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Pega CPMHC Training

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1 Pegasystems 2009 Overview of CTI & PegaCALL along with CPM for Healthcare Matt Ruffing [email protected] Rob Mills [email protected] Frank Hahn [email protected]

Overview of CTI & PegaCALL along with CPM for HealthcareMatt Ruffing Rob Mills Frank Hahn [email protected] [email protected] [email protected]


Pegasystems 2009


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

CPM for Healthcare

Generic CPM HC DEMO CPM HC Class structure Enabling CPM HC Wizard CPM Wizard to create flow Show new flow in HC working Under covers of flow design and structure Changing User Interface of flow Overview of integration to external systems with CPM

Questions Pegasystems 2009


What is CTI?

Computer Telephony IntegrationTechnology that allows telephony events (call delivered to agent, call transferred, etc) to be coordinated or integrated with a computer The timing of events is such that telephony and computer events occur practically simultaneously


Pegasystems 2009

Rules-Driven Computer Telephony Integration (CTI) with PegaCALL for PegaRULES


pre-fetch to drive IVR processing and call routing sRe-use rules to drive IVR decisioning sAdaptive screen pop for effective coordination of call arrival sDesktop and workflow-based telephony controls for improved call management sImplement individually or incrementally!4 Pegasystems 2009

CTI Functions Call Control Customer data pre-fetch Call routing Adaptive screen pop

Desktop Telephony ACD/PBX Login/ Make available/ Hold/Un-hold Answer call Make call Disconnect call Conference call Blind transfer Warm transfer


Pegasystems 2009

Telephony Technology in a Contact Center Interactive Voice Response (IVR) Interactive phone system that can respond to a callers input (voice / keypad) and either complete pre-determined services or assist in properly routing the call to the appropriate agent. Common Vendors: Avaya, Genesys, Syntellect, Nuance

ACD/Call Routing Automatic Call Distributor a device that distributes large volumes of incoming calls to agents. The ACD contains logic that drives routing decisions based on multiple input parameters. Routing parameters can include a combination of data about available agents and their skills, and specific information about the call/caller Common Vendors: Avaya, Aspect, Cisco

Computer Telephony Integration (CTI) 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 supporting data at the same time. Supporting data may come from Pegasystems 2009 the IVR, the phone switch or other sources


Why implement CTI? Cost Savings Avg. savings of 20 seconds/call (Gartner) A contact center that handles 10Kcalls/day can save over 20,000 agent hours/year just by implementing a successful screen pop Customers dont have to repeat information they have provided to the IVR Agents start the call more focused on the customers issue Adds perceived value to entering data in the selfservice IVR, once customers learn they will not have to repeat information to an agent Prefetch and screen pops make agents more efficient Integrated telephony features simplify agent tasks Pegasystems 2009

Increased customer satisfaction

Promotes self-service use:

Increase agent productivity:


PegaCALL Enables PRPC applications with Computer Telephony Integration (CTI) Increased Agent Productivity: Retrieve customer information in advance of the agent receiving the call Deliver the call and the customer information simultaneously Rules driven screen pop delivers the right customer data based on the agent, the customer and the call Close the IVR Gap: Eliminate the need for the customer to repeat information to an agent - IVR data is passed to the agent as the call arrives Agents can know the point at which the customer zeroed out of the IVR BPM-enabled CTI allows the agent to continue service from that point Provide the agent receiving the call with details they need to continue service Pegasystems Allow an 2009 agent to pick up at the point in

Lower Customer Frustration:

Transfer the call and the data:8


Caller is directed to IVR and prompted for information needed to access profile PegaCALL monitors call arrival on premise and may begin customer lookup by ANI. Information is gathered to satisfy IVR data requirements from any available source (see #5) IVR, Pegasystem, or caller request opt out and IVR attaches data to the call for handling by the CTI middle ware. Call is directed to ACD or is managed by CTI middle ware to the correct ACD. CTI Middleware may optionally request final route input from PegaCALL Pegasystems uses any data available to drive rules engine to determine possible route for call PBX places call in queue and maintains update with PegaCALL via link. Call is offered to next available agent in queue PegaCALL obtains message of call offering, starts rules engine with relevant data. Pegasystem drives data needed for POP to the desktop using data obtained in step 5 based on business rules. Desktop requests CTI functions (conference, transfer, hold, etc) via PegaCALL interface methods Pegasystem rules engine instructs CTI Middleware as need via PegaCALL to perform needed functions requested by desktop application.

