SCE orchestration design patterns
SCE orchestration design patterns
Introduction
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
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).
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)
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
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
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
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.