SCE orchestration design patterns

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

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.

A business solution that automates workflows in your organization. Multiple, unrelated applications can be hosted in the same system. You create an application by running the New Application wizard.

A mechanism that secures an object or a ruleset version against changes. You can lock ruleset versions, instances of a concrete class, and the Rule-Application rule type.

Skill rules are instances of the Rule-Admin-Skill rule type. A skill rule gives a name and a range of proficiency value to different user skills. These skills can then be associated with users (in the Operator ID instance), and can form the basis of skill-based routing decisions.

A task that a user completes so that the business process can advance towards the final resolution. You can add assignments to the business process to collect information or seek approvals from users with different roles or levels of expertise. For example, in an online credit card application, a customer needs to fill out the online credit card application form by providing a range of personal and financial details. When the application form is completed, the process advances to the bank employees who can process the request by either approving or rejecting the application.