Care Management F ramework - Pega...Pega Survey User Guide —describes how to author survey rules...

Care Management Framework

Implementation GUIDE

7.12

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Care Management Framework Implementation Guide

Software Version: 7.12

Updated: January 2015

http://www.pega.com/

CONTENTS

About this Document ..................................................................................................................... i Intended audience..................................................................................................................... i Guide organization .................................................................................................................... i Documentation set .................................................................................................................... i Related Pega Survey documentation .......................................................................................ii Education and training ..............................................................................................................ii

Overview .................................................................................................................................... 1-1 What Is the Care Management Framework? ........................................................................ 1-1

What is Already Set Up ............................................................................................................. 2-1 Application rule ...................................................................................................................... 2-1 System administrator account ............................................................................................... 2-2 Work classes ......................................................................................................................... 2-3 Data classes .......................................................................................................................... 2-4 Data pages ............................................................................................................................ 2-6 Inheriting from CMF classes ................................................................................................. 2-8 Configuring CMF application settings ................................................................................... 2-9 Work object naming conventions ........................................................................................ 2-15 Predefined organizations, divisions, and units .................................................................... 2-15 Default work groups and workbaskets ................................................................................ 2-16 Default access groups, operators, and portals ................................................................... 2-17 Predefined access roles and privileges .............................................................................. 2-17 Portal navigation rules ........................................................................................................ 2-18 Correspondences templates ............................................................................................... 2-29 Sample database model ..................................................................................................... 2-30

The Patient Profile ..................................................................................................................... 3-1 Managing CMF Case Types ...................................................................................................... 4-1

Overview ............................................................................................................................... 4-1 Authorization request management ...................................................................................... 4-1 Processing the X12 278 EDI message ............................................................................... 4-15 Care management case ...................................................................................................... 4-15 Admission case ................................................................................................................... 4-18 Utilization management case .............................................................................................. 4-24 Care program management rules ....................................................................................... 4-25

This document describes how to deploy and extend the Care Management Framework (CMF) for initial production use.

Intended audience Before you install,and extend the Care Management Framework (CMF), it is assumed that you have attended the courses given by Pega Academy. The specific user roles addressed include:

Business Managers — responsible for evaluating the Framework and possess a general, non-technical understanding of its features and capabilities.

Project Managers / Business Analysts — responsible for implementing a Framework that can be applied to specific business requirements, and ensures compliance and continuous improvement across organizations.

System Architects / Application Developers — responsible for building, maintaining, modifying, and extending the Framework.

System and Database Administrators — responsible for the installation, security, and ongoing operational functions of the Framework such as access, tuning, and troubleshooting. These users are presumed to be experienced with system operations.

Guide organization This guide contains the following sections:

Documentation set In addition to this document, the CMF documentation set includes:

Care Management Framework Business Use Case Guide — describes the key business processes and case types in the framework and how to use them. It is intended for Care Coordinators and Care Managers.

Care Management Framework Managing Care Templates Guide — describes the creation and management of care program template rules that are used to manage care management programs. It is intended for Business Analysts responsible for authoring care management program content.

About this Document

Chapter 1: Overview Provides an overview of the framework. Chapter 2: What is Already Set Up Describes what is already set up Chapter 3: The Patient Profile Describes the implementation of the patient work object and the

patient profile. Chapter 4: Managing CMF Case Types Describes the management of CMF case types

Care Management Framework Implementation Guide i

TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt

Care Management Framework Installation Guide — describes how to install the framework following the installation of the Healthcare Industry Foundation.

Care Management Framework Upgrade Guide — describes how to upgrade the framework from a previous release after the Healthcare Industry Foundation has been upgraded.

Related Pega Survey documentation Pega Survey User Guide — describes how to author survey rules

All sources are available on the Pega Developer Network (PDN) — a section of the Pegasystems Support Network located at pdn.pega.com. In addition, configuration details, technical notes and how to articles for using PegaRULES Process Commander can be accessed in the online Application Developer Help and on the PDN.

Education and training Pegasystems Educational Services delivers in-depth programs that are designed, and delivered by certified experts for those who would like additional training. Through hands-on, role-based training, students receive critical knowledge from professionals skilled in the implementation of Pega 7 solutions.

For more information about Pegasystems programs and schedules, visit us at http://pega.com/Services/EducationalServices/Education.asp.

The Pega Developer Network (PDN), located at http://pdn.pega.com is the primary technical resource area for the Pega developer community. The PDN contains a broad range of technical articles including troubleshooting and “How-To” information and a comprehensive and searchable knowledgebase to help developers speed their application development. The PDN also links directly to the customer support section of pega.com where customers can submit trouble reports and product enhancement requests.

Care Management Framework Implementation Guide ii

What Is the Care Management Framework? Care management is typically thought of as being four programs, namely; wellness, disease, case, and utilization management. Wellness programs are programs that are typically population-focused with preventative programs that will help “healthy people stay healthy” and help at risk people avoid future health problems. Disease management is typically for a subset population with a particular chronic disease (or diseases) that the payer and/or provider feel will be better served by engaging and implementing educational or other programs to improve the patient’s well-being and simultaneously minimizing the exacerbation of the disease. Case management relates to engagements with patients in pre- or post-acute care or a complex medical scenario. The health plan engages with the identified patient to develop and implement specific care plans to improve the quality of care and help reduce overall medical cost. Utilization Management is the management, approval (or denial) of benefits as it relates to using the entitled benefit packages. For example, a physician preparing to admit a patient in a hospital may need to contact the health plan for approval that the hospital stay will be covered.

The Pega Care Management solution organizes all of the activities and participants around the core subject of all the work that needs to get done, namely, the patient. The patient profile captures detailed information including demographics, program enrolments, open requests, clinical data, recent claims, and authorized contacts. It can also attach documents, notes, and other correspondence. The data in the fully-integrated, patient-centric platform can be updated and modified by the care manager or sourced directly from existing enterprise systems, or both. Because of this integrated patient view, and the flexibility of the solution, healthcare organizations can get started quickly using the Pega solution for one area of care such as managing Disease or Wellness programs and then easily expand to also support Utilization Management and/or Case Management for their patients.

Pega Care Management includes assessment and care plan templates, which care teams can easily customize to meet their needs and accommodate their unique workflows. Care plans can include the Pega best-in-class automated processing to improve consistency, accuracy and productivity. Workflow activities can be easily configured to invite patients to participate and maintain ongoing multi-channel engagements with them, including specific goals and tasks for every participant. This allows care teams to establish best practice workflows, schedules, and tasks to optimize the patient care.

Pega Care Management also helps care teams identify and stratify target patients from across the member population to participate in specific care programs. Alerts can be configured to run on a regular basis, scanning the member base and creating a follow-up set of activities to inform those prospects about the care plan and track their enrolment and participation. Alerts can scan information such as patient claim history to check for the inclusion or absence of certain information (such as a claim’s primary diagnostic code) that helps determine whether a particular care program may be relevant for the plan member.

1 Overview

Care Management Framework Implementation Guide 1-1


Pega is easily configured to route and escalate work to the experts needed to make a decision or move a patient forward in their treatment. Decision rules can automate approval of certain requested services while escalating other types of requests to Utilization Managers or Medical staff for other requested services where human expertise or an individual review of the patient’s circumstances is necessary. As decisions are made by nurses and other experts, or automatically by the software, Pega automatically routes the work to the next stakeholder who needs to perform a particular task, and can manage the entire set of activities against defined time frames, Service Level Agreements (SLAs). Pega Care Management is designed to be in compliance with industry standards such as HIPAA-compliant data usage and other standards.

The key capabilities include:

Unified processes across Utilization Management, Disease Management, Care Management, Health and Wellness Management.

Comprehensive patient 360 profile including demographic, plan benefits, claims, authorizations, and clinical data.

Brings together the patient’s clinical profile including vital signs, lab results, medications, and medical history.

Care Planning templates for business users to configure disease and wellness management protocols that are auto-executable.

Utilization and Case Management capabilities around prior-authorization and pre-certification management

Case Management capabilities to manage admissions, concurrent review, discharge planning, and post-discharge follow-up

Survey tools for patient assessments and problem identification.

Alert rules for monitoring and responding to gaps in care.

Integration with third-party clinical guidelines from McKesson and Milliman bring together state of the art clinical content with superior workflow capabilities.

Automated case management and control sends alerts, notifications, and correspondence to all involved parties, freeing the Care Management from tedious letter creation.

Accelerators help program developers easily create and update the content of a Care Management program.

Real-time dashboards and ad-hoc reporting provide tools to monitor and balance workload.

