Claim API integration
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.
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 formatPOST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims
Output{
"Claim ID": "2017299P0000006000",
"methodStatus": "Good"
} The table below details the key rules used in the processing of the claim through the API.
| Rule name | Rule type | Description |
| Class: PegaHC-Int-ClaimsClass: PegaHC-Int-Claims | ||
| PostClaimAPI | Service activity | This is the method in the REST service to create the claim and return the Claim ICN after executing the claim through the orchestration. |
| Claims | Service REST | The REST service rule that identifies the path, parameters, and methods. |
| MapToEntityWrapper | Data Transform | This is a wrapper data transform which calls “MapToEntity” and can be extended as necessary. |
| MapToEntity | Data Transform | This is the data transform that maps the JSON properties to a claim structure. |
| PostClaimAPI_Extension | Activity | This 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. |
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"
} The table below details the key rules used in the processing of the claim through the API.
| Rule name | Rule type | Description |
| Class: PegaHC-Int-ClaimClass: PegaHC-Int-Claim | ||
| PutClaimAPI | Service activity | This is the method in the REST service to update the claim and return the Claim ICN after executing the claim through the orchestration. |
| Claims | Service REST | The REST service rule that identifies the path, parameters, and methods. |
| MapToEntityWrapper | Data Transform | This is a wrapper data transform which calls “MapToEntity” and can be extended as necessary. |
| MapToEntity | Data Transform | This is the data transform that maps the JSON properties to a claim structure. |
| PutClaimAPI_Extension | Activity | This 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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