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Claim identifiers

Standard Electronic data interchange (EDI) claims transactions require the inclusion of the transaction type code (BHT06). In Pega Smart Claims Engine, the transaction type code is called the claim identifier. The claim identifier is displayed by expanding the claim header section of the claim UI in Smart Claims Engine; the two-digit code is translated for your convenience.

Claim identifier in SCE

The identifier field is auto-populated for electronically submitted claims.

Claim identifier CH

A transaction type code of CH identifies a chargeable claim in Smart Claims Engine. A chargeable claim is a healthcare claim which reports that a service has been provided and requests payment. Claims that report a mixture of capitated and non-capitated services also fall under the CH transaction type code.

Claim identifier RP

A transaction type code of RP identifies a reporting claim in Smart Claims Engine. Reporting claims refer to capitated claims. Capitation is defined as a set amount of money paid to a provider for each assigned member, per period of time (usually per month), whether or not that member seeks care.

  • SCE processes and edits reporting claims the same as chargeable claims with the exception of these values:
    • Paid Amount = 0
    • Paid Date = Claim process date

The claim goes through the adjudication process and calculates values for the Allowed amount, Copay, and Coinsurance, similar to a chargeable claim. However, it sets the Paid Amount to 0.

While payments are not issued for reporting claims, reporting claims are used to support accumulator updates and to calculate member cost shares.

Claim identifier 31

A transaction type code of 31 identifies a Medicaid reclamation (subrogation) claim in Smart Claims Engine. Medicaid reclamation refers to a situation where a Medicaid plan has paid a claim in error. Medicaid is always the payer of last resort, so when other insurance coverage is identified through reconciliation of eligibility files, claims are submitted to that plan in order to reclaim monies.

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