Patient-centric platform Unique patient case that provides an integrated view into all care management activity

Patient case tree captures all cases related to program management for wellness and chronic diseases, admissions, discharge planning, and post-discharge care plans

Work that is pending for the patient is prominently displayed

Centralized notes, correspondence, and case attachment history



Comprehensive audit trail tracking inquiries into patient information

Comprehensive patient 360

Demographic information

Patient contacts

Recent claims summary (medical and prescription claims)

Recent prior-authorization / pre-certifications summary

Vital metrics (height, weight, BMI, blood pressure) – list view as well trend chart

Labs – list view as well as trend chart; out-of-range lab alerts

Medical history

Family history

Program enrollment status

Disease and Wellness program management Care template accelerators to create programs, care plans, problems, intervention tasks,

assessment tasks, fulfillment tasks, goals, and alerts

Automated Care Plan document generation for configured rules

Automated program referral during UM service request processing

New program enrolments

Scheduling of tasks and assessments

Program Opt in and Opt Out

Disease registry containing program enrolment status

Risk assessments

Sample care plans for diabetes, asthma, and smoking cessation

Automated execution of care plan for patient

Tailoring of care plan for patient

Utilization management Pre-certification and prior authorization request management for inpatient and outpatient

service requests, referrals, and prescription prior authorization requests care review

Requesting and Service provider lookup

Service Facility lookup

Patient lookup

Eligibility check

Duplicate validation



Diagnosis and procedure codes lookup

ICD9 and ICD10 Diagnosis codes support

ICD9, ICD10, CPT, and HCPCS Service codes support

Straight-through-processing for auto-approval and denials

Utilization review and medical director escalation

SLA management for routine, expedited, and urgent requests

Automated correspondence generation for approval, denial, and request for additional information

X12 5010 278 EDI transaction support

Admission case management Pre-certification management for admission

Admission case creation and management

Hospital stay concurrent review

Discharge plan management

Post-discharge follow-up assessment

Post-discharge care plan management

Assessment and survey Management

Templates for questionnaire, question page, and question and answer pre-certification management for admission

Business portal for survey management

Pre-configured assessments

Dynamic show-hide logic

Simple and complex question and answer management

Dual navigation options – screen flow / left navigation pane

Auto-generated screens

Healthcare extensions for Answer - Problem mapping

Dynamic integration with patient profile

Interactive care planning

Problem template management

Problem – Intervention task setup

Problem mapping on question and answer templates

Post-assessment care plan with problem tree generation

Intervention task selection and problem activation



Intervention task flow extensions for complex intervention management

Intervention disposition

Problem resolution

Clinical event alert management Alert rule template management

Automated scheduling – single- and multi-occurrence

Data source (claims, authorizations) management

Clinical event configuration (presence or absence of clinical event)

Gaps in Care detection

Automated task generation – notification and correspondence

Automated case owner notification of alert events

McKesson InterQual integration Available as an add-on

Interqual book view for research on guideline subsets from patient portal

Seamless integration of Interqual guidelines during UM Review

Dynamic submission of Pre-Cert information for targeted criteria search


Automated Pre-Cert decision based Interqual criteria met status

Review manager case associated with Pre-Cert request

Milliman CareWebQI integration Available as an add-on

CareWebQI chronic care guidelines lookup from patient portal

Automated CareWebQI Episode generation

Seamless integration of CareWebQI guidelines during UM Review

Dynamic submission of Pre-Cert information for targeted guideline search


Automated Pre-Cert decision based CareWebQI criteria met status

CareWebQI Episode associated with Pre-Cert request

Reporting Realtime dashboard for active case inventory

Smart graphs leveraging Fusion Charts



Summary and drill-down views

Vital metrics and lab results trend charts

Library of pre-configured workforce and workload management reports

Excel and PDF export capability

Ad-hoc reporting for personalized reports

Application layers The Care Management Application contains the following rulesets:

PegaCareTemplates — Care Program Management Sample Instances

PegaClinical – Care Management Layer

PegaSurvey – Survey Management layer

PegaCaretemplates — care program management sample instances This ruleset contains the sample instances of care management rules that make up the clinical content packaged with the framework. The following clinical rule types are included:

Care Plans

Alerts (gaps in care)

Goals

Problems

Tasks

Binary Files (fulfilment material)

Surveys (assessments)

Question pages

Simple questions (and answers)

Complex questions (and answers)

Additional information on creating and maintaining the programs for chronic disease and wellness management using the custom clinical rule forms is available in the Creating and Managing Care Programs chapter of the Care Management Business Use Case Guide.

PegaClinical — care management layer This ruleset contains the core rules for the Care Management Framework including, but not limited to, case types, flows, flow actions, decisions, portals, sections, reports, and integration rules.



PegaSurvey — care management layer This ruleset contains all the rules related to Pega’s Survey management component. For additional information around PegaSurvey, refer to the PegaSurvey User Guide included on your media.

Healthcare Industry Foundation applications The Care Management Application is built on the Healthcare Industry Foundation that provides the enterprise foundation for Pega’s healthcare solutions. Care Management leverages several components from the foundation including the clinical codes, sample member, provider, and other data that is used to showcase the Care Management capability. Refer to the Healthcare Industry Foundation Implementation Guide included on your media for additional details.

Your framework and Pega 7 Pega 7 contains a rules engine, database, processing logic, and functions — providing the base upon which frameworks are built. Frameworks are layered, making use of underlying technology instead of reinventing process flows. Additional flows and rules are contained in the framework layer and support application-specific functions (such as contact management or customer service). The rules you modify when extending the framework are at the top level, as they supersede the framework defaults.

You can use the framework rulesets as a starting point for extending the framework, making it specific to your organization


This chapter describes defaults and samples that are set up and ready for your use. It is expected that you use these as a basis for implementing and extending the framework. The topics include:

Application Rules

System Administrator Account

RuleSet Hierarchy

Work Classes

Data Classes

Data Pages

Inheriting From CMF Classes

Configuring CMF Application Settings

Work Object Naming Conventions

Predefined Organizations, Divisions, and Units

Default Work Groups and Workbaskets

Default Access Groups, Operators, and Portals

Predefined Access Roles and Privileges

Correspondence Templates

CMF Portals

Sample Database Model

Application rule The framework application rule defines an ordered set of rulesets and versions that together identify the parts or the ‘layers’ of the framework. In addition, the application rule relates the application's objectives, use cases, and actors to objects created as part of the Direct Capture of Objectives capabilities. The access groups (listed later) are associated with specific application rule.

The Care Management application rule contains:

PegaCareTemplates: 07-12 — contains the rules necessary to configure Programs/ Care Plans/ Problems/ Tasks/ Alerts/ Goals. It also contains the Survey (Questionnaire) rules used in the application.

PegaClinical: 07-12 — contains core rules required for the care management functions

PegaSurvey: 07-10 - contains the rules required for executing assessments

2 What is Already Set Up



System administrator account The framework uses the following Operator ID as default system administrator account.

Operator IDs are not case-sensitive, but passwords are case-sensitive.

Operator ID: cmsysadmin@MyHealthPlan

Password: install

Ruleset hierarchy You can view a list of the rulesets in the framework by selecting the Designer Studio > Application > Structure > RuleSet Stack landing page option.

The RuleSet Stack tab displays the high level RuleSet stack for each application rule defined in the framework. Expand an application to list its rulesets.



Work classes The classes in PegaHC-Care-Work contain the CMF specific work related rules. Work classes organize the different types of work required by users.



Data classes CMF leverages data classes from the Healthcare Industry Foundation layer. The PegaHC-Data-, PegaHCCMF-Data-, and PegaHCCMF-Data-Party- data classes contain the CMF rules associated with data. The following diagrams show the class inheritance of the data classes and the subclasses they support.

PegaHC-Data-



PegaHCCMF-Data-



PegaHCCMF-Data-Party-

Data pages CMF 7 uses data pages to declaratively access data without needing to call procedural activities to ensure that data is populated prior to usage. Most top-level pages in the application have been converted to data pages. Sections, when rules, flows, flow actions, and other rules types have been updated to reference the updated data pages on their Pages and Classes tab, and in any other references. Activities that procedurally populate top-level pages have been updated to support the creation of data pages. In some cases, the calling activity has had steps commented out to eliminate the procedural call to create a top-level page. This eases integration with sources of truth and allows for re-use of data page definitions across multiple business contexts.

The following is a list of pre-configured data pages, their respective data class, and usage.

