The following Pega Smart Claims Engine for Healthcare global settings are configurable:

• Module Settings
  • Global measurement – An indicator that defines whether a measurement should be captured for all modules.
    • If On, this value overrides the measurement indicators at the module level.
    • If Off, it uses the measurement indicator at the module level.
  • Global audit messages – An indicator that defines whether an audit message should be reported for all modules.
    • If On, this value overrides Audit indicators at the module level.
    • If Off, it uses the Audit indicator at the module level.
• Subscriber Lock Settings
  • Subscriber lock – An indicator that defines whether to use the Subscriber Lock feature in the application.
    • If On, the Subscriber Lock feature is activated, which means that you cannot process any subsequent claims for a specific subscriber until the lock is released for the original claim that suspended or requires the manual Claims Examiner review.
    • If Off, the Subscriber Lock feature is deactivated, which means that claims you are processing are not subject to subscriber locking.
  • Subscriber lock recycle interval – The time when claims that have set the subscriber lock are resubmitted for processing.
• Split Claim Settings
  • On/off radio button enables the manual splitting of claims.
  • Manual split claim threshold defines the maximum number of new claims that may be created upon manually splitting a claim.
• Configuration Settings
  • Configuration applies to – Defines the class that this application references when resolving custom rules.
  • Configuration work class – Defines the class to which claims processed by this application instance are saved.
  • Configuration history class – Defines the class to which the history for claims processed by this application instance is saved.

  • Reprocess Count – Defines the value for how many times the claim can go through reprocess.

  • Process Claim Status List – Identifies the claim status for processing.

• Event Settings
  • Use Client Event Code – Use Client Event Code option will only allow the client’s event codes to displayed in the Event code list. This feature does not yet allow the client to replace the system generated event codes with the client codes. The client codes do not yet display in any other UI or reports.
  • Event code reporting interval – Defines the interval used to report event process times.
  • Event Code Implementation ID Order of Resolution – Defines the order of event codes to be processed in the Smart Claims Engine by their Implementation ID. To Modify, select the Modify Event Code Implementation ID button.
• Claim Processing Settings
  • Process new claims every – Defines the interval used to process incoming (new) claims. Also, you can use the Process Now button to immediately trigger the new claims process.
  • Process Recycle Claims every – You can use the Process Now button to immediately process any claims that are in Process Recycle status
  • Process Pending-Reprocess claims. – Defines the interval used to process claims with Pending-Reprocess status.
  • Initiate 835 Process - The Initiate 835 Process would generate an 835 file considering claims which were not picked since the last 835 generations.
  • Modify Available Claim Identifiers – Allows the user to modify current claim identifiers to support configurations (All, Chargeable, Medicaid Reclamation, Reporting) List of claim identifiers to support configurations.
  • Resolution Flows – List of Resolution flows to support configuration. To Modify, select the Modify Suspend Resolution List button.
  • Create claim WO from EDI batch transactions – User can click Process Now to immediate create claim work objects from EDI batch transactions.