SCE orchestration design patterns
SCE orchestration design patterns
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
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
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
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.
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.