Data Page Name Class Usage

Declare_CommonMedication Code-Pega-List Data page to retrieve medication details using the GetCommonMedication report definition as the source

Declare_pxRecents e-Pega-List Data page to hold recent work items using the pzPopulateRecentGadgetListactivity as the source

Declare_SearchRevenueCodes Code-Pega-List Data page to retrieve revenue codes using the SearchRevenueCodes report definition as the source

D_CMFDashboard Data-Portal Data page to load rule instance count on the dashboard using the DashboardInstancesCount activity as the source

D_AvailableWorkBaskets Embed-PegaHC-Stringlist

Data page to retrieve workbaskets using the LoadWorkBaskets activity as the source.

D_CorrTemplateList Embed-PegaHC-StringList

Date page to retrieve correspondence templates based on correspondence type and associated party

D_StartingFlowsList Embed-PegaHC-StringList

Data page to retrieve flows using the GetFlowList activity as the source

Declare_CM_ENV PegaHC-Care-Env Data page to retrieve CMF configuration details

D_SurveyGridResults PegaHC-Care-Work Data page to hold survey comparison details using the LoadSurveyGridResults activity as the source

D_ListOfDeniedAuthorizations PegaHC-Care-Work-AuthRequest

Data page to retrieve denied authorizations of selected member using the FetchDeniedAuthsForMember Report definition as the source

D_MemberAuthorizationsList PegaHC-Care-Work-AuthRequest

Data page to retrieve authorizations of member using the MemberAuthorizationsList report definition as the source




D_MemberActiveGoals PegaHC-Care-Work-Goal

Data page to retrieve active goals of member using the MemberActiveGoals report definition as the source

D_ClinicalTabSelection PegaHC-Care-Work-Member

Data page to initialize clinical tab using InitializeList as the data source

D_MemberDetails PegaHC-Care-Work-Member

Data page to load member details based on member ID using the GetMemberWorkID report definition as the source

D_MemberActiveProblems PegaHC-Care-Work-Problem

Data page to retrieve active problems of member using the MemberActiveProblems report definition as the source

D_MemberActiveTasks PegaHC-Care-Work-Task

Data page to retrieve active tasks of member using the MemberActiveTasks report definition as the source

D_StartingFlows PegaHC-Care-Work-Task

Data page to retrieve starting flows using the pzGetStartingFlows activity as the source

D_MemberProgramDetails PegaHCCMF-Data-Registry

Data page to retrieve member program details using the LoadMemberProgramsData activity as the source

D_LabResultsByMemberID PegaHC-Data-LabResults

Data page to retrieve lab results of member using the LabResultsByMemberID report definition as the source

D_VitalsByMemberId PegaHC-Data-Measurement

Data page to retrieve member vitals using the MeasurementsByPatientID report definition as the source

D_HistoryByMemberID PegaHC-Data-MedicalHistory

Data page to retrieve medical history of member using MedicalHistoryByMemberID as the source

D_PatientList PegaHC-Data-Party-Member

Data page to retrieve members using the GetPatientLucene activity as the source

D_ProviderData PegaHC-Data-Party-Provider

Data page to retrieve provider details

D_GetProviderList PegaHC-Data-Party-Provider-Practitioner

Data page to retrieve practitioners using the GetProviderList Report definition as the source

D_FacilitiesList PegaHC-Data-Party-Provider-ServicingOrg

Data page to retrieve facilities using the GetFacilitiesList report definition

D_PolicyDetails PegaHC-Data-Policy Data page to retrieve member policies

D_MedicationsList PegaHC-Data-Prescription

Data page to retrieve member prescriptions using the PrescriptionsByPatientID report definition as the source

D_AlertCodeSearchResults PegaHealth-Codes-Data-

Data page to retrieve codesets based on the code type using activity as the source. Used in the alert rule.

D_CodesBasedOnCodeType PegaHealth-Codes-Data-

Data page to retrieve codesets based on the code type using activity as the source.

D_FulfillmentList Rule-File-Binary Data page to retrieve fulfillment tasks using the ListOfMaterials report definition as the source

D_CodeGroupsCMF Rule-HCCodes-CodeGroup

Data page to load CMF code groups using the GetCodeGroups activity as the source

D_fetchCategories Rule-Obj-FieldValue Data page to retrieve field values using GetFieldvalues as the report definition

D_GetCodeTypes Rule-Obj-FieldValue Data page to retrieve code types using the LoadCodeTypes activity as the source




D_ProgramCategory Rule-Obj-FieldValue Data page to retrieve program categories using the GetProgramCategory activity as the source

D_Programs Rule-Obj-FieldValue Data page to retrieve programs for a category using the ProgramsList report definition as the source

D_Alerts Rule-PegaCare-Alert Data page to retrieve alert rules using the AlertList report definition as the source

D_RetrieveAlertsByCategory Rule-PegaCare-Alert Data page to retrieve alerts for a given category using the RetrieveAlertsByCategory report definition as the source

D_CarePlans Rule-PegaCare-CarePlan

Data page to retrieve care plans using the CarePlanList report definition as the source

D_FetchCarePlansByCategory Rule-PegaCare-CarePlan

Data page to retrieve care plans for a given category using the FetchCarePlansByCategory report definition as the source

D_FetchGoalsBasedOnCategory Rule-PegaCare-Goal Data page to retrieve goals for a given category using the FetchGoalsByCategory report definition as the source

D_Goals Rule-PegaCare-Goal Data page to retrieve goals using the GoalList report definition as the source

D_FetchProblemsByCategory Rule-PegaCare-Problem

Data page to retrieve problems for a given category using the FetchProblemsByCategory report definition as the source

D_Problems Rule-PegaCare-Problem

Data page to retrieve problem rules using the ProblemList report definition as the source

D_FetchTasksByCategory Rule-PegaCare-Task Data page to retrieve tasks for a given category using the FetchTasksByCategory report definition as the source

D_TaskList Rule-PegaCare-Task Data page to retrieve tasks using the TaskList report definition as the source

D_QuestionnaireCategory Rule-PegaQ-Questionnaire

Data page to retrieve the questionnaire category using the AssessmentCategories report definition as the source

Inheriting from CMF classes When you deploy CMF in your environment, it is important that your class structure inherit from the CMF class structure. The following table provides an example of how the Acme Company inherits from CMF work classes using both directed and pattern inheritance. Seethe Help and the PDN for more information about setting up directed and pattern inheritance at your site.



Your Class Class Group?

Inherits From

Acme-PegaHC-Care-Work Yes PegaHC-Care-Work (directed) Acme-PegaHC (pattern)

Acme-PegaHC-Care-Work-AdmissionCase No PegaHC-Work-AdmissionCase (directed) Acme-PegaHC-Care-Work (pattern)

Acme-PegaHC-Care-Work-CareManagementCase No PegaHC-Work-CareManagementCase (directed) Acme-PegaHC-Care-Work (pattern)

Acme-PegaHC-Care-Work-UMCase No PegaHC-Work-UMCase (directed) Acme-PegaHC-Care-Work (pattern)

Acme-PegaHC-Care-Work-CarePlan No Acme-PegaHC-Care-Work (directed)

Configuring CMF application settings The key application configuration settings are maintained on the CMF Config Page in the Designer Studio menu. The settings that are configured on this page initialize a requestor-level declare page called Declare_CM_Env.

To configure your own setting:

1. Log in to your system using the following user name and password:

User Name CMSysAdmin@MyHealthPlan

Password install

2. From the Designer Studio menu, select CMF Config Page.

The settings are organized in various stages as follows:

− Work classes



− Rule classes

− Data classes

− Accelerator classes

− Work baskets

− Work object status

− Other settings

3. Update the settings as you configure and implement your solution.

4. Click Save to save the settings



Work classes The Work classes tab defines the key classes for the various case types and work objects managed in the framework.



Rule classes The Rule classes tab defines the key rule classes used in the accelerator rules for creating and maintaining care program template rules.

Data classes The Data classes tab defines some of the key data classes from the Healthcare Industry Foundation leveraged in sections and other rules in the framework.

Accelerator classes The Accelerator classes tab defines the work classes for the accelerator processes for creating and maintaining care program rule templates.



Workbaskets The tab defines the workbaskets used in the framework for the various work objects.



Work object status The Work object status tab defines the default statuses for the care rule work objects

Other settings The Other settings tab defines some of the other attributes that have been parameterized for use in the framework. The ruleset and ruleset version parameters hold the name and version of the open ruleset that will hold care template rules.



Work object naming conventions Work objects (cases) capture and process information about an individual unit of work. When CMF initiates a work object, a predefined data transform rule populates key property values that directly affect the work object. As work objects progress towards resolution, core property values, such as priority and status, are updated to reflect the current state of processing.

