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Mapping data or logic for Claims Inquiry integration with a claims engine

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To map your data or logic to invoke the Claims Inquiry case type in a claims engine, you need to modify the CreateClaimsInquiryInClaimsEngine_Extn data transform.

Check the parameter settings in the CreateClaimsInquiryInClaimsEngine parent data transform. If they meet your business needs, you do not have to perform this task.
  1. In the header of Dev Studio, enter and search for CreateClaimsInquiryInClaimsEngine_Extn.

  2. Click the Data transform rule.

  3. On the Data Transform page, on the Definition tab, click the Add a row icon and follow these steps:

    You are setting multiple properties based on your business requirements so that you can pass results to another claims engine.
    1. In the Action column of the new row, from the list, select Set.

    2. In the Target column, select a property to store the information such as the claims inquiry ID that is created in the claims engine.

      .ServiceCaseID
    3. In the Relation column, select equal to.

    4. In the Source column, enter and select the parameter of the claims engine that corresponds to the Pega Customer Service for Healthcare property in the Target column.

      If you are connecting to Pega Smart Claims Engine and are using the API, you can select the same setting as used in the parent data transform.
    5. Repeat this step for each property that you want to set.

      You might want to store the status that is returned from claims engine. You might enter .ClaimStatus as a target property. Based on the service used and the source parameter, you get a response.
  4. Click Save.

Mapping data or logic for Claims Inquiry integration with a claims engine

To map your data or logic to invoke the Claims Inquiry case type in a claims engine, you need to modify the CreateClaimsInquiryInClaimsEngine_Extn data transform.

Check the parameter settings in the CreateClaimsInquiryInClaimsEngine parent data transform. If they meet your business needs, you do not have to perform this task.
  1. In the header of Dev Studio, enter and search for CreateClaimsInquiryInClaimsEngine_Extn.

  2. Click the Data transform rule.

  3. On the Data Transform page, on the Definition tab, click the Add a row icon and follow these steps:

    You are setting multiple properties based on your business requirements so that you can pass results to another claims engine.
    1. In the Action column of the new row, from the list, select Set.

    2. In the Target column, select a property to store the information such as the claims inquiry ID that is created in the claims engine.

      .ServiceCaseID
    3. In the Relation column, select equal to.

    4. In the Source column, enter and select the parameter of the claims engine that corresponds to the Pega Customer Service for Healthcare property in the Target column.

      If you are connecting to Pega Smart Claims Engine and are using the API, you can select the same setting as used in the parent data transform.
    5. Repeat this step for each property that you want to set.

      You might want to store the status that is returned from claims engine. You might enter .ClaimStatus as a target property. Based on the service used and the source parameter, you get a response.
  4. Click Save.

Mapping request parameters at the implementation layer

To create the required case type in Pega Smart Claims Engine or another claims engine and allow the service or API to operate properly, you need to map the request parameters.

Check the parameter settings in the ClaimsInquiryInSCERequestPOST parent data transform. If they meet your business requirements, you do not need to perform this task.
  1. In the header of Dev Studio, enter and search for ClaimsInquiryInSCERequestPOST_Extn.

  2. Click the Data transform rule.

  3. On the Data Transform page, on the Definition tab, click the Add a row icon and follow these steps:

    1. In the Action column of the new row, from the list, select Set.

    2. In the Target column, select a property that is needed to request information.

      .NationalProviderIdentifier
    3. In the Relation column, select equal to.

    4. In the Source column, enter and select the parameter of the claims engine that corresponds to the Pega Customer Service for Healthcare property in the Target column.

      If you are connecting to Pega Smart Claims Engine and are using the API, you can select the same setting as used in the parent data transform.
    5. Repeat this step for each property that you want to set.

  4. Click Save.

Setting the URL for the environment of the claims engine

Set up this URL so that Pega Customer Service for Healthcare can connect to Pega Smart Claims Engine or another claims engine. You must perform this task if you are extending the Claims Inquiry case type.

  1. In the header of Dev Studio, enter and search for ClaimsEngineIntegrationURL.

  2. Click the Dynamic System Settings rule.

  3. On the Settings tab, enter the URL for the environment of Pega Smart Claims Engine or another claims engine.

  4. Click Save.

Activating the integration flow between Pega Customer Service for Healthcare and a claims engine

Activate the integration flow between Pega Customer Service for Healthcare and Pega Smart Claims Engine for Healthcare or another claims engine so that you can send and receive data. You must perform this task if you are extending the Claims Inquiry case type.

  1. In the header of Dev Studio, enter and search for ClaimsEngineIntegrationExists.

  2. Click the Dynamic System Settings rule.

  3. On the Settings tab, enter true.

  4. Click Save.

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