Pega Product Composer for Healthcare – Product Overview · 2019. 5. 22. · Product lifecycle...

Pega Product Composer for Healthcare

PRODUCT OVERVIEW 7.31

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Pega Product Composer for Healthcare

Document: Product Overview

Software Version: 7.31

Updated: August 2017

CONTENTS

Product overview............................................................................................... 1

High-level functionality ..................................................................................... 2 Integration ..................................................................................................... 2

Integration ................................................................................................ 2 System for Electronic Rate and Form Filing (SERFF) support.................. 2

Search and compare ..................................................................................... 2 Searchable............................................................................................... 2 Enhanced search ..................................................................................... 2

Document generation .................................................................................... 3 Configuration ................................................................................................. 3

Product lifecycle management ................................................................. 3 Reporting ....................................................................................................... 3 Extension ....................................................................................................... 3

Extensible and adaptable ......................................................................... 3 Localization-ready .................................................................................... 3

Building blocks ............................................................................................... 3 Industry specific – Healthcare Industry Foundation (HCIF) ..................... 4 Code group driven healthcare terms ........................................................ 4 Wellness and incentive benefits ............................................................... 4 Support for configuring dental benefits ..................................................... 4

Core elements ............................................................................................... 4 Multi-user, multi-channel, enterprise single-source product repository ..... 4 Web-based group, individual, and exchange sales support ...................... 4 Collaborative environment ....................................................................... 4 Multi-level reuse of production information ............................................... 5 Flexible configuration ............................................................................... 5 UI and architectural changes ................................................................... 6 New methods of cost share calculation .................................................... 6 Pega Product Composer for Healthcare concepts.................................... 6

Process ......................................................................................................... 7 Bulk renewal ............................................................................................ 7 Pega Product Composer for Healthcare import ........................................ 7 Automatic plan bundle update .................................................................. 7

Data model ......................................................................................................... 8

Roles, portals, and dashboards ..................................................................... 17 Pega Product Composer for Healthcare system roles .................................. 17

Product development portal ................................................................... 18

Product manager portal.......................................................................... 18

Stage based life cycle management ............................................................... 20 Life cycle management overview ................................................................. 20

Development .......................................................................................... 21 Implementation ...................................................................................... 22 Production.............................................................................................. 22 Retirement ............................................................................................. 22

Lifecycle process summary .......................................................................... 22

Entity versioning ............................................................................................. 25 Entity versioning introduction ....................................................................... 25 Pega Product Composer for Healthcare versioning ..................................... 26

Creation of default version ..................................................................... 26 Versioning enhancement ....................................................................... 26

Mass Update .................................................................................................... 28 Mass update overview ................................................................................. 28

Feature screen shots ...................................................................................... 30

Pega Product Composer for Healthcare – Product Overview 1

Pega Product Composer for Healthcare is an enterprise-wide healthcare solution designed to support product design, benefit loading, product setup, approval processes, and lifecycle management.

Pega Product Composer for Healthcare offers an agile solution, allowing development and management of innovative healthcare products that support design, approval, operational readiness, and execution. The stage-based life cycle management provides better control over the business process and improves the consistency, effectiveness, and visibility of process handling which, thereby, decreases cost and improves quality.

Pega Product Composer for Healthcare provides dates-driven versioning capabilities to create and maintain different versions of the entities in the same life cycle or different life cycles. In addition, Pega Product Composer for Healthcare also provides the capability to mass update various benefit sets, product templates, products, and plans based on the user specified criteria.

Pega Product Composer for Healthcare also provides a robust product, policy, and coverage repository designed for use across a health plan. The system brings transparency and speed to product development efforts, while driving accurate product delivery. Additionally, the common product repository provides consistent information to all users in the language and format best-suited to their needs. This capability supports accurate, consistent, and transparent customer interactions across such departments as Product Design, Underwriting, Sales, Enrollment, Medical Policy, and Claims. Ultimately, Pega Product Composer for Healthcare provides a single source of truth to create an auditable connection between the documents used for Sales and Product design and the structures, codes, processes, and logic of the adjudication system.

Pega’s unified rules processing technology foundation power the Pega Product Composer for Healthcare unique capabilities. It is a single environment organically developed over 30 years with award-winning Business Process Management (BPM), Business Rules Engine, Dynamic Stage based Case Management, Predictive and Adaptive Analytics, and Decision Management capabilities.

Deployed on the cloud or on premise, Pega Product Composer for Healthcare dramatically reduces time-to-market, introduces customized products at a lower cost, achieves traceable compliance, and grows and retains customer base in an increasingly competitive healthcare market.

Product overview


Integration With Pega Product Composer for Healthcare, you can use the application-provided plan flattening data model to integrate with various formats such as System for Electronic Rate and Form Filing (SERFF).

Integration Integrates into legacy systems and interoperates with other Pega solutions for Service, Sales, Enrollment, Claims, and Care Management for enterprise-wide agility, efficiency, and control.

System for Electronic Rate and Form Filing (SERFF) support Supplies Pega-provided capabilities to extract the complex plan and benefit data into a standard flattened model. Now, you can export Pega Product Composer for Healthcare data into a standard flattened format for use in downstream data such as claims adjudication.

You can also use the extracted data as an input to a SERFF file.

Standard flattened data can speed up the integration efforts to other enterprise applications.

Search and compare You can dynamically configure search screens for all entities. This includes not only high-level optimized properties, but also the properties within the entity data model. You can easily extend the search capabilities.

Searchable Extended ability to set search, sort, and filter items according to category, line of business, and effective date. Enhanced search capabilities allow for easy search for each entity by name, version number, category, line of business, version notes, life-cycle stage, and effective dates. These search fields can easily be extended.

Enhanced search Advanced search feature which provides the user with the ability to configure and manage the search parameters on the application configuration page for all entities including benefits, groupers, benefit sets, networks, product templates, products, plans, plan bundles, policies, and policy terms.

Because the Pega Product Composer for Healthcare data model has a deep hierarchy of nested structures, with the advanced search configuration, the user can search by using any of the properties within the hierarchy. The search is no longer limited to the high-level, exposed properties.

High-level functionality


TITLE of INTERNAL DOCUMENT – Arial Bold 12

Document generation The Summary of Benefits and Coverage (SBC) feature is provided in the product flow. You can extend this feature in your implementation application.