CTI Integration ApproachACD 6CTI middleware places caller in ACD queue as instructed & notifies PegaCALL upon call offering event

2 3

1Member dial 800 # and is directed to IVR for ID prompt


4 5 6 7 8 8 9

3CTI middle ware may request data from Pega for preroute


CTI Middleware requests adjunct route from PegaCall


IVR may access legacy systems if desired



Rules retrieve & evaluate data & determine when/if telephony functions are required by CSR

8MQ or SQL


PegaCALL maintains connection for POP and CTI events


u s t o m

e r


e r v


Production applications Mainframe, OS/390 Oracle DB


Pegasystems 2009

PegaCALL for PegaRULES High Level ArchitecturePSTN1 2IVR Routing Point PBX / ACD





Queue A Queue B Queue C


Workstation 7



Windows Server PegaCALL CTI Link




SOAP Services

SOAP Connectors PegaCALL

Back-End Systems and Databases Containing Real-Time Customer Information

PegaRULES Process Commander

PegaCALL Installation with Genesys


Pegasystems 2009

PegaCALL for PegaRULES CTI support for most major ACDs using industry standard CTI middleware and routing platforms: Envox CT Connect Genesys Aspect Contact Server Cisco ICM

Server-side CTI integration

Real time adaptive screen pops

Provides seamless integration of telephony events and business processes No desktop DLLs to install Puts the right customer information in front of the agents Eliminates need for the customer to repeat to the agent what they just entered into the IVR Fully configurable can trigger different processes based on the agent and customer profiles for enhanced customer service Transfer customer and work object data with the call Pegasystems 2009

Voice and Data Transfer


Coming soon. Configuration Wizard should allow basic connectivity and features (screen pop) to be configured and running in 30-45 minutes, including call data mapping, custom screen pop, etc. This will be a huge help during POCs where CTI is required. Stateful telephony (Genesys only) allows state to be synchronized between PegaCALL and the phone, so that actions taken at the phone (ie put a call on hold) will be reflected in the PegaCALL UI. This also introduces the concept of a CTI Toolbar that can be embedded in CPM. CTILink Hot Failover ability to have a hot standby CTILink that will detect a failure in the primary link and take over automatically 12

The CPM 6.1 release (2009) will include pre-configured voice/data transfer capability, so that when a user Pegasystems 2009

Terms you need to know: Telephony ANI Automatic Number Identification DNIS Dialed Number Identification Service ACD Automatic Call Distributor Skills Based Routing A feature of many ACDs that provide the ability to route calls based on call type and agents skill set VDN/Application Vector Directory Number (Avaya) an extension that directs incoming calls to a specific vector or application. Calls are tracked by vector, the vector drives a specific message and queues. The VDN or App can indicate to the agent (and the software) the type of call Availability Agent driven indication that they are available to receive calls, usually entered into the phone set or the soft phone, but can be software controlled Auto-In/Auto-Ready An indication of the agent state that is automatically established upon release of a phone call. An auto-ready agent will become available as soon as a call is released, versus having to manually indicate availability Whisper a message from the ACD that is whispered to the agents headset just prior to the call being established, typically indicates the call type to the agent IVR/VRU Interactive Voice Response / Voice Response Unit Screen Pop Screen Population CTI Server/Middleware Server component that provides a layer of abstraction between the ACD and client software. Pega supports Envox, Cisco ICM, Genesys and Aspect Contact Server CTILink Pega component that sits between PRPC and the CTI Server Soft Phone Software based phone that allows agents to control telephony functions from their computer Wrap Up Agent state after release of a call that allows them to finalize any work, enter notes, etc. Auto-Ready call centers will have no wrap-up period Idle Agent state where they indicate that they are Unavailable to take phone calls. Many call centers measure idle time and force agents to indicate idle reason prior to going idle (ie Bathroom, etc) Call Disposition/Call Coding Feature of many ACDs that allow the agent to indicate the disposition of a call during the wrap up using either the phone set or the soft phone. Many ACDs provide Call Center dashboards that leverage this data in real time Handle Time/AHT Average Handle Time is the time it takes to handle an interaction. This typically includes wrap and any after call work. Service Levels usually measured as the % of calls that actually make it to an agent without abandoning. A 50% service level means half the calls never get to an agent. Pegasystems 2009


