SCE orchestration design patterns

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SCE orchestration design patterns

Description SCE orchestration design patterns
Version as of 8.7
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Introduction[edit]

In Smart Claims Engine orchestrations are used to group a series of sequences together for the purposes of performing key tasks during the processing of a claim. Each orchestration is made up of one or more module sequences which further contain a sequenced list of modules. These modules can be reused across multiple orchestrations, based on the implementation approaches.

Use case examples[edit]

In Smart Claims Engine (SCE), clients can configure different orchestrations based on their needs. A few sample use cases are listed below.

Sample scenario 1 - Preadjudication edits (or validation processing).[edit]

If the SCE is implemented to perform just pre-adjudication editing as part of the claim processing, client can choose to configure their orchestration with sequences and modules as mention below:

  • Sequence : Preadjudication edits or Validation processing
  • Modules :
    • Process validation edits
    • Member match
    • Member validations
    • Member policy selection and eligibility
    • Subscriber lock
    • Provider eligibility

Samplescenario1.jpg

Sample scenario 2 - Business edits (or Core edits)[edit]

If the SCE is implemented to perform just editing as part of the claim processing, the client can choose to configure their orchestration with sequences and modules as mention below:

  • Sequence : Business edits or Core edits
  • Modules:
    • Claims business edits
    • Claims business audits
    • TPL (Third party liability) edits
    • Split claim

Scenario2Sample.jpg

Sample scenario 3 - Smart Claims Management[edit]

If the SCE is implemented as a smart claims management tool (similar to other implementation approaches such as Claims Repair or Claims Workstation), client can choose to configure their orchestration with sequences and modules as mention below:

Orchestration : SCM

1. Sequence : Preadjudication edits or Validation processing

Modules :

  • Process validation edits
  • Member match
  • Member validations
  • Member policy selection and eligibility
  • Subscriber lock
  • Provider eligibility

2. Sequence : Business edits or Core edits

Modules :

  • Claims business edits
  • Claims business audits
  • TPL (Third party liability) edits
  • Split claim

3. Sequence : Event review

Modules :

  • Episode processing
  • Skill assignment
  • Event code review

Scenario3sample.jpg

Sample scenario 4 - Adjudication and adjustments[edit]

If the SCE is implemented to manage full end-to-end adjudication, clients can choose to create two orchestrations, one for adjudication and another for adjustments.

Sample scenario4.jpg

Results[edit]

To learn more about the different out of the box SCE orchestrations, sequences and modules (and how to view, update them) , explore the Pega Smart Claims Engine community documentation.