Configuration The Pega Product Composer for Healthcare for Healthcare configuration page drives key processes, search settings, application and flow settings, and benefit mapping settings.

Product lifecycle management Delivers Product Design capabilities by:

Streamlining the product design and approval lifecycle, thereby reducing time-to-market for new products.

Enabling creation of innovative and nuanced healthcare products by facilitating tiered- network, carve-out, and value-based benefit arrangements.

Simplifying product management with component-based, re-usable product logic.

Configurable approval processes.

Capturing history for robust audit capabilities.

Refer to Chapter 5 for more details on Product lifecycle management.

Reporting Pega Product Composer for Healthcare includes a set of ready to use reports.

Extension With this capability, you can extend the Pega Product Composer for Healthcare designs and rules to meet your organization’s needs.

Extensible and adaptable Pega Product Composer for Healthcare is extensible and capable of adapting to new business challenges. It provides extension points to enable client-specific customizations.

Localization-ready Pega Product Composer for Healthcare is localization-ready for use beyond the default English language. The entire application UI is formatted to be compliant with current localization standards.

Building blocks The Pega Product Composer for Healthcare building blocks are the entities and features that you use to create the plans that then become available for sale.



Industry specific – Healthcare Industry Foundation (HCIF) Built for healthcare organizations, HCIF provides a healthcare-specific foundation and data model for rapid creation and deployment of solutions that deliver productivity, spur growth, and ensure compliance. Pega Product Composer for Healthcare obtains common healthcare code sets from HCIF such as, ICD-10 DX, CPT, HCPCS, Bill Types, Revenue Codes, and more.

Code group driven healthcare terms Pega Product Composer for Healthcare mapping logic, authorization requirements, coverage notes, benefit descriptions, Summary Plan Descriptions (SPD) content, and inquiry information are based on configurable terms defined by standard healthcare codes. This eliminates interpretation errors and ensures traceable and auditable information, rules, and logic to all consumers and systems.

Wellness and incentive benefits Support for non-medical benefits, including wellness, activity trackers, guardrails in homes, smoking cessation, and other non-medical benefits.

Support for configuring dental benefits Current Dental Terminology (CDT) codes and groups are included as a standard feature. This allows for the creation of complex dental benefits by leveraging the CDT codes and groups. The UI and data model provide support for the dental benefit configuration.

Core elements Core elements are critical to the plan configuration in Pega Product Composer for Healthcare.

Multi-user, multi-channel, enterprise single-source product repository Enterprise repository for product, policy, and coverage information with the capability to customize responses for members, providers.

Web-based group, individual, and exchange sales support Pega Product Composer for Healthcare is a run-time engine designed to supply product, benefit, and policy information to web sales and enrollment systems.

Collaborative environment Pega Product Composer for Healthcare provides a unified environment to enable the creation of a traceable and auditable connection between product terms and descriptions to the actual adjudication calculations. It is a collaborative environment for benefit configurators, product designers, and claim adjudication employees to work collaboratively to deliver a unified solution. What you sell is what you administer.

In a single environment, Pega Product Composer for Healthcare enables:

Collaboration of product design, medical policy, and benefit configuration.

Assembly of healthcare codes into manageable groups and terms that form the foundation for benefit coverage notes, cost share definitions, and exclusions.



Organized benefits, groupers, and networks into the structure of products.

Benefit configurators to map the codes and policy terms from incoming claims to the most appropriate networks and benefits.

Accurate and consistent product information for multiple consumer inquiries.

Capabilities for managing large numbers of plans.

Multi-level reuse of production information A typical health payer has a small number of products which result in hundreds of plans to accommodate large employer accounts and small groups and individuals. To load these plans often requires that all the coverage rules, cost-share parameters, and exclusion logic be copied or replicated for each plan, even when plans have little to no variation from the base product.

Replicating all of that information exposes health payers to retest the entire product for each sale, thereby substantially increasing the time and effort to load benefits.

With Pega Product Composer for Healthcare, when customization to a base product is required, only the specific information changed is captured and stored. All remaining data is reused from the base product. Maximizing reuse of product information:

Reduces product data by over 80% and substantially reduces the system time to load product and benefit information to backend systems.

Reduces the amount of effort required to load and test products by at least 75% and captures the changes requested during the sales process for precise analysis.

Flexible configuration Pega Product Composer for Healthcare provides enhanced capabilities for configuring product information:

Copay

Deductible

Coinsurance

Out-of-Pocket, Maximums

Carryover

Optimized capabilities to configure the variation rules based on the conditions defined, such as place of service, provider specialty, diagnosis or bill type. Variations can be a simple copay/coinsurance variation, or more complex deductible, authorization, limit, or eligibility variations. Exclusions are also included in the unified variation configuration and are accommodated by the UI and data model.

Enhanced user friendly representation of benefits and groupers in the “Configure benefits” screen. This is driven by the product tree that was introduced in version 7.21 of Pega Product Composer for Healthcare.

Cost shares configuration can be configured at the Product and Plan level. Inheritance is followed accordingly.



UI and architectural changes The Pega Product Composer for Healthcare UI for benefit configuration has been streamlined. Once the codes and groups are configured, only those configured entities are displayed. This enhancement eliminates extra blank spaces thereby creating an optimum user experience. By leveraging the Pega Platform elastic search capabilities, indexes are retired thereby reducing the load on the clipboard and providing better system performance.

New methods of cost share calculation With Pega Product Composer for Healthcare 7.31 there are now four options for deductible and out-of-pocket calculation that are available at the product template, product, and plan levels. These new options help to accurately adjudicate claims:

Policy type – the user enters the deductible and/or out-of-pocket maximum amounts based on the policy type tiers that are defined by the product template, product, or plan structures. For example policy types could be defined as, employee, employee + one, family.

Number of family members – the user enters the individual deductible and/or out-of-pocket maximum amount and the number of family members who are required to meet the individual amount. The family deductible and/or out-of-pocket maximum amounts will then be automatically calculated.

Embedded – the user enters the individual and family deductible and/or out-of-pocket maximum amounts.

Subscriber salary – the user enters the deductible and/or out-of-pocket maximum amounts based on the subscriber’s salary. The user can define multiple deductible and/or out-of-pocket maximum amounts based on a salary range. The user can also define salary ranges as needed for the product template, product, or plan structures.

