105343076 Pega CPMHC Training

8/11/2019 105343076 Pega CPMHC Training

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1 Pegasystems 2009

Overview of CTI & PegaCALL

along with

CPM for Healthcare

Matt Ruffing [email protected] Mills [email protected] !ahn [email protected]


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2 Pegasystems 2009

"gen#a

CTI

CTI What and why PegaCALL architecture Integration with PRPC Application Flow Terminology

CPM for Healthcare

eneric CPM HC !"M# CPM HC Cla$$ $tructure "na%ling CPM HC Wi&ard CPM Wi&ard to create flow 'how new flow in HC wor(ing

)nder co*er$ of flow de$ign and $tructure Changing )$er Interface of flow #*er*iew of integration to e+ternal $y$tem$ with CPM

,ue$tion$


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$ Pegasystems 2009

%hat is &'()

Computer Telephony Integration

Technology that allows telephonyevents (call delivered to agent, calltransferred, etc) to be coordinatedor integrated with a computer

The timing of events is such that

telephony and computer eventsoccur practically simultaneously


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* Pegasystems 2009

Rules+,ri-en &omputer 'elephony(ntegration &'(/ with Pega&" for PegaR3

-Legacy pre fetch to drive IVR processing and

call routing -Re use rules to drive IVR decisioning Adaptive screen pop for effective coordination

of call arrival -Desktop and workflow based telephony controls

for improved call management !Implement individually or incrementally


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4 Pegasystems 2009

&'( Functions

Call Control

Customer datapre-fetch

Call routing Adaptive screen

pop

Desktop

Telephony ACD!"# $ogin %a&e available 'oldn-hold

Answer call %a&e call Disconnect call Conference call "lind transfer arm transfer


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5 Pegasystems 2009

'elephony 'echnology in a &ontact&enter

*nteractive +oice esponse (*+) *nteractive phone system that can respond to a callers input(voice &eypad) and either complete pre-determinedservices or assist in properly routing the call to the

appropriate agent

Common -endor$. Avaya, /enesys, 0yntellect, 1uance

ACDCall outing Automatic Call Distributor 2 a device that distributes large

volumes of incoming calls to agents The ACD contains

logic that drives routing decisions based on multiple input

parameters outing parameters can include acombination of data about available agents and their s&ills,and specific information about the callcaller

Common -endor$. Avaya, Aspect, Cisco

Computer Telephony *ntegration (CT*) Technology that allows interactions on a telephone and a

computer to be integrated or coordinated This allows for

an agent to receive both the voice call and the supportingdata at the same time 0upporting data may come from

the *+, the phone switch or other sources


7/566Pegasystems 2009

%hy implement &'()

Cost 0avings

Avg savings of 56 secondscall (/artner) A contact center that handles 768callsday cansave over 56,666 agent hoursyear 9ust byimplementing a successful screen pop

*ncreased customer satisfaction Customers don:t have to repeat information they

have provided to the *+ Agents start the call more focused on thecustomer:s issue

!romotes self-service use. Adds perceived value to entering data in the self-

service *+, once customers learn they will not

have to repeat information to an agent *ncrease agent productivity.

!refetch and screen pops ma&e agents moreefficient

*ntegrated telephony features simplify agenttas&s


8/567Pegasystems 2009

Pega&" nables PRP& applications with&omputer 'elephony (ntegration &'(/

*ncreased Agent !roductivity.etrieve customer information in advanceof the agent receiving the callDeliver the call and the customer

information simultaneouslyules driven screen pop delivers the right

customer data based on the agent, the

customer and the call$ower Customer ;rustration. Close the *+ /ap.