Each work object has a unique property named .pyID that is computed by combining a system assigned number and a prefix, .pyWorkIDPrefix, defined by the work object model. The table below lists the prefixes used by CMF.

ID Prefix Work Object Class Description AC- PegaHC-Care-Work-AdmissionCase Used for Admission Cases

ADMNT- PegaHC-Care-Work-AdmissionNotification Used for Admission Notifications AL- PegaHC-Care-Work-Alert Used for Alerts AUTH- PegaHC-Care-Work-AuthRequest Used for Authorization Requests PXAT- PegaHC-Care-Work-CareAccel User for Care Templates (Accelerators) CM- PegaHC-Care-Work-CareManagementCase Used for Care Management Cases CP- PegaHC-Care-Work-CarePlan Used for Care Plans PGMREF- PegaHC-Care-Work-CMReferral Used for Care Management Program Referral Cases CR- PegaHC-Care-Work-ConcurrentReview Used for Concurrent Review Cases DP- PegaHC-Care-Work-DischargePlan Used for Discharge Plan Cases GO- PegaHC-Care-Work-Goal Used for Goals MBR- PegaHC-Care-Work-Member Used for Members (Patients) PR- PegaHC-Care-Work-Problem Used for Problems PRG- PegaHC-Care-Work-Program Used for (Care Management) Programs TK- PegaHC-Care-Work-Task Used for Tasks UM- PegaHC-Care-Work-UMCase Used for Utilization Management Cases

Predefined organizations, divisions, and units CMF comes with the following predefined organization, division, and units. To display the organizational chart, select the Designer Studio > Org & Security > Organization > Organizational Chart landing page option. Sample Care Management Framework user profiles are configured under the following Division and Units:

Care Management > Program Management

Care management > Utilization Management



Default work groups and workbaskets This table lists the default work groups and workbaskets used in the framework.

Work Groups Work Group Description Manager Default Workbasket

CarePrograms@MyHealthPlan Care Programs Work Group CareManager@MyHealthPlan

CarePrograms@MyHealthPlan

UMReview@MyHealthPlan UM Service Review Work Group

UMServiceManager@MyHealthPlan

UMReview@MyHealthPlan

MDReview@MyHealthPlan Physician Review Work Group

MedicalDirector@MyHealthPlan

MDReview@MyHealthPlan

CareTriage@MyHealthPlan Care Triage Work Group CareTriageManager@MyHealthPlan

RequestInformation@MyHealthPlan

Workbaskets

Workbasket Division Unit Work group CarePrograms@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan CarePlans@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan Alerts@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan Problems@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan Goals@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan Tasks@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan CMReferral@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan AsthmaCases@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan DiabetesCases@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan NewCaseIntake@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan DuplicateCaseIntake@MyHealthPlan CareManagement ProgramManagement CarePrograms@MyHealthPlan Admissions@MyHealthPlan CareManagement UtilizationManagement UMReview@MyHealthPlan



ServiceReview@MyHealthPlan CareManagement UtilizationManagement UMReview@MyHealthPlan MDReview@MyHealthPlan CareManagement ProgramManagement MDReview@MyHealthPlan CorrTasks@MyHealthPlan CareManagement ProgramManagement CareTriage@MyHealthPlan FulfillmentTasks@MyHealthPlan CareManagement ProgramManagement CareTriage@MyHealthPlan

Default access groups, operators, and portals The framework comes with the following access groups, operators, and portals.

Passwords are set to install.

Access Group Operator ID Default Portal PegaCare:Configurator CareTemplateManager@MyHealthPlan CMBusinessAnalyst PegaCare:FulfillmentCoordinator CareFullfillmentUser@MyHealthPlan CMFullfillment PegaCare:CareManager CareManager@MyHealthPlan CMFManager PegaCare:MedicalDirector MedicalDirector1@MyHealthPlan CMFManager PegaCare:MedicalDirector MedicalDirector2@MyHealthPlan CMFManager PegaCare:CareTriage CareSupportUser@MyHealthPlan CMFSupport PegaCare:CareCoordinator CareCoordinator1@MyHealthPlan CMFUser PegaCare:CareCoordinator CareCoordinator2@MyHealthPlan CMFUser PegaCare:CareCoordinator CareCoordinator3@MyHealthPlan CMFUser PegaCare:CareCoordinator CareCoordinator4@MyHealthPlan CMFUser PegaCare:Administrator CMSysAdmin@MyHealthPlan Developer PegaCare:UMCoordinator UMServiceCoordinator@MyHealthPlan UMServiceCoordinator PegaCare:UMManager UMServiceManager@MyHealthPlan UMServiceManager

Predefined access roles and privileges The framework includes a set of predefined access roles and privileges for the standard framework user roles. For information about how to create your own access roles and privileges, see Help or the PDN.



Case Types

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PegaCare:Configurator PegaCare:FulfillmentCoordinator PegaCare:CareTriage x x PegaCare:CareManager x x x x x x PegaCare:MedicalDirector x PegaCare:CareCoordinator x x x x x x PegaCare:Administrator x x x x x x PegaCare:UMCoordinator x x x x PegaCare:UMManager x x x x

Portal navigation rules The framework provides pre-configured Navigation rules that control the privileges on user and manager portal menu options as well as other gadgets.

CMFQuickLinks The CMFQuickLinks navigation rule controls the availability of portal workspaces on CMFUser and CMFManager portals.



The HasManagerPrivilege decision rule controls the display (availability) of the Dashboard and Reports workspaces on the portals, based on access groups.



UMFQuickLinks Similarly, the UMFQuickLinks navigation rule controls the availability of portal workspaces on the UMServiceCoordinator and UMServiceManager portals.



CreateQuickLinksNav The CreateQuickLinksNav navigation rule controls the menu options for the Create gadget on the user portals.

NewProgramEnrollment The NewProgramEnrollment privilege rule defines the access roles that have access to the New Program Enrollment option on the Create menu.



AdmissionNotification The AdmissionNotification privilege rule defines the access roles that have access to the New Admission Notification option on the Create menu.

NewAuthorizationRequest The NewAuthorizationRequest privilege rule defines the access roles that have access to the New Authorization Request option on the Create menu.



NewAuthorizationRequestX12 278 The NewAuthorizationRequest privilege rule defines the access roles that have access to the New Authorization Request X12 278 option on the Create menu.



NewAppealCase The NewAppealCase privilege rule defines the access roles that have access to the New Appeal Case option on the Create menu.

CMFSearchOptions The CMFSearchOptions navigation rule controls the menu options for the Search gadget on the user portals.



SearchAuthorization The SearchAuthorization privilege rule defines the access roles that have access to the Search menu option for authorization search.

SearchCodeGroup The SearchCodeGroup privilege rule defines the access roles that have access to Search menu option for code groups search.

SearchCodeSet The SearchCodeSet privilege rule defines the access roles that have access to Search menu option for code set search.



SearchCodeSet The SearchCodeSet privilege rule defines the Access roles that have access to Search menu option for code set search

SearchPatient The SearchPatient privilege rule defines the Access roles that have access to Search menu option for patient search



My Cases Gadget The MgrCenterProcess section on the portal references the IsPrivilegeForMyCases decision rule for displaying the My Cases list, based on Care Manager and Care Coordinator access groups.



Similarly the IsPrivilegeForBreadCrumb rule is used to control the availability of the parent case hierarchy on case headers.



Correspondences templates The framework comes with a set of sample correspondence fragments and templates used in Authorization Request processing. Fragments are defined as instances of Rule-Corr-Fragment and are used in compiling correspondence templates. Templates are defined as instances under Rule-Obj-Corr.

The sample correspondence templates included with this framework are listed below.

