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Penalty work flow

Suggest edit Updated on April 26, 2021

The objective of the penalty work flow is to “read” and process the penalty variations from the D_BenefitCoverage page in PFHC’s flattened benefit structure which have been created in, and parsed from an external benefit system (e.g., PCS).

The following graphic represents the steps in the penalty work flow:

  • The configured penalty variations are parsed from the flattened benefit structure, and then applied against the logic in the Action code for penalty decision table in the SetActionCodeForPenaltyCalc collection. In that decision table, each combination of configured penalty variations is associated, as a unique instance, to a specific penalty calculation action code.
  • That action code is associated to a formula that will be used to calculate and apply the penalty to the claim/line later on during the adjudication process. For now the action code is set aside.

The following graphics represent: (a) an auth and penalty variation configured in Pega’s PCS application, (b) the same variations as they appear in the D_BenefitCoverage page in PFHC’s flattened benefit structure, and (c) the ActionCodeForPenalty decision table that cross-walks the penalty variations from the flattened benefit structure to a penalty calculation action code.

  1. Auth & penalty variations configured in PCS

  2. Auth & penalty variations on D_BenefitCoverage page in PFHC’s flattened benefit structure.

  3. Penalty variations cross-walked from D-BenefitCoverage page to penalty calculation action codes in ActionCodeForPenalty decision table.

Applying penalties

Penalties may be applied at the claim line level, or at the claim level, depending on how the penalty variations are configured in the benefit system. When a penalty is applied at the claim line level, SCE displays the penalty in the Member Penalty field in the claim line execution results UI.

When a penalty is applied at the claim level, SCE displays the penalty in the Member Penalty field in the claim level payment information execution results UI.

For a detailed discussion on how penalties are calculated and applied at the claim and claim line level, please see Coverages and Accumulators.

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