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

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

Samplescenario1.jpg

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

Scenario2Sample.jpg

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

Scenario3sample.jpg

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.

Sample scenario4.jpg

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.