Pega Product Composer for Healthcare concepts



Process With Pega Product Composer for Healthcare processes, the benefit configurator can create or modify the Pega Product Composer for Healthcare entities in bulk. Common processes include: update, renew, and import.

Bulk renewal With the bulk renewal feature, the user can copy existing application data into a new calendar year or a new line of business. The user can renew all the Pega Product Composer for Healthcare entities including benefits, groupers, benefit sets, networks, product templates, and products. The renewal solution is integrated with existing stage and versioning features of the application, thereby providing a seamless user experience. The built-in validation logic can also be extended to meet the business needs.

Pega Product Composer for Healthcare import Data can be imported from structured and unstructured formats directly into the application. Using the Import feature, benefit, grouper, benefit set, network, policy term, and policy data are imported directly into the application from Excel spreadsheets. This feature greatly reduces the application adoption time and quickly brings the benefit and plan configuration enterprise data into a robust application for complete transparency and increased accuracy, and it acts as a single source of truth.

Automatic plan bundle update Based on the configuration settings chosen when implementing Pega Product Composer for Healthcare, plan bundles are automatically updated to reflect the new version of the plan(s) included in the plan bundle. The Plan Bundle Update feature ensures that the updates to plan bundles are automated in real time, which results in time-saving for the operations teams.

Using the settings on the Product Composer configuration page, the user can control the stages in which the plan bundle update should run


Pega Product Composer for Healthcare consists of flows and processing that create custom rules within the Rule-HC-PCS-hierarchy for:

Benefits

Benefit sets

Groupers

Networks

Product templates

Products

Plans

Policies

Policy terms

Plan bundles

These larger scale objects encapsulate required data and processing to fully describe saleable healthcare insurance products. The objects are both reusable and hierarchically composed to provide leverage over the enormous amount of data required to define insurance products. Pega Product Composer for Healthcare employs work objects to define, save, and associate rules with one another, and saves these as custom rules. Pega Product Composer for Healthcare implements filtered selections for medical, dental, vision, and pharmacy for each of the custom rule definitions to ease tailoring. Each custom rule is designed and implemented for extensibility.

Object Type Description Benefits Collect and contain all the healthcare code groups and code sets that define a benefit.

This data, inherent in the benefit, is referred to as the benefit mapping data. Refer to the Healthcare Common Codes Implementation Guide for further details on code groups and code sets. Benefits also contain notes and optionally, wellness data.

Benefit set Contains a set of benefits that are managed as a single unit. Benefit set rules can be selected for inclusion in product templates, and can be tested for benefit mapping conflicts for specific combinations of code sets. When benefits are included in a benefit set, they are locked to that benefit set and can only be changed after being copied to a new benefit set. Benefit set construction also allows you to define groupers. Pega Product Composer for Healthcare employs benefit set testing functionality to test benefit mapping to claims matching logic.

Groupers Group benefits within a benefit set. Changes to grouper properties permit the contained benefits to inherit those values. Pega Product Composer for Healthcare implements two types of groupers – temporary and permanent. Temporary groupers can be created only within the context of a benefit set while permanent groupers are defined by a creation process. Permanent groupers are used to add benefits to a product template when the Pega Product Composer for Healthcare configuration mode stipulates optional benefit sets.

Data model



Object Type Description Network Represent the cost share levels associated with a provider network contracted to provide

medical coverage for the benefit child items under the network. Networks in Pega Product Composer for Healthcare are lightweight objects whose properties are expected to be obtained by interacting with an external system. In Pega Product Composer for Healthcare 7.13, HCIF networks are consumed. So the network flow is slightly modified to fetch the HCIF provider networks into the Pega Product Composer for Healthcare network object for Pega Product Composer for Healthcare version 7.13 only.

Product template Contain definitions for various aspects of an insurance product and serve as templates for product creation. During product template construction, provider networks are selected together with the benefits each network covers. This process defines a product template tree structure of provider networks and their covered benefits. Within this structure, relevant insurance options and data are defined including: coverage levels, cost share range values, guardrail rules, and general documentation impacting the insurance product. The product template tree structure facilitates inheriting values from a parent node when values are not set on a specific network or benefit.

Product Defined from product template rules to acquire their definitions and cost share selection ranges. During product creation, cost share selections are required for each network, and then the product tree is displayed to make other selections. Again, the product tree facilitates inheriting network values when none are defined in a specific benefit.

Plans Define from products as group or individual type; relevant parties are defined accordingly. During plan configuration, you can edit the values. When edits are within acceptable ranges, approval is bypassed; otherwise there is exception processing to request approval.

Policy Associations of policy terms that are linked to a benefit. Policy term configuration can be inherited by a product template or created within products or plans.

Policy Term Policy term rules contain code set and code group mappings covered by a benefit rule instance and a Note set, similar to benefits. Policy terms are a component of policy rules. Once a term is included in a policy rule, it can be configured for variations in Coverage, Exclusions, Limits, Authorization, and Medical Policy.

Important entity-relationships

Benefit

Class: PegaPCS-HC-USA-Work-Accelerator-Benefit



Grouper

Class: PegaPCS-HC-USA-Work-Accelerator-Grouper

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E m b e d -H C -P C S -C o n d it io n -+ A d m is s io n S o u rc e C o d e : P e g a H C -D a ta -S e rv ic e+ D ia g n o s is G ro u p L is t : E m b e d -H C -P C S -M a p D a ta -+ In d iv id u a lR e la t io n s h ip L is t : P e g a H C -D a ta -P a r ty -M e m b e r+ M o d if ie rL is t : P e g a H C -D a ta -C la im L in e+ P ro v id e rT a x o n o m y S e a rc h L is t : P e g a H e a lth -C o d e s -D a ta -P ro v id e rT a x o n o m y+ P ro v id e rT a x o n o m y S e le c t io n L is t : P e g a H e a lth -C o d e s -D a ta -P ro v id e rT a x o n o m y+ A g e U n its+ A u th o r iz e d+ B illT y p e+ F ro m A g e+ G e n d e r+ J u r is d ic t io n+ P la c e O fS e rv ic e+ P ro v id e rN P IT y p e S e le c t io n+ P ro v id e rR a n k in g+ P ro v id e rT y p e+ P ro v id e rT y p e S e le c t io n+ R e fe rra l+ S e rv ic e B y+ S e rv ic e G ro u p+ S h o w F in d T a x o n o m y+ S p e c ia lC o n d it io n T y p e+ S p e c ia lty+ T a x o n o m y C o u n t+ T o A g e+ T y p e O fC o n d it io n 0 ..*