3liminate the need for the customer torepeat information to an agent - *+data is passed to the agent as the callarrives

Agents can &now the point at which thecustomer


9/569 Pegasystems 2009

&'( (ntegration "pproach

& u s t o m e r 3 e r -

8racle ,Mainframe: 83;$90

SQLNet

MQ or

SQL

(unct

route from Pega&all

1

2

3

5

6

7

8

9

4

Rules retrie-e ? e-aluate#ata ? #etermine when;iftelephony functions are

re=uire# by &3R

Pega&" maintainsconnection for P8P

an# &'( e-ents

&'( mi##leware placescaller in "&, =ueue as

instructe# ? notifiesPega&" upon call

offering e-ent

Member #ial 700 an# is

#irecte# to (



Pega&" for PegaR3!igh e-el "rchitecture

PegaCALL Installation with enesys

(



Pega&" for PegaR3

CT* support for most ma9or ACD:s using industrystandard CT* middleware and routing platforms.

3nvo4 CT Connect /enesys Aspect Contact 0erver Cisco *C%

0erver-side CT* integration !rovides seamless integration of telephony events and

business processes 1o des&top D$$:s to install eal time adaptive screen pops

!uts the right customer information in front of theagents

3liminates need for the customer to repeat to theagent what they 9ust entered into the *+

;ully configurable 2 can trigger different processesbased on the agent and customer profiles forenhanced customer service

+oice and Data Transfer Transfer customer and wor& ob9ect data with the call



&oming soonEE.

Configuration i=ard 2 should allow basic connectivity and

features (screen pop) to be configured and running in>6-?@ minutes, including call data mapping, custom

screen pop, etc This will be a huge help during !C:swhere CT* is reBuired

0tateful telephony (/enesys only) 2 allows state to besynchroni=ed between !egaCA$$ and the phone, so thatactions ta&en at the phone (ie put a call on hold) will be

reflected in the !egaCA$$ * This also introduces theconcept of a CT* Toolbar that can be embedded in C!%

CT*$in& 'ot ;ailover 2 ability to have a hot standby CT*$in&

that will detect a failure in the primary lin& and ta&eover automatically

The C!% 7 release (566) will include pre-configuredvoice data transfer ca abilit so that when a user


13/561$ Pegasystems 2009

'erms you nee# to now Telephony

A1* 2 Automatic 1umber *dentification D1*0 2 Dialed 1umber *dentification 0ervice ACD 2 Automatic Call Distributor

0&ills "ased outing 2 A feature of many ACD:s that provide the ability to route calls basedon call type and agents s&ill set +D1Application 2 +ector Directory 1umber (Avaya) 2 an e4tension that directs incoming

calls to a specific vector or application Calls are trac&ed by vector, the vector drives aspecific message and Bueues The +D1 or App can indicate to the agent (and thesoftware) the type of call

Availability 2 Agent driven indication that they are available to receive calls, usuallyentered into the phone set or the soft phone, but can be software controlled

Auto-*nAuto-eady 2 An indication of the agent state that is automatically establishedupon release of a phone call An


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1* Pegasystems 2009

CPM for Healthcare


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14 Pegasystems 2009

Pegasystems 'he !ealthcarePM ea#er

Target Mar$etarge Payers G 2MM Members'op Pharma ; ife3cience &os!ealthcare Ho-ernment3electi-e Pro-i#ers;(,As;PMs

Mar$et Mo%et'%16 new customers in past 17 months90I license# our solution framewors3ignificant repeat businessnterprise bacbone commitments8-er 94M co-ere# li-es* of top 4 payers44I of &3 Plans

HC Practice Overview*0I of Pega usiness,eep #omain eCpertise

(e)'lt) * (OI64I re#uction &laims aclog$0I increase 1st pass rate97I re#uction in group enrollment costs20I increase issues han#le# per contact20I re#uction call han#ling time40I re#uction in training times


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15 Pegasystems 2009

. .

of top " argest # $ Payers

%

! of &lues 'etwork

%

" of

lues (embers " million covered lives

ar*uee +ealthcare Clients

r an sf orm in g + a lt hc ar

c ro s s ,h l o b

- C O C
http://www.novartis.com/http://www.cms.hhs.gov/http://www.baxter.com/http://www.kendle.com/http://www.csc.com/http://www.carefirst.com/main/html/HomePage.html


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16 Pegasystems 2009

+,ec'tio -a.) Clo)e 0 O'r C')to%er)

Medical Management

FDA & OIGCompliance

HIPAA, CMS & BluesCompliance

Su!ogation,Collections &

"eco#e!$

Inte!nal Se!#icingBac%one

Claims andAdustments

Se!#ice '(ceptionsP!ocessing

'nte!p!ise Case &'#ent Management

C!oss)Sell, *p)sell

+e Sel)Se!#ice

-./ Deg!ee 0iew othe Custome!