Name Rule Type Label Description AuthApproved Corr Approval correspondence for approved requests AuthDenied Corr Denial correspondence for denied requests

RequestAdditionalInformation Corr Correspondence for requesting additional information from the provider

Annual_Influenza_Vaccination_Reminder Corr Influenza vaccination reminder letter to member

Diabetes_Program_Invitation Corr Welcome letter for inviting members to the diabetes program

Dilated_Eye_Exam_Reminder Corr Letter reminder to member regarding annual dilated eye exam

DM_Provider_DisEnroll_Notify Corr Letter reminder to the member’s PCP about program unenrollment of their patient

Glycosolated_Hemoglobin_Reminder Corr Letter reminder to member about getting a



Name Rule Type Label Description glycosylated hemoglobin lab test

Lipid_Profile_Reminder Corr Letter reminder to member about getting a lipid profile lab test

Nephropathy_Testing_Reminder Corr Letter reminder to member about getting nephropathy testing

Provider_Diabetic_Foot_Exam_Notify Corr Letter recommendation to the member’s PCP about a diabetic foot exam evaluation for a diabetic patient

DM_Provider_DisEnroll_Notify Corr Letter reminder to the member’s PCP about program unenrollment of their patient

Provider_Lipoprotein_Notify Corr Lipoprotein test reminder

Provider_Statin_Combo Corr Notification about Patient's prescription for statin/selective cholesterol absorption inhibitor combination medication

Routine_Foot_Exam_Reminder Corr Letter reminder to diabetic members about getting an annual foot exam

Semi-Annual_Physical_Reminder Corr Letter reminder to diabetic members about getting a physical exam

Serum_Creatinine_Testing_Reminder Corr Letter reminder to diabetic members about getting a serum creatinine lab test

Smoking_Cessation _Program_Invitation Corr Welcome letter for invited members to the smoking cessation program

Sample database model When CMF is installed, the following tables are added to the internal PegaRULES database to manage work, data, and rules. In addition to the tables listed below, CMF also leverages many data tables from the Healthcare Industry Foundation. Refer to the Healthcare Industry Foundation Implementation Guide for additional details. The data table list also includes tables from the Healthcare Industry Foundation.

Work table cmf_work —CMF work objects

Data tables The following data tables shown below are available in the PegaClinical ruleset in the framework.



The Audit Log table is used to store the audit history of user access to patient 360.

The Service Type Codes – DSM Diagnosis Code Type table stores the Service Type codes that control the availability of DSM as diagnosis code set while creating an authorization request.



The Duplicate Check Rules table stores the duplicate match condition and weight used in matching potential duplicate records for new authorization requests.

The Service Type Codes – Authorization Type table stores the association of available Service Type codes depending on the type of Authorization Request selected during the New Authorization Process:

AR – Admission (Inpatient) Review

HS – Health Services (Outpatient) Review

SC – Specialty Care (Referral) Reviews

DR – Drug (Prescription) Reviews


This chapter describes the implementation of the patient work object and the patient profile.

Previous versions of CMF referred to the Patient as a Member. While every attempt has been made to replace the ‘member’ reference on screens to ‘patient’, the rule names have not been changed to maintain backward compatibility.

Patient search The Search link at the of the user portal drives the patient search. The framework leverages Lucene capability for implementing the patient search. The search model for the patient includes patient’s First Name, Last Name, and Patient ID. The PatientSearchResults activity is triggered when you click the Search button. This activity calls the pxRetrieveSearchData activity to perform the Lucene search on patient records.

After the search results are retrieved, links are displayed in the results window, allowing you to click on a result to view the patient profile. A single click on the Patient ID calls the GetMemberWorkID activity, which retrieves the patient profile. If the CareManagement Framework does not find a work object for the selected patient, a new patient profile work object is created. The patient profile contains data within the PegaHC-Care-Work.Member page of the PegaHC-Data-Party-Member class.

3 The Patient Profile



The framework leverages sample patient (member), provider, and other data from the Healthcare Industry Foundation. Refer to the Healthcare Industry Foundation Implementation Guide for additional information on the sample data instances.

The Patient work object is of class PegaHC-Care-Work-Member as shown below.



The Patient ID from the retrieved profile is mapped to the .pyCustomer top-level property on the patient work object. In the sample data instances of the Healthcare Industry Foundation, the unique key to the unique instance and the patient ID is pyWorkPartyUri and the value of that is set to the .pyCustomer as seen below.



Rule Name Class Description

PatientSearchResultsAction Data-Portal Flow Action to hold the section for the search results and pre-activities called for the Lucene search implementation

SearchResults Data-Portal Section holding search results PatientSearchResults Data-Portal Activity which implements the Lucene search for patient search. pySearchModel PegaHC-Data-Party-Member Data transformation model to set the exposed properties for

search parameters MemberSearch PegaHC-Data-Party-Member Report Definition used for the Lucene search RuleFormLayout PegaHC-Data-Party-Member Section used for the Lucene implementation on search

parameters

Patient profile The patient profile information is organized in a series of tabs as follows:

Active tab

Cases tab

Profile tab

Clinical tab

Audit log tab

Active tab The Active tab is the default tab displayed on the patient profile. It displays active problems, tasks, goals, and assessments associated with the patient.



The framework leverages the Responsiveness option available in repeat grids so that screen layout is adjusted according to screen size, providing an optimal user experience on a desktop, tablet, and phone.



Key rules in the Active tab

Rule Name Rule Type Class Description

MemberActiveTab Section PegaHC-Care-Work-Member Section to display data of an active member

MemberActiveProblems DataPage

Data page for the active member problems

MemberActiveProblems Report Definition PegaHC-Care-Work-Member Source for the D_MemberActiveProblems data page

D_MemberActiveTasks DataPage

Data page for the active member tasks

MemberActiveTasks Report Definition PegaHC-Care-Work-Member Source to data page D_MemberActiveTasks

D_MemberActiveGoals DataPage

Data page for the active member goals

MemberActiveGoals Report Definition PegaHC-Care-Work-Member Source for the D_MemberActiveGoals data page



Cases tab The Case Tree displays all cases related to the patient. This includes Care Management, Admission, Utilization Management, and Appeal case types. The tree nodes can be expanded to view child items. The case tree provides a link navigation option to open the selected node in a new harness.

The pyLoadMyCasesTree activity retrieves all parent cases for the patient and is called when the Cases tab loads. When you click the expand icon, the defer load activity pyLoadMyCasesNestedWrapper loads all the child cases of the parent case.



Key rules in the Cases tab

Rule Name Rule Type Class Rule Name

MemberCaseTree Section PegaHC-Care-Work-Member Section to display the member case details

pyLoadMyCasesTree Activity PegaHC-Care-Work Activity to load the parent member cases

pyLoadMyCasesNestedWrapper Activity Work-Cover- Activity to load the child cases

AddCaseActions Navigation PegaHC-Care-Work-Member Allows the creation of CM/UM/DM cases for the member

AddCaseByType Flow action PegaHC-Care-Work Allows the selection of case type

CreateCaseByType Activity PegaHC-Care-Work

Activity for setting up the required parameters and invoking the flow for case creation

CreateCaseForMember Flow PegaHC-Care-Work Starter flow for case creation

Patient profile The patient profile information is organized in a series of tabs as follows:

Member tab

Provider tab

Contacts / care teams tab

Claims tab

Authorizations tab

Programs tab

Member tab The Member tab in the profile section displays demographic information about the patient, the contact information, and a list of policies associated with the patient.



Primary care provider tab The Primary care provider tab displays the patient’s primary care physician (PCP) demographic information.

Contacts / care team tab The Contacts / care team tab provides a list of all associated contacts and care team roles.

Claims tab The Claims tab displays the list of all medical and pharmacy claims associated to the patient.



Authorizations tab The Authorizations tab displays the list of all prior authorization requests for the patient.

Programs tab The Programs tab displays the program enrollment history of the patient and provides links to maintain the enrolment status (Opt-In/Opt-Out).



Key rules in the Profile tab


MemberProfileDetailsTabs Section PegaHC-Care-Work-Member

Wrapper section which contains the Tab group to display member profile details

MemberBasicInfo Section PegaHC-Care-Work-Member Section to display member information and policy details

ProviderData Section PegaHC-Data-Party-Provider Section to display members’ PCP details

MemberContacts Section PegaHC-Care-Work-Member Section to display member contacts

ContactsByMemberID Report Definition PegaHCCMF-Data-Party-Contact Report definition to retrieve member contacts

MemberClaims Section PegaHC-Care-Work-Member Section to display the medical claims of a member

MemberMedicalClaimsList Report Definition PegaHC-Data-Claim Report definition to retrieve member claim details

PharmaClaims Section PegaHC-Care-Work-Member Section to display pharmacy claims of members

ClaimsList Report Definition PegaHC-Data-Claim Report definition to retrieve pharmacy claim details

MemberAuthorizationList Section PegaHC-Care-Work-Member Section to display member authorization details

D_MemberAuthorizationsList DataPage

Data page for Member Authorization details

MemberAuthorizationsList Report Definition PegaHC-Care-Work-AuthRequest

Source for the D_MemberAuthorizationsList data page

MemberEnrollmentHistory Section PegaHC-Care-Work-Member Section to display member program details

AddNewContact Activity PegaHC-Care-Work-Member Activity to add new contact to member

OptMemberOutOfAllPprograms Activity PegaHC-Care-Work-Member Activity to opt out of enrolled programs

Clinical tab The Clinical profile information is organized in a series of tabs as follows:

Vitals tab



Medications tab

Lab results tab

Medical / family history tab

Assessments tab

Vitals tab The Vitals tab displays patient vital metrics and the ability to view it as a list or as a trend graph. You can also add or edit the information. The vitals information can also be added from an assessment.