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P e g a P C S -D a ta -C o n fig+ A u th o r iz a t io n In s tru c t io n s : E m b e d -H C -P C S -In s tru c t io n s -+ C o v e ra g e In s tru c t io n s : E m b e d -H C -P C S -In s tru c t io n s -+ E x c u ls io n s In s tru c t io n s : E m b e d -H C -P C S -In s tru c t io n s -+ L im itIn s tru c t io n s : E m b e d -H C -P C S -In s tru c t io n s -+ C la im S y s te m D e s c r ip t io n+ C la im S y s te m N a m e

0 ..*

$ C L A S S

P e g a H C -D a ta -L in e O fB u s in e s s+ *p x C re a te D a te T im e+ L in e O fB u s in e s s+ p y N o te

R u le -H C -P C S -P o lic y+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ C a te g o ry

D a ta -A d m in -O p e ra to r - ID+ *p y U s e rId e n tif ie r

R u le -H C -T e rm+ *E ffe c t iv e D a te+ *N a m e+ A u th o r iz a t io n V a r ia t io n s : E m b e d -H C -P C S -V a r ia t io n -+ C o v e ra g e V a r ia t io n s : E m b e d -H C -P C S -V a r ia t io n -+ E x c lu s io n V a r ia t io n s : E m b e d -H C -P C S -V a r ia t io n -+ L im itV a r ia t io n s : E m b e d -H C -P C S -V a r ia t io n -+ M e d ic a lP o lic y : E m b e d -H C -P C S -C o n s u m e rN o te -+ T a g L is t : E m b e d -H C -P C S -P o lic y T a g -+ C a te g o ry+ C o n fig u re M o d e+ C o p ie d F ro m+ C o p y O rN e w+ D ra ft+ E d itM o d e+ E x c lu s io n C o n fig u re M o d e+ L im itC o n fig u re M o d e+ L in k V ie w N a m e+ M e d P o lic y C o n fig u re M o d e+ T a g+ T a g 2+ T a g 3+ T e rm D a te

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D a ta -W o rk A tta c h -+ p y L a b e l+ p y N o te

E m b e d -H C -P C S -In s tru c t io n s -+ E v e n t+ P e n d In s tru c t io n

E m b e d -H C -P C S -V a r ia t io n -+ A u th o r iz a t io n T y p e s : E m b e d -H C -P C S -A u th o r iz a t io n -+ C o n d it io n s : E m b e d -H C -P C S -C o n d it io n -+ L im itC o m p a re : E m b e d -H C -P C S -V a r ia t io n -L im it-+ L im itF ix e d : E m b e d -H C -P C S -V a r ia t io n -L im it-+ A lw a y s O rC o n d it io n a lly+ A u th o r iz a t io n T y p e+ C a lc u la t io n M e th o d F o rA u t+ C a lc u la t io n M e th o d F o rP e n a lty+ C la im O rL in e L e v e l+ C o n fig u re M o d e+ D a y s D e s c r ib e d A s+ D ia g n o s tic C o n d tio n+ E ffe c t iv e D a te+ E v e n tT y p e+ E x c lu s io n S P D+ F ix e d O rC o m p a re+ F la tA m o u n tIn t+ F lo a tin g P e r io d 1+ F lo a tin g P e r io d 1 T y p e+ F lo a tin g P e r io d 2+ F lo a tin g P e r io d 2 T y p e+ F re q u e n c y D a y s+ F re q u e n c y F o rP e n a lty+ F re q u e n c y M a x im u m In t+ F re q u e n c y M e th o d F o rP e n a lty+ G e n e ra te d S P D A u th o r iz a t io n+ G e n e ra te d S P D C o v e ra g e+ G e n e ra te d S P D E x c lu s io n s+ G e n e ra te d S P D L im its+ G u id e lin e s+ H a s E rro r+ In itD e fa u lt+ Is A p p ly P e n a lty+ Is M a s te rL is t+ Is M a s te rL is tD is a b le d+ Is S te p N e e d e d+ Is W a iv e+ L im itC o m p a re O p e ra to r+ L im itP e r io d+ M e a s u re m e n t+ M e a s u re m e n tP r io r+ M e th o d T y p e+ N u m b e r+ O th e rG u id e lin e s+ P e n a lty M e th o d+ P e n a lty T y p e+ P e rc e n ta g e O fP e n a lty+ S e le c te d B e n e fit+ S e rv ic e G ro u p+ S te p D o w n G u id e+ S te p D o w n In s tru c t io n s+ T e rm D a te+ W a it in g P e r io d M o n th s

0 ..*

0 ..*

0 ..*1

R u le -H C -P C S -B e n e fit+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ C o n s u m e rN o te s : E m b e d -H C -P C S -C o n s u m e rN o te -+ C o n s u m e rN o te s C R : E m b e d -H C -P C S -C o n s u m e rN o te -+ E x c lu s io n s : E m b e d -H C -P C S -E x c lu s io n -+ p y C u s to m F ie ld s : E m b e d -C u s to m F ie ld s L is t+ p y P a g e s A n d C la s s e s : E m b e d -P a g e s A n d C la s s e s+ B e n e fitS e tN a m e+ C a te g o ry+ R a n k+ T e m p K e y+ W o rk O b je c tIn s K e y

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P e g a P C S -D a ta -B u n d le+ *B u n d le ID+ *E ffe c t iv e D a te+ *T e rm D a te+ D e n ta lP la n s : P e g a P C S -D a ta -P la n+ M e d ic a lP la n s : P e g a P C S -D a ta -P la n+ P la n s : P e g a P C S -D a ta -P la n+ R x P la n s : P e g a P C S -D a ta -P la n+ V is io n P la n s : P e g a P C S -D a ta -P la n+ A lia s N a m e+ F ix e d O rC h o ic e+ p y D e s c r ip t io n