Call Center


CPM for Healthcare


Pegasystems 2009

Pegasystems The Healthcare BPM LeaderHC Practice Overview40% of Pega Business Deep domain expertise

Market Momentum

Results - ROI

75% reduction Claims Backlog 30% increase 1st pass rate 98% reduction in group enrollment costs 20% increase issues handled per contact 20% reduction call handling time 50% reduction in training times

17 new customers in past 18 months 90% licensed our solution frameworks Significant repeat business Enterprise backbone commitments Over 95M covered lives 4 of top 5 payers 55% of BCBS Plans

Target MarketLarge Payers > 2MM Members Top Pharma / LifeScience Cos Healthcare Government Selective Providers/IDNs/PBMs


Pegasystems 2009

Marquee Healthcare ClientsTransforming Healthcare Across The Globe


4 of top 5 Largest U . S . Payers 34 % of Blues Network Blues Members - Pegasystemsmillion covered lives 95 2009

55 % of

Execution Gaps Closed by Our CustomersNew BusinessTime to Market

Customer Relationship ManagementCSR Desktop

Servicing BackboneEnterprise Case & Event Management

Risk, Fraud, & Compliance ManagementSubrogation, Collections & Recovery

Tailored Offerings

360 Degree View of the Customer

Service Exceptions Processing

HIPAA, CMS & Blues Compliance


Web Self-Service

Claims and Adjustments

FDA & OIG Compliance

Sales Process Management

Cross-Sell, Up-sell

Internal Servicing Backbone

Medical Management


Pegasystems 2009

SmartBPM for HealthcareNew BusinessNew Business Backbone

CRMCPM for Healthcare

Servicing BackboneCare Mgmt Backbone *NEW* Claims Backbone


Risk Fraud &

Sales Process Manager

Membe r Service s

Provide r Service s

Care Management

Claims Repair

Claims WS+

Build Risk Fraud & Complia nce Rules In Industry Backbon es

HC Product Configuration *NEW*

CPM HC Foundation

Clinical Foundation

Claims Foundation

New Member EnrollmentHealthcare Common Object Model X12 EDI Message Support

Appeals & Grievances Manager

Authorization Management Sample Simulated Data Sample Organizational Model

Healthcare Industry Foundation

PegaRULES Process Commander (PRPC)18 Pegasystems 2009

Healthcare Industry FoundationInter action Mana gementHealthcare Common Object & Data Model

HC Enterprise Organization Structure HealthCare Object Search & Retrieval EDI Message Support HIPAA X12 Healthcare Portals HealthCare Standard SLAs HIPAA Standard Code Sets

Case Mana gement & Contr olNew Business Member Enrollment

CRM Authorization Management

Servicing Backbone Appeals and Grievances

Risk and Fraud Mgmt Authorization Management


Pegasystems 2009

HC Industry Framework (Representative Functionality)Member Application & Enrollment Processing Pre-configured Healthcare Components

Sample enrollment workflows driving intake, data

entry & output Intent-led data entry; automated data population for PDF and email applications Intelligent enrollment application routing Per member risk factor computation & underwriting approval recommendation based on medical underwriting

