Virtusa orchestrated the claims editing process by implementing Pega SCE to connect the legacy adjudication platform and the editing software. Pega SCE facilitates validating the adjudicated claims to ensure data validity and completeness and check for fraud, abuse, and waste.
- Watches and stores the adjudicated claim information in a massive Kafka database.
- Listens to the Kafka database, retrieves the claims data, assembles them in the format expected by the third-party software.
- Exchanges the claims data with the third-party software using APIs.
- Receives the response and sends updates back to the legacy claims adjudication platform through the MuleSoft middleware tool
- Sends edited adjudicated claims to be processed for payment.
- Gathers all the updates to past historical claims and sends them over to the third-party software for validation
- Using this platform and process offered the payer real-time claims editing capabilities.