Extending processing flows with action codes.

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Utilizing action codes to manage SCE processing /
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Extending processing flows with action codes.

Warning: Display title "Extending processing flows with action codes." overrides earlier display title "Utilizing action codes to manage SCE processing".
Description Guidelines for extending processing flows by using action codes
Version as of 8.5
Application Pega Smart Claims Engine for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Definition[edit]

Action codes are codes that are raised on a claim during adjudication by Smart Claims Engine (SCE). These codes can be raised when:

  • Adjudication (or orchestration) reaches a certain point within the code (or its lifecycle) while processing the claim.
  • A claim meets a predefined criteria based on the data submitted on it.
  • When exception handling is required.

Concept[edit]

SCE action codes allow for adjudication, in order to alter the processing of the claim. Action codes are designed to apply exception handling. Based on the configuration, SCE can report an action code anywhere within its orchestration to support different claims processing or exception handling scenarios.

Use case examples[edit]

Once identified on a claim, action codes can override events, assign work to a specific work queue, change the urgency of an event, and bypass modules.

AUP1 - Bypass pricing modules[edit]

This action code is raised when authorization-based pricing is applied to claims in the SCE; when this action code is raised on a claim, the claim will bypass the pricing module as authorization pricing is always applied when available.

A-417 – Claim latency[edit]

SCE raises this action code when the service level agreement (SLA) on the claim has exceeded the claim latency percentage configured in the system settings. When the action code is added to a claim, the urgency is increased.

Activity driven Action codes[edit]

SCE can raise a configured action code to reflect an activity performed on the claim. For example, within the orchestration code, an action code can be configured to be assigned to a claim when units are converted from miles to kilometers. This action code can then drive ambulance pricing and other validations as needed. The action code would be shown on the claim user interface to assist with any examiner review.

General guidelines[edit]

  • Action codes raised on a claim may be viewed in the claims user interface by clicking Actions>View claim history, and then expanding the Action codes section.
  • Review and familiarize yourself with the existing action code data models as a starting point. Action code should be raised based on your need to alter claims processing.

Reference materials on Community[edit]

  1. For more information, see Action codes in the SCE User Guide