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About processing Subrogation Demand claims

Suggest edit Updated on April 26, 2021

For the Medicaid Subrogation Demand claims, Pega Smart Claims Engine for Healthcare checks if the value of Medicaid Paid Amount is less than the value of Calculated Allowed Amount. If it is, the application performs the tasks in the table below.

Is Medicaid Paid Amount at the Line Level Greater than 0?Then Pega Smart Claims Engine for Healthcare does the following:
Yes
  • Zeroes out all the adjustments at the header and line level.
  • Sets the value of Calculated Allowed Amount at the line level equal to the value of Medicaid Paid at the line level.
  • Sets the value of Calculated Allowed Amount at the header level equal to the value of Sum of Calculated Amounts at the line level.
  • Adds the new adjustment code 215 Billed Amount equals the Approved Amount
No
  • Zeroes out all the adjustments at the header and line level.
  • Sets the value of Calculated Allowed Amount at the header level equal to the value of Medicaid Paid at the header level.
  • Adds the new adjustment code 215 Billed Amount equals the Approved Amount
  • Previous topic Identifying Subrogation Demand claims
  • Next topic About voiding or cancelling Medicaid Subrogation Demand claims
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