CS" Des%top

Sales P!ocessManagement

'n!ollment

1ailo!ed Oe!ings

1ime to Ma!%et

(i)$ 3ra' &Co%.liaceMaage%et

4ervicig

Bac$0oe

C')to%er(elatio)hi.Maage%et

5ew B')ie))
http://www.cms.hhs.gov/http://www.csc.com/


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17 Pegasystems 2009

2ew BusinessBac%one

Pega"*3'S P!ocess Commande! 4P"PC5

Healthca!e Indust!$ FoundationHealthcare Co%%o O06ect MoelX12 +DI Me))age 4'..ort

4a%.le 4i%'late Data4a%.le Orgai7atioal Moel

New BusinessNew Business CRMCRM Servicing BackboneServicing Backbone

RiskRiskFraud &Fraud &

ComplianceCompliance

CPM o! Healthca!e

Me%0er

4ervice

)

Provier

4ervice

)

a le s P ro ce ss

(anager

HC P!oductHC P!oductConigu!ationConigu!ation

62'+662'+6

Claims Bac%one

Clai%)

(e.air

Clai%)

849

BuildBuild"is%"is%

F!audF!aud&&

CompliaCompliancence

"ules"ulesInIn

Indust!$Indust!$Bac%onBac%on

eses

CPM HC FoundationCPM HC Foundation Claims FoundationClaims Foundation

$mart&P( for +ealthcare

Ca!e Mgmt Bac%one62'+6

Care

Maage%et

Clinical FoundationClinical Foundation

5ew Me%0er+roll%et

A'thori7atioMaage%et

A..eal) & -rievace)Maager


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19 Pegasystems 2009

Healthcare I')tr 3o'atio

Healthcare Co%%o O06ect & Data Moel

HC +ter.ri)e Orgai7atio 4tr'ct're

HIPAA X12 +DI Me))age 4'..ortHealthcare Portal)HealthCare O06ect 4earch & (etrieval HealthCare 4taar 4LA)HIPAA 4taar

Coe 4et)

5ew B')ie))Me%0er +roll%et

C ( MA'thori7atio Maage%et

4ervicig Bac$0oeA..eal) a -rievace)

(i)$ a 3ra' Mg%tA'thori7atio Maage%et

Int raction Manag m nt

Cas Manag m nt & Control

HC I t 3 $


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20 Pegasystems 2009

HC I')tr 3ra%ewor$ (Representative Functionality)

( , , ,-ork Parties member provider broker plan, , )sponsor agency etc

+IPAA .DI /01 $upport ( , ,+ealthcare Common 2b3ects claims authori4ation

, , , , )premium benefits C2& policy etc

-Pre configured +ealthcare Components

Reusable -ork ,emplates &(ember $earch Review &Claim $earch Review &Provider $earch Review &Authori4ation $earch Review &Policy $earch Review

-Pre built +IPAA 5unctionality

Correspondence eneration

-Reusable standard letter templates compileddynamically when needed

- ;Automated or on demand choose to re*uire review orallow edits

(aintained as part of inalterable audit trail forcompliance reporting

( & - )Automated file input batch real time &/01 message parsing mapping +IPAA property validation +IPAA /01 .DI samples

Reporting

, &2ut of the bo/ productivity *uality aging reports

-Drill down review capabilities Custom report wi4ard

Automated Authori4ation Re*uest (anagement

Provides -eb $ervice $2AP (essage for providers to -submit /01 167 transactions through $elf service

portal - -5acilitates straight through processing of /01 167

based on easily customi4ed sample business rules &Routes prioriti4es pending transactions for

manual processing

&(ember Application .nrollment Processing

,$ample enrollment workflows driving intake data&entry output

- ;Intent led data entry automated data population for

PD5 and email applications Intelligent enrollment application routing &Per member risk factor computation underwriting

approval recommendation based on medicalunderwriting

&Appeals rievances (anagement

- - , ,(ulti channel guided intake for web phone email andfa/

Comprehensive member composite - , ,Pre packaged workflows for Appeals rievances & /Re*uestor Party Information service claims

information Concurrent assignments to multiple departments for

&research response -$ecure one time link for e/ternal parties to provide

data and work cases


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CPM HC


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22 Pegasystems 2009

CPM*HC (Representative Functionality)

