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Claim API integration

Suggest edit Updated on August 31, 2021

The Smart Claims Engine provides two methods for claims entry into the SCE via APIs. The first is the Post claim, which is used to publish a new claim into the SCE for processing. The second is the Put claim, which is used to update an existing claim in the SCE.

Post (create) claim

The post claim service rule takes the claim JSON as a parameter and returns the created Claim ICN in the JSON format after running the claim through the orchestration.

The SCE expects external systems to send the post JSON with a “processStatus” as “New” or blank (“”).

URL format

POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims

Output

{ 
    "Claim ID": "2017299P0000006000", 
    "methodStatus": "Good" 
} 
Key processing rules

The table below details the key rules used in the processing of the claim through the API.

Rule nameRule typeDescription
Class: PegaHC-Int-Claims
PostClaimAPIService activityThis is the method in the REST service to create the claim and return the Claim ICN after executing the claim through the orchestration.
ClaimsService RESTThe REST service rule that identifies the path, parameters, and methods.
MapToEntityWrapperData TransformThis is a wrapper data transform which calls “MapToEntity” and can be extended as necessary.
MapToEntityData TransformThis is the data transform that maps the JSON properties to a claim structure.
PostClaimAPI_ExtensionActivityThis activity maps the claim JSON to the Pega claim work object and processes the claim using the submitted or the configured orchestration ID. The newly created claim ICN is returned.
Put (update) claim

The put claim service rule takes the claim JSON as a parameter and matches the claim with the claim ICN that was passed. If the claim ICN was found, it is updated with the input JSON, adjudicated through the orchestration ID entered or configured and will return the claim ICN.

URL format

PUT https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims

Output

{ 
    "Claim ID": "2017299P0000006000", 
    "methodStatus": "Good" 
} 
Key processing rules

The table below details the key rules used in the processing of the claim through the API.

Rule nameRule typeDescription
Class: PegaHC-Int-Claim
PutClaimAPIService activityThis is the method in the REST service to update the claim and return the Claim ICN after executing the claim through the orchestration.
ClaimsService RESTThe REST service rule that identifies the path, parameters, and methods.
MapToEntityWrapperData TransformThis is a wrapper data transform which calls “MapToEntity” and can be extended as necessary.
MapToEntityData TransformThis is the data transform that maps the JSON properties to a claim structure.
PutClaimAPI_ExtensionActivityThis activity matches the claim in the system with the ICN submitted, then maps the claim JSON to the Pega claim work object of the matched claim. The claim is then processed the submitted orchestration ID or the configured orchestration. The ICN is returned.
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