0 ..*

R u le -H C -P C S -+ L im its : E m b e d -H C -P C S -L im it-+ R u le H is to ry : H is to ry -P e g a P C S -H C -U S A -W o rk+ D is p la y D a te+ H is to ry D a te C re a te d+ p y C irc u m s ta n c e+ p y R u le A v a ila b le

0 ..*

0 ..*

P e g a H C -D a ta -P a r ty -M e m b e r+ *p y W o rk P a rty U r i+ D e s c r ip t io n

P e g a H C -D a ta -C la im L in e+ P ro c e d u re M o d if ie r

H is to ry -P e g a P C S -H C -U S A -W o rk+ *p x H is to ry F o rR e fe re n c e+ *p x T im e C re a te d

D a ta -A d d re s s+ p y E m a ilA d d re s s

L in k -A tta c h m e n t+ *p x C re a te D a te T im e+ *p x L in k e d R e fF ro m+ E ffe c t iv e D a te+ E x p ira t io n D a te+ F ile N a m e+ p y C a te g o ry+ p y M e m o+ p y T re e G r id Ic o n

R u le -H C -P o lic y+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *p y C la s s N a m e+ T e rm s : R u le -H C -T e rm+ B e n e fitO rG ro u p e r+ C o p y O fP o lic y+ C o p y O rN e w+ N e w O rC o p y+ S e le c te d P o lic y+ S h o rtD e s c r ip t io n+ T e m p K e y+ T e rm D a te

0 ..*

R u le -H C -P C S -B e n e fitS e t+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fits : E m b e d -H C -P C S -B e n e fit-+ C a te g o ry+ D e te c te d C o n flic ts+ P C S R e le a s e V e rs io n

0 ..*

E m b e d -H C -P C S -A u th o r iz a t io n -+ A u th o r iz a t io n T y p e+ A u th o r iz a t io n T y p e S e le c te d

R u le -H C -+ C la im In s tru c t io n s : P e g a P C S -D a ta -C o n fig

0 ..*

D a ta -W o rk A tta c h -F ile+ *p x A tta c h K e y+ *p x R e fO b je c tK e y+ E ffe c t iv e D a te+ E x p ira t io n D a te

D a ta -P a r ty+ *p y W o rk P a rty U r i+ p y A d d re s s e s : D a ta -A d d re s s+ p y A d d re s s+ p y C o m p a n y+ p y C o rrP re fe re n c e s+ p y E m a il1+ p y F irs tN a m e+ p y F u llN a m e+ p y H o m e P h o n e T im e s+ p y L a s tN a m e+ p y M id d le In it ia l+ p y M o b ile P h o n e T im e s+ p y O th e rP h o n e T im e s+ p y P a rty C la s s P ro m p t+ p y P a rty L a b e l+ p y P a rty N o tif ie d+ p y P a rty R o le R e q u ire d+ p y P a rty R o le V is ib le O n E n try+ p y R e s p o n s e M o d e 1+ p y U s e rN a m e+ p y W o rk C ity+ p y W o rk C o u n try+ p y W o rk P h o n e+ p y W o rk P h o n e T im e s+ p y W o rk P o s ta lC o d e+ p y W o rk S ta te

0 ..*

E m b e d -H C -P C S -B e n e fit -+ D is p la y D a te+ L O B O ffe r in g+ N a m e+ P ro d u c tC a te g o ry+ R a n k+ R e q u ire d+ T e m p In s N a m e+ T e m p K e y

P e g a H e a lth -C o d e s -D a ta -P ro v id e rT a x o n o m y+ *C o d e+ C la s s if ic a t io n+ S p e c ia liz a t io n+ T y p e+ p y S e le c te d

P e g a P C S -H C -U S A -W o rk -A c c e le ra to r -G ro u p e r+ *p y ID+ B e n e fit : R u le -H C -P C S -B e n e fit+ B e n e fitS e t : R u le -H C -P C S -B e n e fitS e t+ C h ild Ite m : $ C L A S S+ G ro u p e r : R u le -H C -P C S -G ro u p e r+ P o lic y : R u le -H C -P C S -P o lic y+ P ro d u c t : R u le -H C -P C S -P ro d u c t+ T e rm : R u le -H C -T e rm+ p y W o rk P a rty : D a ta -P a r ty+ A s s ig n T o O p e ra to r+ A s s ig n T o P ro p e r ty+ C o n firm a tio n N o te+ C re a te d F ro m G ro u p e r+ D e s c r ip t io n+ N a m e+ P o lic y C o n fig u re M o d e+ R e tire d+ U p d a te P ro c e s s+ W B N a m e+ p y A c tio n P ro m p t+ p y A g e F ro m D a te+ p y A tta c h m e n tT y p e+ p y C a p tio n+ p y C a te g o ry+ p y C o n firm a tio n N o te+ p y D is p la y M o d e+ p y E ffo r tE s t im a te+ p y E la p s e d C u s to m e rU n s a tis f ie d+ p y E la p s e d S ta tu s N e w+ p y E la p s e d S ta tu s O p e n+ p y E la p s e d S ta tu s P e n d in g+ p y F lo w K e y+ p y F lo w N a m e+ p y F o ld e rT y p e+ p y F o rm P o s t+ p y In c lu d e S u b C a s e s+ p y In s tru c t io n s+ p y L a b e l+ p y L a b e lO ld+ p y N e x tE m a ilT h re a d ID+ p y N o te+ p y N o tify Q u ic k S tre a m+ p y O r ig D iv is io n+ p y O r ig O rg+ p y O r ig O rg U n it+ p y O r ig U s e rD iv is io n+ p y O r ig U s e rID+ p y O r ig U s e rW o rk g ro u p+ p y O w n e rD iv is io n+ p y O w n e rO rg+ p y O w n e rO rg U n it+ p y P a rty C la s s P ro m p t+ p y P ro b le m R e a s o n+ p y R e s o lv e d D iv is io n+ p y R e s o lv e d O rg+ p y R e s o lv e d O rg U n it+ p y R e s o lv e d T im e+ p y R e s o lv e d T im e s ta m p+ p y R e s o lv e d U s e rD iv is io n+ p y R e s o lv e d U s e rID+ p y R e s o lv e d U s e rW o rk g ro u p+ p y R o o tC a u s e+ p y S a tis fa c t io n C h a n g e T im e s ta m p+ p y S h o w C a s e s+ p y S h o w C o m p le te d A s s ig n m e n ts+ p y S h o w O p e n A s s ig n m e n ts+ p y S p e c ia lty C o m p o n e n tD a ta+ p y S ta tu s C u s to m e rS a t+ p y S ta tu s L a b e l+ p y S ta tu s W o rk+ p y S ta tu s W o rk O ld+ p y S ta tu s W o rk T im e s ta m p+ p y T e m p la te D is p la y T e x t+ p y T e m p la te In p u tB o x+ p y T e m p o ra ry O b je c t+ p y U rg e n c y W o rk A d ju s t+ p y W a s T r ig g e re d B y D e p e n d e n c y+ p y W o rk ID P re fix+ p y W o rk P a rt ie s R u le

