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Claims adjudication process

Claims adjudication explained

Claims adjudication is the complex process applied by healthcare payers to determine their responsibility for the member's benefits, member's liability, provider payment, and plan liability.

When healthcare payers process medical and dental claims, they have three primary objectives:

  1. Accuracy - transparently applying the correct benefits and pricing to the claim
  2. Timeliness - processing the claims and issuing payment per various contractual obligations or state or federal mandates
  3. Efficiency - auto-adjudication (automatic processing) of the highest number of claims possible to reduce overhead costs and penalties. Healthcare payers have a goal of maximizing user efficiency when processing claims and performing other claim-related operations.

Pega Smart Claims Engine™ for Healthcare is designed to assist payers in meeting each of these goals.

Adjudication overview

You can build orchestration layers in Smart Claims Engine for specific purposes such as applying and resolving pre-adjudication edits, applying and resolving post adjudication edits, external pend management, and end-to-end claim adjudication.

Orchestration begins with the intake of claims via XML, EDI, or API; claims may also be manually keyed in Smart Claims Engine.  Once a claim enters Smart Claims Engine, data included on the claim or in the claims file guides the claim to the correct orchestration layer. The orchestration layer then drives the claims through the configured orchestration modules.

Claims that travel through the orchestration may auto-adjudicate or be suspended for claims examiner review as business rules that require manual review and a decision from a claims examiner are encountered.

The Smart Claims Engine orchestration layer manages claims from intake through finalization or export to another system.

If claims are finalized in Smart Claims Engine, the claims data is extracted, payment (if any) is issued, and claims are resolved. Documents (electronic or paper) are created to explain the claim processing and payment decisions to providers and members.

Claims adjudication activity

In the following image, click the + icons to learn more about claims processing in Smart Claims Engine.

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