With only a single claim in a single EDI file, the creation of a direct work object was previously required. With the implementation of de-batch logic SCE has introduced a new step of creation of N837 file from the actual EDI file. This N837 file will be saved to the data base.
EDI files which are submitted will be picked by the file listeners, and then from these files the de-batching logic will work where the multiple claims submitted in a single file will be split into individual components or claims. For each de-batch file an N837 file (data object) will be created.
From the N837 (data object) the work object will be created. This is the step in which the actual mapping occurs.
Once the work object is created the claim’s status becomes New. The claim will then go through the entire adjudication process after being picked up by an agent, as per the configured interval, or upon the Claims examiner’s clicking of the Process now button.
Pega Smart Claims Engine for Healthcare also handles exceptions as part of this de-batch process, which can happen at any stage of file ingest until the work object is created and adjudicated. If exceptions occur at any stage in the process, they will be tracked in the exceptions database table.