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1

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E m b e d -H C -P C S -P o lic y T a g -+ T a g

R u le -H C -P C S -G ro u p e r+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fits : R u le -H C -P C S -B e n e fit+ F o u n d D ra ftC o n te n ts : R u le -H C -P C S -+ L O B O ffe r in g s L is t : P e g a H C -D a ta -L in e O fB u s in e s s+ A lia s N a m e+ C a te g o ry+ C o p ie d F ro m+ C o p y O rN e w+ D ra ft+ H a s A u th o r iz a t io n V a r ia t io n+ H a s C o v e ra g e V a r ia t io n+ H a s E x c lu s io n V a r ia t io n+ H a s L im itV a r ia t io n+ L O B S e le c te d V a lu e+ N e w O rC o p y+ O rig in a lB e n e fitS e t+ P re v io u s S e le c te d B e n e fitS e t+ S e le c te d B e n e fitS e t+ S h o rtD e s c r ip t io n+ S ta tu s+ T e rm D a te+ p y R u le S e t+ p y R u le S e tV e rs io n

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P e g a H C -D a ta -S e rv ic e+ A d m is s io n S o u rc e C o d e+ P ro c e d u re C o d e

E m b e d -H C -P C S -L im it -

P e g a P C S -D a ta -P la n+ *C o n tra c tID+ *C u s to m e rID+ *E ffe c t iv e D a te+ *P ro d u c tID+ *T e rm D a te+ A s s o c ia t io n D a te+ A s s o c ia t io n E n d D a te+ D e n ta lN a m e+ D e n ta lP la n K e y+ M e d ic a lN a m e+ M e d ic a lP la n K e y+ R x N a m e+ R x P la n K e y+ V is io n N a m e+ V is io n P la n K e y+ p y T e m p la te R ic h T e x tE d ito r

E m b e d -H C -P C S -E x c lu s io n -

P e g a P C S -H C -W o rk -A c c e le ra to r -B u n d le+ *p y ID+ E ffe c t iv e D a te+ T e rm D a te

E m b e d -H C -P C S -V a r ia t io n -L im it-+ L im itA m o u n t : E m b e d -H C -P C S -R a n g e V a lu e s -+ A m o u n t+ E d itM o d e+ L im itT y p e+ U n its+ V is its

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Benefit Set

Class: PegaPCS-HC-USA-Work-Accelerator-BenefitSet

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R u le -H C -P C S -+ L im it : E m b e d -H C -P C S -L im it-

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E m b e d -H C -P C S -T e s tB e n e fitS e t -

P e g a H C -D a ta -C la im L in e

E m b e d -H C -P C S -M a p D a ta -



R u le -H C -P C S -B e n e fitS e t+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fitC o n flic ts : E m b e d -H C -P C S -B e n e fitC o n flic t-+ B e n e fits : E m b e d -H C -P C S -B e n e fit-+ B u lk C la im T e s ts : P e g a P C S -D a ta -C la im T e s tR e s u lt+ T e s tM a p p in g s : R u le -H C -P C S -B e n e fit+ te s tD ia g n o s is C o d e s : E m b e d -H C -P C S -T e s tB e n e fitS e t-+ te s tD ia g n o s is C o d e s I : E m b e d -H C -P C S -T e s tB e n e fitS e t-+ te s tS e rv ic e C o d e s : E m b e d -H C -P C S -T e s tB e n e fitS e t-+ te s tS e rv ic e L in e s : P e g a H C -D a ta -C la im L in e+ R e tire d

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P e g a P C S -D a ta -S e tt in g+ *A p p lic a t io n+ *A p p lic a t io n V e rs io n

E m b e d -H C -P C S -M a p p in g -+ C o d e G ro u p : E m b e d -H C -P C S -M a p D a ta -+ O v e rr id e S e rv ic e G ro u p s : E m b e d -H C -P C S -M a p D a ta -+ S e rv ic e G ro u p s : E m b e d -H C -P C S -M a p D a ta -

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P e g a P C S -D a ta -C la im T e s tR e s u lt+ *C la im ID

D a ta -P a r ty+ *p y W o rk P a rty U r i+ p y A d d re s s e s : D a ta -A d d re s s 0 ..*

P e g a P C S -H C -U S A -W o rk -A c c e le ra to r -B e n e fitS e t+ *p y ID+ B e n e fit : R u le -H C -P C S -B e n e fit+ B e n e fitS e t : R u le -H C -P C S -B e n e fitS e t+ G ro u p e r : R u le -H C -P C S -G ro u p e r+ p y W o rk P a rty : D a ta -P a r ty+ C u rrQ P a g e In Q u e s tio n S c re e n F lo w+ C u rre n tQ u e s tio n+ L a s tQ u e s tio n+ L a s tQ u e s tio n P a g e+ n e x tIn d e x O rF in is h In d e x

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E m b e d -H C -P C S -B e n e fit -

$ C L A S S

R u le -H C -P C S -G ro u p e r+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fits : R u le -H C -P C S -B e n e fit

0 ..*

E m b e d -H C -P C S -L im it -

R u le -H C -P C S -B e n e fit+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ C h ild Ite m : $ C L A S S+ C o n s u m e rN o te s : E m b e d -H C -P C S -C o n s u m e rN o te -+ M a p p in g : E m b e d -H C -P C S -M a p p in g -+ M a p p in g G ro u p s : E m b e d -H C -P C S -M a p p in g -

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E m b e d -H C -P C S -B e n e fitC o n flic t -+ B e n e fits : E m b e d -H C -P C S -B e n e fit-