Inbound Customer Call

&Automated email receipt casecreation

(anual inbound correspondencecase creation

Customer verification *

Interaction Driver ,( with &suggested customer processes

offers

$mart Dialog ,( interactionscripting

&Interaction log audit trail *

-Automated interaction wrap up

Communication workflow

Contact Priority 'ote

-(ulti policy servicing includinginactivity logic

Designee management *

-Role based authority management *

Reference #tilities for Reference,(aterials Location 5inder and 5ind

Provider

$mart View ,( customer data composite( , , , ,policy member provider facility

, ,claims authori4ations& )contact plan sponsor

&eneral Informationprofile -(ulti channel interactionhistory $ervice history &enefit Review &Claim search review &Authori4ation searchreview

'otes Add a Contact

8uick Contact Add

pdate Contact 'ame Profile*

pdate Contact Address Profile

Add Attachment

/Complaint Compliment

Dispute Claim

5re*uently Asked 8uestions

eneral $ervice Case

(aterials 5ulfillment

(ember .ligibility

(ember $earch

( ,$chedule Activity call

, )appointment task

$end Correspondence

* 5acilitates +IPAACompliance

nteraction (anagement

ustomer (anagement

eneral $ervice

e*uest Processing

ember $ervice Re*uest

Processing Add a 'ewborn

2rder ID Card ,#pdate (ember Address &irth

,date 'ame

#pdate Primary Care Physician *

#pdate Privacy $ettings*

- / (ulti member (ulti policy

in*uiry facilities

rovider $ervice Re*uest

Processing

Appeal Prior Auth Denial

.nroll in a Provider 'etwork (anage 'ational Provider ID

Re*uest Prior Authori4ation

#pdate Provider Credentials

#pdate Provider Profile

,I 5acilities

&C,I Login Availability

-$creen pop with data collection

from IVR

Desktop telephony controls

CPM HC


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2$ Pegasystems 2009

-$ystem assigned routing based on

case urgency , &$ervice level goals deadlinesescalation events

#ser work lists

$ystem workbaskets

et (ost #rgent -ork functionality

--ork re assignment

-Customer based service level

profiles

-Customer based service level

override

Interaction reports

Productivity reports

8uality reports

Aging reports

Campaign reports

&Pipeline opportunity reports

8uality Performance Reports

9nowledge (anagement Reports

Custom report wi4ard

-Drill down review capabilities

&Automatic manual

generation

&Create modify templates

, , &(ail email fa/

capabilities

, &Review editingverification privileges

, &Access groups privileges userportals for*:

, &(ember Provider #niversalC$Rs

, &(ember Provider #niversal(anagers

$ales Representatives$ales (anagers$ystem Administrators

, &2perator profile schedule skills

management

-orkbasket assignments

$ecure login

&Random manual work selection

, &.mployee review rating scoring

& -Coaching sessions real time

coaching tips

Reporting

&

ork Assignment

ervice evel (anagement

orrespondence

eneration

uality Performance

(anagement

/

ccess Roles

perator

(aintenance

CPM*HC (Representative Functionality)

nowledge (anagement

9nowledge content rules and usage

statistics

&9nowledge in*uiry response

#ser suggestions for content

update

* 5acilitates +IPAACompliance

, &ffer 2pportunity

erritory (anagement

- , ,Cross sell retention, &restitution reward wellness campaigns - &Campaign set up wi4ard scriptdefinition

