There are two methods that the SCE uses when deciding which orchestration to execute. The first is a configurable decision table utilizing information on the claim to help identify the appropriate orchestration. The second is utilizing the orchestration that is passed as part of the Put or Post claim API payload.
In addition, you can also manually select the appropriate orchestration to execute in the test claim interface. Each time the claim is executed, the orchestration will be reselected based upon the information in the claim.
Note: if a claim processing in an orchestration gets into an infinite loop due to a bad configuration or design, event code SGB-0022 will be assigned, causing the loop to be broken and the claim to be routed to a system workbasket for review.Configuring the orchestration selection table
The orchestration configuration table, Derive orchestration, can be found under Orchestration configuration in the Orchestration section of the Delegated rules menu in the portal. To view or update this table, select the gear icon.
This will then present the Derive orchestration decision table which can be modified and saved utilizing the standard Pega development process. This table can be extended by clients to add new fields, but is delivered with the following columns:
|Manual adjustment||This identified if the claim has been manually or mass adjusted based on a flag populated during the manual or mass adjustment process|
|Claim frequency type||The frequency code submitted on the claim. This may also be the last character of the bill type. For example: 1 (admit through discharge), 7 (replacement of prior claim)|
|Claim transaction type||The type of transaction being submitted. For example: CH (chargeable), RP (reporting), 31 (Medicaid reclamation/subrogation)|
|Claim payer ID||The payer ID submitted on the claim|
|Claim form type||The type of claim being submitted. For example: P (professional), I (institutional), D (dental).|
|Return||The name of the orchestration being selected based upon the values in the table|
The SCE provides an error handling orchestration if no orchestration is found through the selection. This sets the event code SGB-0048 – Orchestration not found. This event code will also set if the name of the orchestration returned by the decision table is not found in the configured list of orchestrations.API payload
If an orchestration is submitted on the API XML payload then this will be selected for processing. If that orchestration is not found, then the system will set an event code SGB-0048 – Orchestration not found. The orchestration is submitted in the API in the orchestrationName field. If an orchestration is not submitted in the API payload, then the derive orchestration process will be executed to select the appropriate orchestration for the processing.Test claims
The test claims tools provide the ability to manually select an
orchestration via the drop-down list or utilize the derive orchestration table
by selecting the blank row prior to executing the test claim.