Medications tab The Medications tab displays medication history for the patient. You can add or edit the information. The medications information can be automatically updated from an assessment.

Lab results tab The Lab results tab displays the lab results maintained on the patient’s profile. CMF also lets you evaluate entered labs against normal ranges.



History tab The History tab displays the medical and family history associated with the patient.

Assessments tab The Assessments tab displays the completed assessments of the patient. You can compare similar assessments completed over time.



You can review completed assessments, export them as a PDF file, and also print them.

Key rules in the Clinical tab


VitalsSMI Section PegaHC-Care-Work-Member

Section to display member vitals

MeasurementsByPatientID Report Definition PegaHC-Data-Measurement

Report definition to retrieve member vitals

SaveUpdateMeasurement Activity PegaHC-Care-Work-Member Activity to save member vitals

VitalsSMI Section PegaHC-Data-Measurement Section to display vitals chart

PrescriptionsByPatientID Report Definition PegaHC-Data-Prescription

Report definition to retrieve member medications




MedicationsByMember Section PegaHC-Care-Work-Member

Section to display member medications

SaveUpdateMedication Activity PegaHC-Care-Work-Member

Activity to save member medication details

LabResultsGridWrapper Section PegaHC-Care-Work-Member Section to display lab results

LabResultsMatrics Section PegaHC-Data-LabResults

Section to display trend charts of lab results

LabResultsByMemberID Report Definition PegaHC-Data-LabResults

Report definition to retrieve member lab results

HistoryWrapper Section PegaHC-Care-Work-Member

Section to display member history details

MedicalHistoryByMemberID Report Definition PegaHC-Data-MedicalHistory

Report definition to retrieve member medical history details

FamilyMedicalHistoryByMemberID Report Definition PegaHC-Data-MedicalHistory

Report definition to retrieve member family history details

FamilyHisorySaveInstance Activity PegaHC-Care-Work-Member

Activity to save family history details

MedicalHisorySaveInstance Activity PegaHC-Care-Work-Member

Activity to store member history details

SurveyAssessments Section PegaHC-Care-Work-Member

Section to display member assessment details

ListAllCompletedAssessments Report Definition

PegaHC-Care-Work-Task

Report definition to fetch member assessments

CompareAssessmentsGridResultsWrapper Section PegaHC-Care-Work-Member

Section to display member assessment comparison details

D_SurveyGridResults DataPage

Data page to display survey comparison details

LoadSurveyGridResults Activity PegaHC-Care-Work

Source for the D_SurveyGridResults data page

Audit Log Tab

The Audit Log tab captures the access to patient profiles by users with a date and timestamp of the event.



Key rules in the Audit Log tab

Rule Name Rule Type Class Description GetMemberAuditLogInfo Section PegaHC-Care-Work-Member Section to display audit details

GetMemberAuditLog Report Definition PegaHC-Data-AuditLog Report definition to retrieve audit details

Notification layout

The Notifications section in the patient profile displays all notes, attachments, and correspondence associated with the patient.

Pega Pulse gadget

Pega Pulse provides capabilities for collaboration by application developers, business analysts, and end users. Team members connect to create new applications, capture requirements, share documents, request assistance, or contribute information. It is provided when the Pega-Social ruleset is in your application; the gadget automatically appears in the portal and in your user forms.




Overview The Care Management Framework provides the capability to manage many different cases, sub-cases, and work types that can be generated by the Framework or manually created by the user.

Authorization request management The Care Management Framework includes the capability to manage prior-authorization and pre-certification requests. This includes a manual intake of the request as well processing the X12 278 EDI message. The capability includes processing the following three types of request:

Health Service Review (HS) — a request for prior certification of a service (such as CT Scan)

Admission Review (AR) — a request for prior authorization for admission to a hospital or skilled nursing facility

Specialty Care Review (SC) — a request for authorization of a referral to a specialist

Drug Review (DR) – a request for prescription

Case definition The Prior-Authorization request case type is organized to include the following stages:

Intake

Auto Authorization

Clinical Review

MD Review

Notification

Outbound Message Generation

Closure

4 Managing CMF Case Types



Intake stage The Intake stage defines the process of creating a new request. The AuthorizationIntake flow rule is used to create the detailed authorization request. Once the authorization request is created, the DuplicateCheck process is called to check for any potential duplicate requests. After the duplicate check validation, the Framework runs the CheckEligibility process to validate if the member is eligible for the requested service.

Auto Auth stage After the authorization request is created and validated for duplicates and eligibility, the Auto Auth stage provides the ability to add straight-through-automation logic to automatically approve specific requests based on your business rules. The framework provides some sample business rules to demonstrate this ability. The sample rules are organized by the type of requests.



Requests for health services review The HealthServicesDecision flow uses sub-flows, decision tables, and decision trees to evaluate each requested service (procedure). Once each requested service is evaluated, the overall status of the authorization request is determined.

The procedure code of each requested service is evaluated by the ProcedureDecision flow.



Treatment decision table The Treatment decision table evaluates each procedure code to determine a treatment category.

For example, an authorization request with procedure code 93000 is determined to be in the treatment category EKG. If the procedure code does not map to one of the defined treatment categories, it is mapped to a category called General Services.





TreatmentDecision Decision Tree Once each requested service has been categorized, the TreatmentDecision decision tree decides how each treatment category should be processed. Certain Treatment categories are automatically set to Not Certified.

The decision rule showcases the flexibility to call additional decisions for specialized evaluation of certain treatment categories. The framework provides the following three examples:

Cardiac Rehab Decision

Podiatry Service Decision

Chiro Service Decision

AuthorizationDecision decision tree Once each service line has been evaluated, the status of the overall authorization request can be determined. The AuthorizationDecision decision tree looks at each service line decision and sets the status of the authorization request.



If any service line in the authorization request has a status of Pended, the AuthorizationDecision decision tree sets the status of the authorization request to Pended and routes the authorization request to the ServiceReview@MyHealthPlan workbasket.

The status of the authorization request is set by the HealthServicesDecision flow, which also sets the X12 action code for the authorization request and sets the certification dates. The effective date is set to the current date and the expiration date is determined by the SetExpirationDays decision tree.



Requests for admission review Authorization requests for admission review are evaluated in the AdmissionDecision flow. The framework pends all admission review requests for clinical review.

Requests for specialty care review The Specialty Care Review authorization requests are evaluated in the SpecialtyCareDecision flow. The framework approves all specialty care review (referral) requests. The effective date is set to the current date and the expiration date is set to the current date plus 365 days. The approved number of visits is set to the requested number of visits.



Extension Note: Work with your implementation team to extend the Auto-Authorization capability to identify scenarios of different requests that can be automatically approved based on your business rules.

Clinical Review stage This stage defines the process for utilization review of a new authorization request that was routed to the ServiceReview@MyHealthPlan workbasket. It includes processes to review clinical guidelines, request additional supporting information from the provider, routing and seeking medical director review, and processing the decision.



You can associate clinical guidelines and list the required supporting documents. If supporting documents are required and not checked as attached to the case, the Framework routes the case to the RequestInformation@MyHealthPlan workbasket.

After you complete reviewing and associating the guidelines, the Framework runs a program recommendation process, which evaluates the RecommedProgram decision tree rule that evaluates for program recommendation criteria.



Extension Note: Work with your implementation team to extend this capability to identify and create additional rules for automated program referrals from prior authorization and pre-certification requests. You can create custom code groups for such analysis as well as include other attributes from the patient’s profile for more targeted programs.

MD Review stage This stage controls the process involved in medical director review of the pending authorization requests. The framework leverages skills-based routing rules to assign the request to a medical director based on defined skills.



After the medical director completes the review and recommends disposition, the case is routed back to the clinical review staff for final disposition.

Notification stage In this stage, the Framework generates an admission case if the request is for an inpatient review and if it is partially or completely approved. The admission case is assigned a Pending-Notification status.



The FinalizeAuthorization process sets the resolution status to the authorization request and saves an instance to the data repository. The AuthNotifications flow determines the appropriate correspondence template and which party needs to be notified (requesting provider and/or member).