$uggested offer processing

,2pportunity creation assignment

& resolution

&'amed customer territory

assignments

1h CS" d %t i i t t d i d1h CS" d %t i i t t d i d


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2* Pegasystems 2009

1he CS" des%top is intent)d!i#en and1he CS" des%top is intent)d!i#en andconigu!ed to optimi7e e#e!$ custome!conigu!ed to optimi7e e#e!$ custome!inte!action and o#e!all CS" eicienc$inte!action and o#e!all CS" eicienc$

Sma!t Dialog8Cote,t*)e)itiveCote,t*)e)itive.er)oali7e ialog.er)oali7e ialog

Inte!action D!i#e!8

Cote,t*)e)itiveCote,t*)e)itive.er)oali7e ta)$).er)oali7e ta)$)

Sma!t 0iews8Cote,t*)e)itiveCote,t*)e)itive)'%%ar ifor%atio)'%%ar ifor%atioea0le) re)earch &ea0le) re)earch &reviewreviewcoc'rret withcoc'rret with.roce)).roce))

f'lfill%etf'lfill%et

Sma!t Sc!ipting8Da%ic )cri.tigDa%ic )cri.tig

%ii%i7e) traiig a%ii%i7e) traiig ae)'re) )ervicee)'re) )erviceco)i)tecco)i)tec

Me%0er4.ecificProce))e

)

Me%0er4.ecific:iew)

1h I t ti D i 8 ti i t1h I t ti D i 8 ti i t


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24 Pegasystems 2009

1he Inte!action D!i#e!8 anticipates1he Inte!action D!i#e!8 anticipatescustome! !e9uests, suggests ne(t stepscustome! !e9uests, suggests ne(t steps& 9ueues tas%s o! mo!e eecti#e se!#ice& 9ueues tas%s o! mo!e eecti#e se!#ice

PegaH+ALTHPegaH+ALTHMe%0erMe%0er4ervice)4ervice)

C')to%er ata availa0le o e%aC')to%er ata availa0le o e%aIteractio logIteractio logwhere C4() 0ee a goigwhere C4() 0ee a goig

4cri.tig g'ie4cri.tig g'ie')er with %ii%al')er with %ii%alC4( traiigC4( traiig

Atici.ate) c')to%er itet a g'ie) C4(Atici.ate) c')to%er itet a g'ie) C4(

- i & A l


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25 Pegasystems 2009

-rievace) & A..eal) (Representative Functionality)

, ,Phone email fa/ or -eb

/ /2riginal email fa/ stored w work item

uided data entry

ulti Channel Intake

istorical Composite (ember View

Automatic retrieval of relevant legacy data (ember &enefits Provider Contract

#ser s access group controls information display

re Packaged -orkflows

orrespondence eneration



(aintained as part of inalterable audit trail forcompliance reporting

Appeals (anagement Processes rievance (anagement Processes

Case Creation Re*uestor Party Information /$ervice and or claims information

ulti Party Processing

Concurrent assignments to multiple departments for

&research response

-$ecure one time link for e/ternal parties to providedata and work cases

.asily attach supporting documents includingmedical notes

Reporting

, &f the bo/ productivity *uality aging reports

-l down review capabilities

m report wi4ard

ompliance 5eatures

Automated service levels to ensure compliance andmove cases towards timely resolution

Comprehensive audit trail documents all human andsystem generated activities


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26 Pegasystems 2009

Co%.rehe)ive Care Maage%et

Care Pla Maage%et

-oal Maage%et

Alert Maage%et

Ta)$ Maage%et

are (anagement 5ramework

HealthCare Paer O06ect a Data Moel

Patiet !"; Portal

A'thori7atio 4)te% Iterface

ICD* Coe Loo$'. CPT Coe Loo$'. HCPC4 Coe Loo$'. 5DC Coe Loo$'.