Work Parties (member, provider, broker, plan sponsor, agency, etc) HIPAA EDI x12 Support Healthcare Common Objects (claims, authorization, premium, benefits, COB,Functionality Pre-built HIPAA policy, etc) Automated file input (batch & real-time) x12 message parsing & mapping HIPAA property validation HIPAA x12 EDI samples

Appeals & Grievances Management

Multi-channel guided-intake for web, phone, email and Comprehensive member composite Pre-packaged workflows for Appeals, Grievances,fax Requestor Party Information & service/claims information Concurrent assignments to multiple departments for research & response Secure one-time link for external parties to provide data and work cases

Reusable Work Templates

Member Search & Review Claim Search & Review Provider Search & Review Authorization Search & Review Policy Search & ReviewReporting

Automated Authorization Request Management

Provides Web Service SOAP Message for providers tosubmit x12 278 transactions through Self-service portal Facilitates straight-through-processing of x12 278 based on easily customized sample business rules Routes & prioritizes pending transactions for manual processing

Out of the box productivity, quality & aging reports Drill-down review capabilities Custom report wizardCorrespondence Generation

Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail forcompliance reporting allow edits dynamically when needed


Pegasystems 2009

Customer Process Manager for HealthcareInter action Mana gementPhone Interactions HC Customer ID & Verification Customer Linking Contact Center Portals CTI HC 360 Degree View Customer Alerts Email Response Interaction Driver Customer Profile Management Interaction Analytics Dialog Management Interaction Tracking Knowledge Management Campaign Management Interaction Coaching Customer Surveys

Fax & Mail Interactions Web Self-Service InteractionsCC Configuration Wizards Web Contact Center Object & Data Model

Healthcare Common Object , Data Model & Policy Structure HC Payer Enterprise Organization Structure CC Queue Management Customer SLAs CC Quality Mgt CC Productivity Analytics Customer Security

Member Ser vice

Case Mana gement & Contr olBoth Member & Provider Ser viceGeneral Service Requests Materials Fulfillment Complaint / Compliment Send Correspondence Prior Authorization Review Claim Status Review

Provider Ser vice

Member Healthcare diagnostic

Appeal Prior Auth Denial Manage Provider Participation

Dispute Claim Payments / Multi-member / Multi policy inquiry Denial Add Newborn Order ID Cards Add / Update PCP Manage Privacy Settings HealthCare - FAQs Schedule Activities Diagnose Problems Member Eligibility

Request Pre-certification / Prior Authorizat Mange Provider Credentialing Manage National Provider ID Manage Group Participation

Wor k Automation21 Pegasystems 2009

CPM-HC (Representative Functionality)Interaction Management Inbound Customer Call Automated email receipt & case creation Manual inbound correspondence case creation Customer verification * Interaction DriverTM with suggested customer processes & offers Smart DialogTM interaction scripting Interaction log & audit trail * Automated interaction wrap-up Communication workflow Contact Priority Note Multi-policy servicing including inactivity logic Designee management * Role-based authority management * Reference Utilities for Reference Materials, Location Finder and Find CTI Facilities Provider CTI Login & Availability Screen-pop with data collection from IVR Desktop telephony controls22

Customer Management Smart ViewTM customer data composite (policy, member, provider, facility, claims, authorizations, contact & plan sponsor) General Information & profile Multi-channel interaction history Service history Benefit Review Claim search & review Authorization search & review Notes Add a Contact Quick Contact Add Update Contact Name & Profile* Update Contact Address & Profile

General Service Request ProcessingAdd Attachment Complaint/Compliment Dispute Claim Frequently Asked Questions General Service Case Materials Fulfillment Member Eligibility

Member Search Schedule Activity (call, appointment, task) Send Correspondence

Member Service Request Processing Add a Newborn Order ID Card Update Member Address, Birth date, Name Update Primary Care Physician * Update Privacy Settings* Multi-member / Multi policy inquiry facilities Pegasystems 2009

Provider Service Request Processing Appeal Prior Auth Denial Enroll in a Provider Network Manage National Provider ID Request Prior Authorization Update Provider Credentials Update Provider Profile

