meta-data on or associated to the inbound record.

Smart Claims Engine must have default orchestrations set for adjudication and adjustment processing. Only one default may be set for each type.

Orchestration level customization can be achieved via the initialization and finalization extension points.

Multiple orchestrations can be combined to accommodate complex, phased implementations. For example, pre-adjudication, adjudication, and post-adjudication orchestrations can be introduced at different intervals to mitigate risk and enhance control during major system replacements.

Special orchestrations can be created to facilitate testing while executing the same sequences planned for production. This leverages the modular design so any special steps can be modified for test purposes without altering the primary logic.

Reference materials on Community

Manipulating sequences