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Product template

Class: PegaPCS-HC-USA-Work-Commercial-Medical-PTemplate



Product

Class: PegaPCS-HC-USA-Work-Commercial-Medical-Product

E m b e d -H C -P C S -M e th o d -

R u le -H C -P C S -C o s tS h a re+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e

E m b e d -H C -P C S -R a n g e V a lu e s -

P e g a P C S -D a ta -C o n tra c t+ *C o n tra c tID+ *C u s to m e rID+ *E ffe c t iv e D a te+ *P ro d u c tID+ *T e rm D a te

R u le -H C -P C S -N e tw o rk+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e

E m b e d -H C -P C S -G u a rd ra ilR u le -

P e g a P C S -D a ta -S e tt in g+ *A p p lic a t io n+ *A p p lic a t io n V e rs io n

R u le -H C -P C S -P ro d u c t+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ A s s u m p tio n L is t : E m b e d -H C -P C S -D O ID a ta -+ B e n e fit In d e x : In d e x -H C -P C S -R u le+ B e n e fitS e tT re e : R u le -H C -P C S -P ro d u c t+ C o v e ra g e L e v e lL is t : R u le -H C -P C S -C o v e ra g e L e v e ls+ C o v e ra g e L e v e ls : E m b e d -H C -P C S -C o v e ra g e L e v e l-+ C o v e ra g e s : R u le -H C -P C S -C o v e ra g e+ E lig ib il ity R u le s : E m b e d -H C -P C S -C o v e ra g e -+ G u a rd ra il : E m b e d -H C -P C S -G u a rd ra il-+ N e tw o rk s : E m b e d -H C -P C S -N e tw o rk -+ P r ic in g In fo rm a tio n L is t : E m b e d -H C -P C S -P r ic in g -+ P ro d u c tT e m p la te In d e x : In d e x -H C -P C S -R u le+ R e g io n A v a ila b il ity : E m b e d -H C -P C S -R e g io n s+ R is k L is t : E m b e d -H C -P C S -D O ID a ta -+ W e lln e s s B e n e fitT re e : R u le -H C -P C S -P ro d u c t+ B e n e fitC o v A u to+ B e n e fitC o v N o te s+ B e n e fitL im itA u to+ B e n e fitL im itN o te s+ B e n e fitM a p p in g A u to+ B e n e fitM a p p in g N o te s+ B e n e fitW e b S v c s N o te s+ C o p ie d F ro m+ C o p ie d F ro m K e y+ C re a te d F ro m+ C re a te d F ro m K e y+ C u rre n tT re e V ie w N a m e+ D e s ire d O u tc o m e+ G ro u p e rC o v A u to+ G ro u p e rC o v N o te s+ G ro u p e rL im itA u to+ G ro u p e rL im itN o te s+ G ro u p e rS P D N o te s+ G ro u p e rW e b S v c s N o te s+ N o O fB e n e fits+ N o O fN e tw o rk s+ P ro d u c tM a n a g e r+ P ro d u c tT e m p la te+ P ro d u c tT e m p la te K e y+ P ro je c tS p o n s o r+ R e q u e s tID+ R e tire d+ S e le c te d T e m p la te+ S tru c tu re M o d e+ T a rg e tA p p ro v a lD a te+ V e rs io n

0 ..*

0 ..*

1

0 ..*

0 ..*

0 ..*

0 ..*

1

0 ..*

0 ..*

1

0 ..*

E m b e d -H C -P C S -C o v e ra g e -

R u le -H C -P C S -C o v e ra g e L e v e ls+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e

$ C L A S S

E m b e d -H C -P C S -N e tw o rk -+ C o s tS h a re s : E m b e d -H C -P C S -C o s tS h a re -

0 ..*

R u le -H C -P C S -G u a rd ra il+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ C o s tS h a re R u le s : E m b e d -H C -P C S -G u a rd ra ilR u le -+ N e tw o rk R u le s : E m b e d -H C -P C S -G u a rd ra ilR u le -+ O th e rR u le s : E m b e d -H C -P C S -G u a rd ra ilR u le -

0 ..*


E m b e d -H C -P C S -C o s tS h a re -+ A m o u n tR a n g e V a lu e s : E m b e d -H C -P C S -R a n g e V a lu e s -+ C a lc u la t io n M e th o d s : E m b e d -H C -P C S -M e th o d -+ F a m ily R a n g e V a lu e s : E m b e d -H C -P C S -R a n g e V a lu e s -+ O c c u rre n c e M e th o d s : E m b e d -H C -P C S -M e th o d -+ P e r io d R a n g e V a lu e s : E m b e d -H C -P C S -R a n g e V a lu e s -+ S in g le M a x R a n g e V a lu e s : E m b e d -H C -P C S -R a n g e V a lu e s -+ T im e M e th o d s : E m b e d -H C -P C S -M e th o d -+ A m o u n tIn c re m e n t+ A m o u n tR a n g e C o u n t+ C a lc u la t io n M e th o d s C o u n t+ F a m ily R a n g e C o u n t+ O c c u rre n c e M e th o d s C o u n t+ S in g le M a x R a n g e C o u n t+ T im e M e th o d s S e le c t io n

0 ..*

0 ..*

D a ta -W o rk A tta c h -+ p y A tta c h m e n tW o rk g ro u p R e s tr ic t io n s : E m b e d -W o rk A tta c h R e s tr ic t io n s