* Facilitates HIPAA Compliance

CPM-HC (Representative Functionality) Random & manual work selection Employee review, rating & scoring Coaching sessions & real-time coaching tips

Quality Performance Management

Knowledge Management Knowledge content rules and usage statistics Knowledge inquiry & response User suggestions for content update


Access Roles /

Access groups, privileges & user portals for*: Member, Provider & Universal CSRs Member, Provider & Universal Managers Sales Representatives Sales Managers System Administrators Operator profile, schedule & skills management Workbasket assignments Secure login Correspondence

Operator Maintenance

Work Assignment & Service Level Management

Interaction reports Productivity reports Quality reports Aging reports Campaign reports Pipeline & opportunity reports Quality Performance Reports Knowledge Management Reports Custom report wizard Drill-down review capabilities

System-assigned routing based on case urgency Service level goals, deadlines & escalation events User work lists System workbaskets Get Most Urgent Work functionality Work re-assignment Customer-based service level profiles Customer-based service level override

Offer , Opportunity & Territory Management Cross-sell, retention, restitution, reward & wellness campaigns Campaign set-up wizard & script definition Suggested offer processing Opportunity creation, assignment & resolution Named customer & territory assignments

Generation Automatic & manual generation Create & modify templates Mail, email, & faxcapabilities Review, editing & verification privileges * Facilitates HIPAA 23Compliance

Pegasystems 2009

The CSR desktop is intent-driven and configured to optimize every customer interaction and overall CSR efficiencySmart Dialog Context-sensitive, personalized dialog

Smart Scripting Dynamic scripting minimizes training and ensures service consistency

Interaction Driver Context-sensitive, personalized tasks

Member Specific Processe s

Member Specific Views


Pegasystems 2009

Smart Views Context-sensitive, summary information enables research & review concurrent with process fulfillment

PegaHEALTH Member Services

The Interaction Driver anticipates customer requests, suggests next steps & queues tasks for more effective service

Scripting guide user withAnticipates customer intent and guides CSR minimal CSR training

Interaction log Customer data available on deman where CSRs been and going


Pegasystems 2009

Grievances & Appeals (Representative Functionality)Multi - Channel Intake Pre - Packaged Workflows

Phone, email, fax or Web Original email/fax stored w/work item Guided data entry

Appeals Management Processes Grievance Management Processes Case Creation Requestor Party Information Service and/or claims informationMulti - Party Processing

Historical Composite Member View

Automatic retrieval of relevant legacy data Member Benefits Provider Contract Users access group controls information displayReporting

Concurrent assignments to multiple departments forresearch & response Secure one-time link for external parties to provide data and work cases

of the box productivity, quality & aging reports

Easily attach supporting documents includingmedical notes

l-down review capabilities om report wizard

Correspondence Generation

Compliance Features

Reusable standard letter templates - compileddynamically when needed Automated or on-demand; choose to require review or allow edits Maintained as part of inalterable audit trail for compliance reporting

Automated service levels to ensure compliance and Comprehensive audit trail documents all human andsystem generated activities move cases towards timely resolution


Pegasystems 2009

Care Management FrameworkInter action Mana gementX12 278 STP Medical Claim System Interface Patient 360 Portal Authorization System Interface Patient Event Visualizer Pharmacy Claim System Interface

HC Clinical Object and Data Model HealthCare Payer Object and Data Model HC Payer Enterprise Organization Structure ICD-9 Code Lookup CPT Code Lookup HCPCS Code Lookup NDC Code Lookup Correspondence Templates

Case Mana gement & Contr olGoal Management Comprehensive Care Management Assessment Management Alert Management Task Management Care Plan Management Campaign Management Authorization Management Goal Template Wizard Care Plan Template Management Task Template Wizard Alert Template Wizard Code Group Management

