Smart Claims Engine personas and portals

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Smart Claims Engine personas and portals

Description SCE access groups, roles and portals summary
Version as of 8.7
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Smart Claims Engine access groups, roles and portals[edit]

The Smart Claims Engine (SCE) comes packaged with a series of access groups that can be used to enable different capabilities across operators (users). Access groups may be associated with one or more portals, roles, and claims field edit capabilities. Roles may be associated with multiple privileges. The following tables summarizes the access groups, roles and portals used by different SCE personas.

Persona Access Groups Roles Portals
Junior claims examiner PegaClaims:JuniorClaimsExaminer PegaClaims:JuniorClaimsExaminer Claims examiner
Claims examiner PegaClaims:ClaimsExaminer PegaClaims:ClaimsExaminer Claims examiner
Senior claims examiner PegaClaims:SeniorClaimsExaminer PegaClaims:SeniorClaimsExaminer Claims examiner
Claims supervisor PegaClaims:ClaimsSupervisor PegaClaims:ClaimsSupervisor Claims manager
Claims manager PegaClaims:ClaimsManager PegaClaims:ClaimsManager Claims manager
Business analyst PegaClaims:BusinessAnalyst PegaClaims:BusinessAnalyst Business analyst
Test analyst PegaClaims:TestAnalyst PegaClaims:TestAnalyst Test analyst
System manager PegaClaims:SystemManager PegaClaims:SystemManager System manager

SCE portals left side menus options[edit]

The portals associated with the access groups may be  configured with different left side menu options. Menu options such as creating and searching for claims and inquiries, mass adjustments, mass transfers, etc. are available under the left side menu. The portal displayed (upon login) is based on the default access group associated with the operator. The selections on the left side menu for all the portals are as follows.

Menu item Menu item description Claims examiner portal Claims manager portal Business analyst portal Test analyst portal System manager portal
+ (New) This feature provides you with the ability to create new claim inquiries, claims and mass adjustments. Create new:
  • Test claims
  • Claims inquiry
Create new:
  • Test claims
  • Mass adjustments
  • Claim inquiry
Create new:
  • Test claims
  • Mass adjustments
Not available Not available
Dashboard Selecting Dashboard brings you back to your portal display. Yes Yes Yes Yes Yes
Claims This feature provides you with the ability to search for claims, mass adjustments and mass transfers. Available options :
  • Claims search
Available options :
  • Claims search
  • Mass adjustments
  • Mass transfer
Available options :
  • Claims search
  • Mass adjustments
  • Mass transfer
Available options :
  • Claims search
Available options :
  • Claims search
  • Mass adjustments
  • Mass transfer
Claims inquiry This feature provides you with ability to search for claims inquiries. Claims inquiry search available Claims inquiry search available Claims inquiry search available Not available Claims inquiry search available
Configuration This feature provides you with the ability to configure specific elements of the SCE, including event codes, attestation text, and random audits. Not available Not available Yes - Different configuration options available. Not available Yes - Different configuration options available.
Test Suite This feature provides you with the ability to create and manage test claims, test scenarios and test sets. This feature is typically made available in the development environment. Not available Not available Available options :
  • Test claims
  • Test scenarios
  • Test sets
Available options :
  • Test claims
  • Test scenarios
  • Test sets
Available options :
  • Test claims
  • Test scenarios
  • Test sets
Member search This feature provides you with the ability to search for members. Member search available Member search available Not available Not available Not available
Notification configuration This feature provides you with the ability to add notifications to the notifications widget. Not available Notification configuration available Notification configuration available Not available Notification configuration available
Reports This feature provides you with the ability to access reports. Different reports available Claims Operation Reports (Claim backlog, First pass rate, Average claim processing count, Average days on hand, Average resolution time in days, First pass rate and other reports available. Different reports available Different reports available Six reports (Total number of claims processed, Exception records, Claim statistics from files received, Average claim processing, Total number of claims processed, Number of files processed). Other reports available as well.

Note:

1. A user can change the WorkActionsReview and pyWorkActionsPerform rules to customize the action menu for each role as needed.

2. A user can change the ClaimManualEditsConfiguration and ClaimManualEditsConfigurationClaimUpdate decision tables to customize the field access for each persona as needed.