HC Paer +ter.ri)e Orgai7atio 4tr'ct're

HC Cliical O06ect a Data Moel

X12 2 4TP Patiet +vet :i)'ali7er

Ca%.aig Maage%et

A'thori7atio Maage%et

Care Pla Te%.late Maage%et

-oal Te%.late 8i7ar

Alert Te%.late 8i7ar

Ta)$ Te%.late 8i7ar

Coe -ro'. Maage%et

A))e))%et Maage%et

Phar%ac Clai% 4)te% IterfaceMeical Clai% 4)te% Iterface

Corre).oece Te%.late)


Wor !"tomation



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27 Pegasystems 2009

are (anagement 4"ep!esentati#e Functionalit$5

omprehensive Call (anagement

atient %:;

orrespondence eneration



(aintained as part of inalterable audit trail for

compliance reporting

, - -Patient %:; degree view provides a complete up to date profile of the member s care and compliancewith Care Plans

Comprehensive view of patient demographics

, ,including contacts providers policies/eligibility benefit information

Reporting

, &2ut of the bo/ productivity *uality aging reports

-Drill down review capabilities Custom report wi4ardutomated (onitoring of Care Plans ,Automated monitoring of complications e/ceptions to

, -optimal care avoidable utili4ations of high cost( ,services emergency department care

, )hospitali4ations etc Alerts notify Care (anagers of a patient s lack of

compliance with a Care Plan ,Automated creation of correspondence to patients

,providers and case managers

i4ard Driven Program Creation

,$tructured wi4ard driven creation of Care(anagement programs

Reusable components optimi4e Program creation 5le/ible design allows for Programs to be createdand deployed rapidly by business users Automated documentation of Care Plans help ensure

consistency and support meeting operational goalsof Care (anagement programs

nified Care (anagement

,$ingle portal for Disease (anagement Case

(anagement and #tili4ation (anagement

$upports managing participants across the spectrumof care

Improves the delivery of Care (anagement programs by providing a complete view of the patient s care

-Automated straight through processing ofauthori4ations

$upport for creating and routing of authori4ationre*uests

, ,Drill down views of medical claims pharmacy claimsand authori4ations

$chedule Call tasks support fle/ible scheduling of periodic monitoring and assessment of the patient s

health

Automated scheduling of follow up calls Powerful assessments support branching and hidelogic for *uestions

Assessments perform risk calculation and automaticcreation of Care Plans based on risk

utomated Case Creation

2ut of the bo/ support for automated case creationwith automatic assignment of Programs and Care

Plans


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29 Pegasystems 2009

ealthcare Claims $uite

&ealthcare Payer Common 2b3ect Data (odel

C Payer .nterprise 2rgani4ation $tructure

ealthcare Portals

r io ri ti4 at io n an d .s cal at io n

laims %:; degree

Dashboard

l ai m .d itslaim Inventory (anagement

utomated -ork

Distribution

roductivity Analytics

( Inbound Claims

mage Viewer

Integration

eg ac y C la im $y ste m

Connectors

IPAA


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$0 Pegasystems 2009

Finalized Claims

New

Claim

Files

New

Claim

FilesPreProcess

ing

PreProcessing

Adjudicati

on

Adjudication

Pend

edClaim

Files

Pended

Claim

Files

!ealthcare &laimsE

Actual Customer Results

!" impro#ement in $irst pass rate %&" to '(")

*+" increase in sta$$ producti#ity&+" ,TP o$ pre#iously manually processed work'-" reduction in training time . e/pense*+" throughput increase in $irst week&(" reduction in a#erage in#entory days on hand %'01 to )*1" o$ duplicate claim de$errals repaired automatically

CLAIM4 (+PAI(CLAIM4 (+PAI(

CLAIM4 (+PAI(CLAIM4 (+PAI( CLAIM4 8O(


31/56

$1 Pegasystems 2009

Clai%) (e.air (Representative Functionality)

Code ,ranslations (ember

Provider ,imely 5iling Duplicate Claim Routing Rules Accident Claims Revenue CP, Code

Validations

Pre*A6'icatio B')ie)) +it)

Routine .ye ./ams Common .ye

$urgeries

Chiropractor$ervices Podiatry $ervices Anesthesia $ervices Inpatient $ervices Ambulance $ervices Lab ,ests

Prostate $creening+emoccult &lood

Po)t*A6'icatio B')ie)) +it)