Wor k Automation27 Pegasystems 2009

Care ManagementWizard - Driven Program Creation

(Representative Functionality)Comprehensive Call Management

Structured, wizard driven creation of Care

Management programs Reusable components optimize Program creation Flexible design allows for Programs to be created and deployed rapidly by business users Automated documentation of Care Plans help ensure consistency and support meeting operational goals of Care Management programs

Schedule Call tasks support flexible scheduling of

periodic monitoring and assessment of the patients health Automated scheduling of follow up calls Powerful assessments support branching and hide logic for questions Assessments perform risk calculation and automatic creation of Care Plans based on risk

Patient 360

Unified Care Management

Patient 360 degree view provides a complete, up-todate profile of the members care and compliance with Care Plans Comprehensive view of patient demographics including contacts providers, policies, eligibility/benefit information

Single portal for Disease Management, Case Supports managing participants across the spectrum Improves the delivery of Care Management programs Automated straight-through processing ofof care by providing a complete view of the patients care Management and Utilization Management

Automated Case Creation

authorizations Support for creating and routing of authorization requests Drill down views of medical claims, pharmacy claims, and authorizations

Out of the box support for automated case creationwith automatic assignment of Programs and Care Plans


Automated Monitoring of Care Plans

Automated monitoring of complications, exceptions tooptimal care, avoidable utilizations of high-cost services (emergency department care, hospitalizations, etc) Alerts notify Care Managers of a patients lack of compliance with a Care Plan Automated creation of correspondence to patients, providers, and case managers28

Out of the box productivity, quality & aging reports Drill-down review capabilities Custom report wizardCorrespondence Generation

Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail forcompliance reporting Pegasystems 2009

dynamically when needed allow edits

Healthcare Claims SuiteClaims 360 degree Dashboard XML Inbound Claims

Inter action Mana gementHIPAA X12 837 Outbound HIPAA X12 837 Inbound Legacy Claim System Connectors

Healthcare Portals Image Viewer Integration

Healthcare Payer Common Object & Data Model HC Payer Enterprise Organization Structure Automated Work Productivity Analytics Inventory ManagementClaim Edits and Escalation Claim Distribution

m Prioritization

Case Mana gement & Contr olClaims Repair Both claims repair & wor kstation + Claims RepairIntent Lead Desktop Claim Corrections

Pre-Adjudication Duplicate Validation Pre-Adjudication Member Edits / Corrections Claim File Management Edits / Corrections

Automated Pended Claim Corrections Pre-Adjudication -Provider Edits / Corrections

Pre-Adjudication Professional Service Pre-Adjudication Institutional Service Edits / Corrections Edits / Corrections

Wor k Automation29 Pegasystems 2009

Healthcare ClaimsAnthem/Wellpoint Pre-Adjudication IBC Pre-Adjudication HealthNow Extended Adjudication XC Rules

New New Claim Claim Files Files


NASCO Adjudication Rules In Data Entry UB04

CareFirst Pre-Adjudication BCBSMN Pre RX

PreProcess PreProcess ing ing

CSC Customer Service HealthNow Post-Adjudication, Anthem/Wellpoint BPM BPM CareFirst BPM Adjudication

BCBSNC Post-Adjudication Duplicates

Anthem/Wellpoint Group-Subgroup Great West Life Service Payment Rules SEPY/BSBS

BCBSXX Core Adjudication Rules

Adjudicati Adjudicati on on

Pend Pend ed ed Claim Claim Files FilesNASCO Post Repair

CLAIMS REPAIRAnthem/Wellpoint Post-Adjudication


Finalized ClaimsActual Customer Results 39% improvement in first pass rate (63% to 72%) 40% increase in staff productivity 60% STP of previously manually processed work 75% reduction in training time & expense 40% throughput increase in first week 62% reduction in average inventory days on hand (7.8 to 3) 48% of duplicate claim deferrals repaired automatically

Recent Claims Automation Projects Anthem: Group-Subgroup Load CMS: Medicare Enrollment into Core Admin New Client: Enrollment COB Mgmt Anthem: Benefit Plan Mgmt and Core Admin load Great West Life Service Payment Rule load Vendor of Choice for four additional new clients