Key rules in authorization management

Rule Name Rule Type Description pyDefault Case Type Case definition for an authorization case AuthorizationDefault Work Parties Work party rule for an authorization case pyStartCase Flow Starter flow for an authorization request process AuthorizationIntake Flow Flow for creating an authorization request DuplicateSearchCases Flow Flow to check duplicate authorization requests CheckEligibilityFlow Flow Flow to check Member eligibility



Rule Name Rule Type Description AuthorizationDecision Flow Starter Flow for auto authorization stage

AdmissionDecision Flow Flow to invoke auto authorization on inpatient review requests

HealthServicesDecision Flow Flow to invoke auto authorization on outpatient review requests

ProcedureDecision Flow Flow to evaluate the procedure code of each requested service

SpecialtyCareDecision Flow Flow to invoke auto authorization on specialty care reviews (referrals)

DrugReviewDecision Flow Flow to invoke auto authorization on drug reviews ClinicalReviewUtilizationManagement Flow Flow for clinical review

AssociateWithCase Flow Flow for associating an authorization request to utilization management case

AddChildToUMCase Flow Flow to add the authorization request as child to UM case

AssociateWithCase Flow Action Launches a new UM case or associates the authorization request to existing UM case

ProcessAuthorization Flow Action Launches authorization processing pyDefault Case Type Case definition of referral case CreateCareManagementReferral Flow Starter flow for referral case EnrollInProgram Flow Action Launches recommended program enrollment process DeferProgramEnrollment Flow Action Provides the ability to defer program enrollment CheckForProgramRecommendation Activity Activity to recommend program

RecommendProgram Decision Tree Decision tree which returns the program name based on the authorization details

MedicalDirectorReview Flow Flow used for MD review

CreateAdmissionCase Flow

Flow triggered if the authorization request is of type Inpatient and it is approved. It will create an admission case

AddAdmissionCaseToUM Flow

Flow to add admission case to utilization management case

ProcessAuthorization Flow Action Allows nurse to process authorization MDReviewGuidelines Flow Action Allows medical director to process authorization

SetAuthDecisionManual Activity Activity used to set authorization decision based on the action codes on procedure or drug code lists

FinalizeAuthorization Flow Flow for finalizing the authorization decision AuthNotifications Flow Flow used for notifying the work parties

AttachAuthXML Activity Activity used to create Authorization xml and attach it to the case



Processing the X12 278 EDI message CMF includes the ability to manage X12 278 5010 messages for authorization request and response. In production, the EDI message integrates with CMF using one of the service and listener rules such as MQ, File, and SOAP.

Once the X12 278 file is made available to CMF, the 278 message segments are parsed and the data in the segments are mapped to the X12 properties on the clipboard. The X12 segments and properties are then mapped to the business-specific properties to create an authorization request work object.

For purposes of demonstration, CMF includes sample X12 278 files that can be manually submitted for processing. The process is initiated from the user portal.

Key rules in X12 278 EDI request management Rule Name Rule Type Class Description SelectX12File Flow Action PegaHC-Care-Work Allows X12 file upload

NewX12AuthRequest Flow PegaHC-Care-Work-AuthRequest Flow to process the x12 request

ProcessX12N278 Activity PegaHC-Care-Work-AuthRequest Activity to process the x12 request

X12ParseMessageStart Activity PegaHC-Care-Work-AuthRequest Activity to parse the x12 request

Statistics Harness PegaX12-Data Harness to display the x12 processing summary

X12ParseMessageType Activity PegaX12-Data Checks the message type and calls parse message

X12ParseMessage Activity PegaX12-Data-N278 Parser activity for the 278 request

ProcessTransaction Activity PegaX12-Data-N278-Transaction

Activity to construct an authorization request from the 278 message

ProcessAuthorization Activity PegaX12-Data-N278 Activity used to create a work page and launch flow on this page

NewWork Flow PegaHC-Care-Work-AuthRequest

Flow to process an authorization request created from x12 request

Care management case The Care Management case can be initiated by leveraging the New Program Enrollment option on the user’s portal as seen below.



A new Care Management case can also be created from the Add Case option on the Cases tab of the patient composite.

Case definition

The CreateCareManagementCase starting flow initiates the process. The case definition also provides a list of child case types that can be covered under the Care Management Case.



Care Plans

Alerts

Goals

Tasks

The CustomerID associated with the care management case is used for the ‘bread-crumb’ navigation on the case header. If the customer is not available in the Care Management case, the Framework retrieves it from the Member work object for the associated member. If a member work object does not exist, the Framework creates a new member work object for the patient.

The initial care plan configured for the selected program is automatically generated as a subcase to the Care Management case.



Data Propagation Key metadata associated with the Care Management parent case is propagated to child cases.

Key rules in care management case

Rule Name Rule Type Description pyDefault Case Type Case definition for a care management case CreateCareManagementCase Flow Starter flow for a care management case CaseManagementDefault Work Parties Work party rule for a care management case

pyDefault Data Transform Data transform used in the care management starter flow

Admission case A new admission case is automatically generated when an inpatient authorization request is approved. A Pending-Notification status is assigned to the newly created admission case.

You can also generate a new admission case by launching the New Admission Notification process from the user portal.



If an admission case Pending-Notification is available for the selected patient, then the existing admission case is updated with additional metadata captured during the notification. If there is no matching admission case found for the patient, the Framework creates a new one during admission notification.

You can indicate if a concurrent review is required for the admission by checking the appropriate flag during the notification. If checked, the Framework creates a Concurrent Review subcase under the admission case. If you do not indicate the need for a concurrent review, the Framework automatically generates a Discharge Plan subcase under the admission. Otherwise, the Discharge Plan subcase is generated when the discharge day is flagged during the concurrent review.



Case definition for admission case

The Admission starting flow initiates the process. The case definition also provides a list of child case types that can be covered under the Admission case.

Authorization Request

Concurrent Review

Discharge Plan

Care Plan

Task

Concurrent review During Admission Notification, you can indicate if a concurrent review is required for the admission by checking the appropriate flag during the notification. If checked, the Framework creates a Concurrent Review subcase under the admission case.



When you process the Concurrent Review Case, the Framework lets you track the patient's progression over the length of stay and the ability to reschedule the review as well.

Discharge plan The Discharge Plan case is created from the Concurrent Review case when you flag a review date as the discharge date. The Discharge Plan Case is a child case of the Admission Case.





Case Definition for Discharge Plan

Key rules in admission, concurrent review, and discharge plan Rule Name Rule Type Class Description

NewAdmissionNotification Flow

PegaHC-Care-Work-AdmissionNotification

Flow to create a new admission notification

NotificationScreenFlow Flow PegaHC-Care-Work-AdmissionNotification Screen flow to capture admission details

CheckOpenAdmissions Activity PegaHC-Care-Work-AdmissionNotification

Activity to check if there are any open admission cases for the patient

SelectPatient Flow Action PegaHC-Care-Work-AdmissionNotification

Provides search and selection of the patient

SelectReqProvider Flow Action PegaHC-Care-Work-AdmissionNotification

Provides search selection of the requesting provider

LookupFacility Flow Action PegaHC-Care-Work-AdmissionNotification Provides search and selection of facility

ManageNotification Flow Action PegaHC-Care-Work-AdmissionNotification

Provides for update or creation of an admission case

pyCaseDefault Case Type PegaHC-Care-Work-AdmissionCase Case definition for admission case

Admission Flow PegaHC-Care-Work-AdmissionCase Starter flow for admission case

AddAuthSubCase Flow PegaHC-Care-Work-AdmissionCase

Flow to add authorization as a subcase to the admission case

AddConcurrentSubCase Flow PegaHC-Care-Work-AdmissionCase

Flow to add the concurrent review subcase to the admission case

CreateCarePlan Flow PegaHC-Care-Work-AdmissionCase

Flow to add a post-discharge care plan to the admission case

AddSubCase Flow PegaHC-Care-Work- Flow to add a discharge plan subcase to




AdmissionCase the admission case

pyCaseDefault Case Type PegaHC-Care-Work-ConcurrentReview

Case definition for concurrent review case

ConcurrentReview Flow PegaHC-Care-Work-ConcurrentReview Starter flow for a concurrent review case

ConcurrentReview FlowAction PegaHC-Care-Work-ConcurrentReview Update a patient concurrent review day

pyCaseDefault Case Type PegaHC-Care-Work-DischargePlan

Case definition of the discharge plan case

DischargePlan Flow PegaHC-Care-Work-DischargePlan Starter flow for the discharge plan

DischargeToFacilityAgency Flow PegaHC-Care-Work-DischargePlan

Flow used when the patient is discharged to another facility

DischargeToHome Flow PegaHC-Care-Work-DischargePlan

Flow called when a patient is discharged to home or self-care

Utilization management case During prior authorization review, you can associate the prior authorization request with a UM Case. If the Framework finds an open UM Case associated with the patient, the Framework provides the ability to include the prior authorization request as a subcase to the existing UM Case. If an open UM Case is not available, the Framework generates a new one and associates the prior authorization request as a child case to it.