Pending &enefits .mergency Room $ervices Pending &enefits Cardiac Rehab $ervices Pending Pricing +ome +ealth In3ectable Drugs Pending Potential Duplicate Claim

Clai%) I.'t & O't.'t Proce))

Corre).oece -eeratio

Critical .rror Claims (ember 'ot 5ound

- ( )7%6 Claim Pre Processing 5lat 5ile


32/56

$2 Pegasystems 2009

Clai%) 8or$)tatio9 ERepresentative Functionality)

$ecure Login :Access roups Claims

, ,./aminer (gr $ysAdmin

:Custom Portals Claims, ,./aminer (gr $ysAdmin -Role based workflow

: /privileges ./aminer (gr

4ig*O / 4ig*Off & 4ec'rit

A'to%ate (o'tig to8or$0a)$et)

Duplicate claim detection

Routing to specified workbasket

- -Primary routing by line ofbusiness

$econdary routing by pend code : &,ertiary routing claim type

total charge amount


-Auto correspondence for re3ected( & )claims $ubscriber Provider

-Auto correspondence option for

re*uesting additional info( / / )patient provider medical

-Pre configured templates forinfo re*uests

Published Claim


33/56

$$ Pegasystems 2009

Manage# ,estopManage! t"e core systems

Cotrol wor$flow with

Pega Da)h0oar of

the clai% wor$

o06ect a

.roce))ig o.tio)

Ho)t clai%)a6'icatio))te%

I%agig ))te%

Pega))te%clai% wor$ o06ect

Itegrate with clai%)a6'icatio ))te%

a i%agig ))te%

?)e PegaIMA-+ :ieweror thir .art tool to

view the clai% i%age


34/56

$* Pegasystems 2009

ales Process (anager

O..ort'it Maage%et

Ce)') Maage%et

Large -ro'. Maage%et

Agec A Bro$er

Profile Maage%et

Co%.a Profile Maage%et

4%all -ro'. ='ote Maage%et

4%all a Large -ro'. (atig

(eewal Maage%et

4ale) Ta)$ Maage%et

Pro.o)al geeratio -ro'. a 4'0gro'. A..licatio -eeratio

Healthcare Paer Co%%o O06ect & Data Moel

HIPAA X12 +DI Me))age 4'..ort Healthcare Portal)

ealthCare O06ect 4earch & (etrieval HealthCare Paer 4taar 4LA)HIPAA 4taar

Coe 4et)

HC Paer +ter.ri)e Orgai7atio 4tr'ct're

Pro'ctCofig'ratio



Wor !"tomation

4ale) Proce)) Maager


35/56

$4 Pegasystems 2009

4ale) Proce)) Maager 4"ep!esentati#e Functionalit$5

, ,Company *uote opportunity agency and brokerprofile management Automatic and ad hoc correspondence generation

leveraging correspondence templates Activity management

Profile Maage%et

(atig & Pricig

-.mployee based demographic rating for health anddental products

$upports actuarial and underwriting tables( -effective dated for use across multiple rating

)periods

(anages rating tables through an ./cel interface -(aintains group specific calculations for later

audits

='otig & Pro.o)al Maage%et


-Reusable standard letter templates compileddynamically when needed - ;Automated or on demand choose to re*uire review or

allow edits (aintained as part of inalterable audit trail for

compliance reporting

(anages opportunities for multiple brokers workingwith the same company

Creates rate card across multiple lines of business $upports both automated and manual census entry Automatically suggests products based on customer

& -profile census information to reduce antiselection

Packages professional proposals in multiple formats -including PD5 for print or e mail to additional

parties

(e.ortig

, &f the bo/ productivity *uality aging reports-down review capabilitiesm report wi4ard