Pegasystems 2009

Claims Repair (Representative Functionality)Pre-Adjudication Business Edits Claims Input & Output Process

Code Translations Member Provider Timely Filing Duplicate Claim Routing Rules Accident Claims Revenue CPT Code Validations

Surgeries Chiropractor Services Podiatry Services Anesthesia Services Inpatient Services Ambulance Services Lab Tests Prostate Screening Hemoccult Blood

Routine Eye Exams Common Eye

837 Claim Pre-Processing (Flat File XML Conversion) 837 XML Input Process Pended Claim XML Input Process Claim Mapping & Work Object Creation Repaired Claim Output File

Pre-Built Interface Capability

Post-Adjudication Business Edits

Pending Pending Pending Pending

Benefits Emergency Room Services Benefits Cardiac Rehab Services Pricing Home Health Injectable Drugs Potential Duplicate Claim

Claim Repository Member Eligibility Provider Data DRG Agreement Data ITS Prefix Data Revenue Code CPT Code List Diagnosis & Procedure Code Data


Authorization Data

re-adjudication Claim Repair Count Report ost-adjudication Claim Repair Count Report ustom Report Generation Wizard

Referral & Authorization Data RetrievalCorrespondence Generation

Critical Error Claims Member Not Found


Pegasystems 2009

Claims Workstation+ (Representative Functionality)Sign-On / Sign-Off & Security Correspondence Generation Claim Prioritization

Secure Login Access Groups: Claims Examiner, Mgr, SysAdmin Custom Portals: Claims Examiner, Mgr, SysAdmin Role-based workflow privileges: Examiner/ Mgr Automated Routing to Workbaskets

Auto-correspondence for rejectedclaims (Subscriber & Provider) Auto-correspondence option for requesting additional info (patient/provider/medical) Pre-configured templates for info requests Service Level Management

Prioritization for select pendcodes (header & line-level) Primary points by claim age Additional points by Provider Groups, Preferred Subscriber Groups & dollar total charge thresholds Claims Adjudication System Integration Tools

Duplicate claim detection Routing to specified workbasket Primary routing by line-ofSecondary routing by pend code Tertiary routing: claim type &total charge amount business

Overall pended claim assignment:

Provider Information Request Patient/Subscriber Info Request Medical Info Request Other Hold Reason

SysAdmin tools for managing

desktop w/multiple claim systems Automatic retrieval of claim from adjudication system Split-screen desktop display during claim processing

Automated Work Assignment

Claim File Feed Intake

Random Claims Audit

Primary determination by users personal worklist assignments Secondary determination byworkbasket assignments on users profile Tertiary determination by thresholds set on workbaskets

Published Claim XML DTD File-Service-Intake (Listeners) XML Parser to parse claim

Random selection of completed

elements Claim work object creation Finalized claim reconciliation (updating & resolving work objects)

claims for audit Selected claims transferred to Audit Review workbasket Auditor review of selected claims


Pegasystems 2009

Managed DesktopManage the core systems Control workflow with Pega Dashboard of the claim workImaging system Host claims adjudication system

object and processing options Integrate with claims adjudication system and imaging system

Use PegaIMAGE ViewerPegasystem claim work object

or third party tool to view the claim image


Pegasystems 2009

Sales Process ManagerHIPAA X12 EDI Message Support

Inter action Mana gementHealthcare Payer Common Object & Data Model HC Payer Enterprise Organization Structure Product Configuration HealthCare Payer Standard SLAs

Healthcare Portals

HealthCare Object Search & Retrieval

HIPAA Standard Code Sets

Case Mana gement & Contr olOpportunity Management

Proposal generation

Group and Subgroup

Application Generation

Company Profile Management Agency And Broker Profile Management Large Group Management

Sales Task Management

Census Management

Small and Large Group Rating

Small Group Quote Management

Renewal Management

Wor k Automation34 Pegasystems 2009

Sales Process Manager (Representative Functionality)Profile Management Quoting & Proposal Management

