Mass reprocessing, event groups, and event recycle

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Mass reprocessing, event groups, and event recycle

Description When to use a mass reprocess/adjustment, an event group or an event code recycle
Version as of 8.5
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Description[edit]

This design pattern will provide guidance on when it is best to utilize a mass reprocess, an event group or an event code recycle configuration in the Smart Claims Engine for Healthcare. All of these tools can be used to automate some of the resolution of claims, but each provides distinct advantages over the other. This wiki article should assist in identifying which pattern to use.

Use case examples[edit]

The use cases below provide some common examples on which tool should be used:

  1. A spike in event codes being reported due to an incorrect system setting, benefit configuration, provider or member configuration. In this situation, the number of events being reported is high. This is a prime example of a use case where after resolving the issue at hand, the claims setting those events are reprocessed.
  2. A series of claims have adjudicated incorrectly due to a pricing error or benefit configuration error. This is a prime example where a mass adjustment would be required. The mass adjustment would adjust the original claim and reprocess it against the correct price or configuration.
  3. Claims setting event codes where the information required to proceed is not found. For example: Member not found, procedure code not found, authorization not found. This is a prime example where a claims recycle would be configured to attempt to find the information prior to potentially denying or routing for review.
  4. A spike in claims setting a configuration event code for a specific member or provider. These would indicate a configuration error that would be resolved and a claims examiner would then be able to reprocess the grouped claims together. Note, that if the volume is high, this may then require a mass reprocess to resubmit all the claims against the new configuration.

Before you begin[edit]

Identifying the types of configuration that would be required for the resolution of the event codes should be taken as part of the initial event code review. For claims that may not have a member or provider on file and need recycling, understanding the latency between these databases being updated and the information being submitted to the claims processing database will help understand the length of time that the recycle may need before the second action is taken.

For member/provider/plan configuration issues, a review of the fields that would need to be linked for the event group should be identified. For example, do all the claims having a provider contracting issue all share the same billing provider, servicing location or rendering provider? For member contract or benefit issues, are these linked by the plan selected or are they configured by the employer group?

Process/Steps to achieve objective[edit]

The steps to configure event codes, event groups and mass reprocess and adjustments are documented in the user guide for the Smart Claims Engine for healthcare.

Configuring the recycle:

Once the event codes where data is not found is identified, the settings for the recycle are suggested:

Recycle daily for X times where X is the time is takes to update the claims reference system from the source of truth plus two days.

  • Example 1: member data for new enrollees takes a week from the enrollment (when the member knows their ID number) to be available for claims adjudication (the ID's are available for adjudication). So, X would be 9
  • Example 2: Newly released procedure codes take 2 weeks to be added to the benefits for adjudication, so X would be 16.

Note that the maximum for X should always be less than the system SLA to resolve the claims.

Configuring Event Groups:

Once the event codes that reflect contracting or configurations and the fields indicating a match are identified, the event group can be configured.

  • For example: The event code for an invalid affiliation between the service location and the billing provider is SPE-0089. In this situation, the event group configuration will be the service location - Facility name, facility address and the billing provider Tax ID could be suitable fields for the event group.

Configuring a mass reprocess or mass adjudication

These will use the search capabilities available within the tool to identify the population of claims needing adjusting/reprocessing.

  • For example, selecting all claims that set event code SVE-0002 or all claims for billing provider ABCDEF with processing dates > 20210101.

Results[edit]

The goal of these tools are to make operational processing as efficient as possible and reduce the number of claims that require an operator to touch. The recycle logic enables claims to process without needing manual review, the event group logic enables a single examiner to immediately reprocess a population of claims based on the matching key attributes without needing to touch them individually.