Case definition



Key rules in the UM case Rule Name Rule Type Description pyDefault Case Type Case definition for the UM case UtilizationMangement Flow Starter flow for the UM case UMManagementDefault Work Parties work party rule for the UM case AddChildToUMCase Flow Flow to add an authorization request as child to the UM case

Care program management rules The Care Management Framework provides the capability to define best practice protocols to manage chronic conditions as well as wellness and preventative programs. These reusable care template rules allow you to create and maintain care plans to manage programs based on your policies and guidelines.

The specialized rule templates provide you and your clinical staff the opportunity to create and maintain care program management protocols based on your best practices and standards.

Types of care template rules The framework provides the ability to configure the following types of care program management rules and reuse them across multiple case and disease management programs:

Program - specifies the name of the clinical condition or chronic disease program that is being managed (such as Diabetes, Asthma, Smoking Cessation, Post-Discharge (Re-Admission Prevention), Falls Risk, and High-Risk Maternity). The programs are categorized as Disease Management, Case Management, or Health and Wellness programs.

Care Plan - defines the pre-configured combination of tasks, goals, and alerts used to manage the program. There can be multiple care plans created for a given Program (for example, Low Risk Diabetes, High Risk Diabetes and so on).

Task - defines the automated and manual user actions such as scheduled phone calls, schedule risk assessments, sending fulfillment, sending correspondence (emails and letters), and interventions.

Assessment - defines a survey or questionnaire composed of a set of question pages (groups of questions) that can be used to assess a patient’s health status, determine risk, and update the patient’s profile.

Goals - defines an objective to be met by the patient within a given time frame (e.g. achieve HbA1c levels <7 and so on).

Alerts - defines the automated queries against claims and authorizations data sources used for monitoring changes (presence or absence of clinical events).

Problems - defines issues associated with the patient that need to be addressed.



The following graphic provides a view into how the care template rules can be combined to create one or more care plans to manage programs. The framework provides the flexibility to embed other rule templates within some rules. The following rule types can contain a combination of other rules:

Care Plans – can contain tasks, goals, and alerts

Alerts – can spawn tasks and goals

Problems – can spawn tasks and goals

The following graphic showcases the different permutations and combinations of care template rules that can be combined to manage a program.

Refer to the Managing Care Templates document included on your media for additional details on creating and maintaining the care template rules.

The work objects generated at run time when the care template rules are leveraged as part of the patient’s program management and care planning initiatives are managed as case types.



Care plan case The Care Plan case is generated as a subcase to the Care Management case when the patient is enrolled in a new program. The system generates a new care plan case automatically based on the initial care plan associated with the program.

Case definition

The Care Plan case can contain subcases depending on the preconfigured template rule or available to be added manually when assigned to a patient:

Alerts

Goals

Tasks

Problems



Data propagation The following properties are propagated from the Care Management case to the Care Plan case when it is generated during new program enrollment.



Starting process

The starter flow for the care plan case is CreateCarePlanCase. The Framework iterates through the alert, goal, and task rules as configured in the Care Plan rule and creates child cases for the same under the parent care plan case.

Alert case The alert case is generated as a child case of a care plan when the care plan is first created for the patient based on pre-configured template. You can also manually add it to an existing care plan from the patient composite.



Case definition

Data propagation The following properties are propagated from Care Plan case to the Alert case when it is generated.



Starting process

The CreateAlertCase starting flow initiates the processing. The Alert processor is invoked to check whether the clinical conditions (code groups or code lists) defined in the Alert rule are met on the designated data source (for example, claims). If the Framework finds instances of the claims for the patient that meet the criteria, the Framework spawns the configured goals and tasks as child cases to the Alert case. Otherwise, the alert case is resolved with a Condition-NotMet status.

Goal case The Goal case is generated as a child case of a care plan when the care plan is first created for the patient based on pre-configured template. You can also manually add it to an existing care plan from the patient composite.

Case definition



Data propagation The following properties are propagated from the Care Plan case to the Goal case when it is generated.

Starting process

Problem case The Problem case is generated as a child case of a care plan when the care plan is first created for the patient based on a pre-configured template. It can also be created in custom care planning after an assessment if the answers to specific questions are tagged with one or more problems.



Case definition

Data propagation The following properties are propagated from the Care Plan case to the Problem case when it is generated.



Starting process

When the Problem case is generated, the framework iterates through the associated tasks and goals configured in the problem template and creates required subcases.

Task case The Task case is generated as a child case of a care plan when the care plan is first created for the patient, based on a pre-configured template. It can also be generated as a child case of an Alert case if the condition is met on the alert. Similarly, a task can also be generated as a subcase to a Problem case. You can also manually add task cases to an existing care plan from the patient composite.



Case definition

Data propagation The following properties are propagated from the Care Plan case to the Task case when it is generated.



Starting process

The ExecuteTask process calls the respective task process, based on the task type.

ExecuteScheduleCallTask This process is used to initiate a Schedule Call task. If the Task has a recurring schedule, the Framework prompts the user to select a date for the next call.

ExecuteNotifyCaseOwnerTask This process is used to notify the case owner of an event (for example, an alert).

ExecuteCorrTask This process is used to generate correspondence or fulfillment to the member or provider.



ExecuteInterventionTask This process is used to manage interventions.

ExecuteAssessmentTask This process is used to manage assessments.

Key rules in custom rule cases Rule Name Rule Type Class Description pyDefault Case Type PegaHC-Care-Work-CarePlan Case definition for a care plan CreateCarePlanCase Flow PegaHC-Care-Work-CarePlan Starter flow for a Care plan case

pyDefault Data Transform PegaHC-Care-Work-CarePlan Data transform used in the care plan starter flow

pyDefault Case Type PegaHC-Care-Work-Alert Case definition for an alert RunAlertProcessor Activity PegaHC-Care-Work-Alert Activity for an alert processor

ChekForCodesOnAuths Activity PegaHC-Care-Work-Alert Activity to compare codes on an alert rule and authorizations

ChekForCodesOnClaim Activity PegaHC-Care-Work-Alert Activity to compare codes on an alert rule and claims

CreateAlertCase Flow PegaHC-Care-Work-Alert Starter flow for an alert case

pyDefault Data Transform PegaHC-Care-Work-Alert Data transform used in the alert starter flow

pyDefault Case Type PegaHC-Care-Work-Task Case definition for a task case

AddAttachmentsToTask Activity PegaHC-Care-Work-Task Activity used to add attachments to the case for a fulfillment task

CreateTaskCase Flow PegaHC-Care-Work-Task Data transform used in the task starter flow

ExecuteTask Flow PegaHC-Care-Work-Task Flow to execute a task

ExecuteScheduleCallTask Flow PegaHC-Care-Work-Task Flow to execute a scheduled assessment task

CallPatient Flow PegaHC-Care-Work-Task Flow to call patient and update call details

NewWorkAssessment Flow PegaHC-Care-Work-Task Flow to execute an assessment RecurringTask Flow PegaHC-Care-Work-Task Flow to execute a recurring task

RiskStratification Flow PegaHC-Care-Work-Task Flow to assess risk level based on assessment

SpawnProblems Flow PegaHC-Care-Work-Task Flow to add problems to the care plan identified in the assessment

ExecuteNotifyCaseOwnerTask Flow PegaHC-Care-Work-Task Flow to notify the case owner

ExecuteCorrTask Flow PegaHC-Care-Work-Task Flow to execute correspondence tasks

ExecuteAssessmentTask Flow PegaHC-Care-Work-Task Flow to execute an assessment task

ExecuteInterventionTask Flow PegaHC-Care-Work-Task Flow to execute intervention tasks



Rule Name Rule Type Class Description pyDefault Case Type PegaHC-Care-Work-Goal Case definition for a goal case CreateGoalCase Flow PegaHC-Care-Work-Goal Starter flow for a goal case

ExecuteGoal Flow PegaHC-Care-Work-Goal Flow used to update goal progress

pyDefault Data Transform PegaHC-Care-Work-Goal Data transform used in a goal starter flow

pyDefault Case Type PegaHC-Care-Work-Problem Case definition for problem case CreateProblemCase Flow PegaHC-Care-Work-Problem Starter flow for problem case

pyDefault Data Transform PegaHC-Care-Work-Problem Data transform used in the problem starter flow


Date post:	25-May-2020
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