Company, quote opportunity, agency and broker profile management Automatic and ad hoc correspondence generation leveraging correspondence templates Activity management Rating & Pricing

Manages opportunities for multiple brokers working Creates rate card across multiple lines of business Supports both automated and manual census entry Automatically suggests products based on customerprofile & census information to reduce antiselection Packages professional proposals in multiple formats including PDF for print or e-mail to additional parties Product Configuration with the same company

Employee-based demographic rating for health and Supports actuarial and underwriting tablesdental products (effective- dated for use across multiple rating periods) Manages rating tables through an Excel interface Maintains group-specific calculations for later audits Group Enrollment

Manages complex product hierarchies Assembles data entry screens and validation rules

Packaged enrollment workflows Electronic submission of group application to

for each product based on the included components Allows easy definition and modification of the product structure through custom-purposed rule forms

legacy systems Notifies & assigns tasks to internal & external parties Manages completion via customizable SLAs Reporting

Correspondence Generation dynamically when needed allow edits

Reusable standard letter templates - compiled Automated or on-demand; choose to require review or Maintained as part of inalterable audit trail forcompliance reporting

of the box productivity, quality & aging reports l-down review capabilities om report wizard


Pegasystems 2009

Product Configuration

SmartBPM Healthcare Sales Solutions DrivingMembership Growth & Retention

Sales Process Manager

Identify Market Opportunities RFPs: National Acct

Develop Solutions Product Development

Manage Sales Opportunities Prospecting Campaign Management Lead Management

Quoting & Rating Select Benefits Calculate Rates Generate Quotes

Close / Optimize Sale Right Products Right Price

Enrollment Collect Enrollment Data

Market Segmentation essional Mandate: Medicare Part D Premium Rate Setting Preferred Broker: Large Account Individual: HSA Regulatory Filings Materials Creation Product Load

Verify Eligibility & Contract Term

Upload Systems w/Group / Subgro Right Effort / Cost Fulfill & Activate Contract Positive Customer Experience Configure Claims System

Operationalize Sales Channels Generate Proposals Cross-Sell/ Up-Sell Manage Renewals Verify Inputs

Approve Rates and Riders


Streamlined Quoting & Rating for Group & Individual 1 Million Medicare Part D Members Captured DuriInitial Open Enrollment


Sales Channel & Broker Management Automated Proposal Generation Component-based Product Creation & Maintenance Group & Prospect Management36

98% Quote Delivery Time Reduction 200% Enrollment Processing Improvement 35% Cost of Sale Reduction 42% New Member Service Calls Reduction 75% Manual Steps Eliminated

Pegasystems 2009

CPM for Healthcare In Action


Pegasystems 2009

CPM Configuration Setup

Create a rule set and version


Pegasystems 2009

CPM ruleset for new additions


Pegasystems 2009

CPM Setup update application

Be sure to add both rulesets


Pegasystems 2009

Sample PRPC Configuration

Be sure Profile reflects changes


Pegasystems 2009

CPM setup Work Pools

Work Pool update needed


Pegasystems 2009

CPM Wizard setup




Pegasystems 2009

CPM setup Wizard is now available


Pegasystems 2009

CPM setup Service Process Accelerator


Pegasystems 2009

CPM wizard Select ruleset and version


Pegasystems 2009

CPM Wizard name the new process


Pegasystems 2009

CPM Wizard When and where would you like it?

This will direct where your new process will be placed


Pegasystems 2009

CPM Wizard something special needed?

This will make it easy to change screen content later


Pegasystems 2009

CPM Wizard start enhancing

You are ready to test & refine!!


Pegasystems 2009

Standard PRPC update the UI


Pegasystems 2009

CPM Wizard Flow Action defaults


Pegasystems 2009

CPM Wizard Flow Action defaults


Pegasystems 2009

CPM New process in action


Pegasystems 2009

CPM add/update dialog defaults


Pegasystems 2009

CPM update new flow


Pegasystems 2009