-ro'. +roll%et

Packaged enrollment workflows .lectronic submission of group application to

legacy systems & &'otifies assigns tasks to internal e/ternal

parties

(anages completion via customi4able $LAs

Pro'ct Cofig'ratio

(anages comple/ product hierarchies Assembles data entry screens and validation rulesfor each product based on the included

components

Allows easy definition and modification of the -product structure through custom purposed rule

forms

Pro'ctC fi ti

4ale)P


36/56

$5 Pegasystems 2009

mart&P( +ealthcare $ales

olutions

r i v i n g

m b r s hi p r o wt h R t n ti o n

>uoting . Rating7anage ,ales 9pportunities

Prospecting

6ead 7anagement

9perationalize ,ales Channels

,elect :ene$its

3enerate >uotes

3enerate Proposals

=eri$y Inputs

Calculate Rates

Appro#e Rates and Riders

De#elop ,olutions

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Premium Rate ,etting

7anage Renewals

Cross4,ell?@p4,ell

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denti$y 7arket 9pportunities

Regulatory Filings

7aterials Creation

Product 6oad

RFPs2 National Acct

ssional 7andate2 7edicare Part D

Pre$erred :roker26arge Account

Indi#idual2 ,A

Close ? 9ptimize ,ale

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Right 8$$ort ? Cost

Positi#e Customer 8/perience

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Collect 8nrollment Data

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@pload ,ystems w?3roup ? ,u5gr

Ful$ill . Acti#ate Contract

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B$N$+#4SB$N$+#4S

B 7illion 7edicare Part D 7em5ers Captured DurInitial 9pen 8nrollment

!1" >uote Deli#ery Time Reduction(++" 8nrollment Processing Impro#ement-" Cost o$ ,ale Reduction*(" New 7em5er ,er#ice Calls Reduction'-" 7anual ,teps 8liminated

Cofig'ratio Proce))Maager

Con$igure Claims ,ystem
http://www.carefirst.com/main/html/HomePage.html


37/56

$6 Pegasystems 2009

CPM for Healthcare I Actio

&PM &onfiguration 3etup


38/56

$7 Pegasystems 2009

&PM &onfiguration 3etup

Create a r'le )et a ver)io

&PM ruleset for new a##itions


39/56

$9 Pegasystems 2009

&PM ruleset for new a##itions

&PM 3etup up#ate application


40/56

*0 Pegasystems 2009

&PM 3etup up#ate application

Be )'re to a 0oth r'le)et)

3ample PRP& &onfiguration


41/56

*1 Pegasystems 2009

3ample PRP& &onfiguration

Be )'re Profile reflect) chage)

&PM setup %or Pools


42/56

*2 Pegasystems 2009

&PM setup %or Pools

8or$ Pool '.ate eee

&PM %iJar# setup


43/56

*$ Pegasystems 2009

&PM %iJar# setup

After

Before

&PM setup %iJar# is now a-ailable


44/56

** Pegasystems 2009

&PM setup %iJar# is now a-ailable

&PM setup 3er-ice Process "ccelerator


45/56

*4 Pegasystems 2009

&PM setup 3er-ice Process "ccelerator

&PM wiJar# 3elect ruleset an# -ersion


46/56

*5 Pegasystems 2009

&PM wiJar# 3elect ruleset an# -ersion

&PM %iJar# name the new process


47/56

*6 Pegasystems 2009

&PM %iJar# name the new process

&PM %iJar# %hen an# where woul# you lie it)


48/56

*7 Pegasystems 2009

&PM %iJar# %hen an# where woul# you lie it)

Thi) will irect where o'r ew.roce)) will 0e .lace

&PM %iJar# something special nee#e#)


49/56

*9 Pegasystems 2009

&PM %iJar# something special nee#e#)

Thi) will %a$e it ea) to chage)cree cotet later

&PM %iJar# start enhancing


50/56

40 Pegasystems 2009

&PM %iJar# start enhancing

Fo' are rea to te)t & refieGG

3tan#ar# PRP& up#ate the (


51/56

41 Pegasystems 2009

3tan#ar# PRP& up#ate the (

&PM %iJar# Flow "ction #efaults


52/56

42 Pegasystems 2009




53/56

4$ Pegasystems 2009


&PM Aew process in action


54/56

4* Pegasystems 2009

&PM Aew process in action

&PM a##;up#ate #ialog #efaults


55/56

44 Pegasystems 2009

&PM a##;up#ate #ialog #efaults

&PM up#ate new flow


56/56

&PM up#ate new flow

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