0 ..*

E m b e d -H C -P C S -D O ID a ta -+ L in e Ite m

P e g a P C S -H C -U S A -W o rk -C o m m e rc ia l-M e d ic a l-P ro d u c t+ *p y ID+ B e n e fitS e tT re e : R u le -H C -P C S -P ro d u c t+ C o m p a re P ro d u c ts : R u le -H C -P C S -P ro d u c t+ C o n tra c t : P e g a P C S -D a ta -C o n tra c t+ C o s tS h a re s : E m b e d -H C -P C S -C o s tS h a re -+ G ro u p e r : R u le -H C -P C S -G ro u p e r+ P ro d u c t : R u le -H C -P C S -P ro d u c t+ P ro d u c tB U : R u le -H C -P C S -P ro d u c t+ S e le c te d B e n e fitS e ts : R u le -H C -P C S -B e n e fitS e t+ S e le c te d B e n e fits : R u le -H C -P C S -B e n e fit+ S e le c te d N e tw o rk s : R u le -H C -P C S -N e tw o rk+ p y W o rk P a rty : D a ta -P a r ty+ B U P ro d u c tP a re n t+ B e n e fitS e tM o d if ie d+ B e n e fits M o d if ie d+ C o s tS h a re E x c e p tio n+ C u rrQ P a g e In Q u e s tio n S c re e n F lo w+ C u rre n tQ u e s tio n+ E ffe c t iv e D a te+ E x c e p tio n A p p ro v a lF la g+ E x p a n d C o lla p s e Q G T re e+ Is P ro d u c tB U C o m p le te+ L a s tQ u e s tio n+ L a s tQ u e s tio n P a g e+ N e tw o rk s M o d if ie d+ Q u o te F la g+ n e x tIn d e x O rF in is h In d e x 10 ..*

1

0 ..*

1

0 ..*

0 ..*

0 ..*

0 ..*

E m b e d -H C -P C S -G u a rd ra il-

E m b e d -W o rk A tta c h R e s tr ic t io n s

R u le -H C -P C S -B e n e fit+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e

R u le -P e g a Q -Q u e s tio n n a ire+ *p y C la s s N a m e+ *p y P u rp o s e

P e g a S u rv e y -D a ta -Q u e s tio n n a ire s+ Q u e s tio n n a ire R u le s : R u le -P e g a Q -Q u e s tio n n a ire

0 ..*

E m b e d -H C -P C S -P r ic in g -+ B e n e fitA d ju s te d B a s e R a te+ C a te g o ry+ Is S e n io rP ro d u c t+ M e m b e rO O P+ N e tw o rk R e s tr ic t io n+ P M P M B a s e R a te+ P ro d u c tF a m ily+ P ro d u c tT y p e C o d e+ T re e C o s t

R u le -H C -P C S -+ C h ild Ite m : $ C L A S S+ C o s tS h a re s : E m b e d -H C -P C S -C o s tS h a re -+ C o n fig u re M o d e+ Is C o v e re d

0 ..*0 ..*

D a ta -W o rk A tta c h -N o te+ *p x A tta c h K e y+ *p x R e fO b je c tK e y

E m b e d -H C -P C S -R e g io n s


E m b e d -H C -P C S -C o v e ra g e L e v e l-


R u le -H C -P C S -B e n e fitS e t+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fits : E m b e d -H C -P C S -B e n e fit-

0 ..*

P e g a P C S -D a ta -D ic t io n a ry+ *D ic t io n a ry T y p e+ P ro to ty p e ID

D a ta -P a r ty+ *p y W o rk P a rty U r i+ p y A d d re s s e s : D a ta -A d d re s s

0 ..*

E m b e d -H C -P C S -B e n e fit -


In d e x -H C -P C S -R u le+ *p x In d e x C o u n t+ *p x In d e x P u rp o s e+ *p x In s In d e x e d K e y

R u le -H C -P C S -C o v e ra g e+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ M e th o d s : E m b e d -H C -P C S -M e th o d -

0 ..*

P e g a P C S -H C -U S A -W o rk -C o m m e rc ia l-M e d ic a l-P T e m p la te(S e p a ra te D ia g ra m )

+ *p y ID



Plan

Class:PegaPCS-HC-USA-Work-Commercial-Medical-Contract

In d e x -H C -P C S -C o n tra c tD e lta+ *p x In d e x C o u n t+ *p x In d e x P u rp o s e+ *p x In s In d e x e d K e y+ L o c a tio n D is p la y+ P ro p e r ty D is p la y

R u le -H C -P C S -M e th o d+ *E ffe c t iv e D a te+ *N a m e+ *T y p e+ *p y C la s s N a m e

D a ta -A u to T e s t -R e s u lt -C a s e+ *p y C a s e ID+ *p y R e q u e s tT im e+ *p y S u ite N a m e+ p y D iffe re n c e s : $ A N Y

0 ..*

P e g a P C S -D a ta -C o n tra c t+ *C o n tra c tID+ *C u s to m e rID+ *E ffe c t iv e D a te+ *P ro d u c tID+ *T e rm D a te+ P ro d u c t : R u le -H C -P C S -P ro d u c t+ P ro d u c tC h a n g e s : D a ta -A u to T e s t-R e s u lt-C a s e+ P ro d u c tIn d e x : In d e x -H C -P C S -R u le+ W o rk P a rt ie s : D a ta -P a r ty+ S e le c te d C u s to m e r+ S e le c te d P ro d u c t

1

1

1

0 ..*

R u le -H C -P C S -N e tw o rk+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e

R u le -H C -P C S -P ro d u c t+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ B e n e fitS e tT re e : R u le -H C -P C S -P ro d u c t+ C h ild Ite m : $ C L A S S+ P r ic in g In fo rm a tio n L is t : E m b e d -H C -P C S -P r ic in g -+ R e g io n A v a ila b il ity : E m b e d -H C -P C S -R e g io n s+ B e n e fitC o v A u to+ B e n e fitC o v N o te s+ B e n e fitL im itA u to+ B e n e fitL im itN o te s+ B e n e fitM a p p in g A u to+ B e n e fitM a p p in g N o te s+ B e n e fitW e b S v c s N o te s+ G ro u p e rC o v A u to+ G ro u p e rC o v N o te s+ G ro u p e rL im itA u to+ G ro u p e rL im itN o te s+ G ro u p e rS P D N o te s+ G ro u p e rW e b S v c s N o te s+ S e le c te d T e m p la te

1

0 ..*

0 ..*

0 ..*

E m b e d -H C -P C S -C o n tra c tD e lta -

$ C L A S S

R u le -H C -P C S -G u a rd ra il+ *E ffe c t iv e D a te+ *L O B O ffe r in g+ *N a m e+ *P ro d u c tC a te g o ry+ *p y C la s s N a m e+ C o n fig u re M o d e

P e g a P C S -H C -U S A -W o rk -C o m m e rc ia l-M e d ic a l-C o n tra c t+ *p y ID+ B e n e fitS e tT re e : R u le -H C -P C S -P ro d u c t+ C h ild Ite m : $ C L A S S+ C o n tra c t : P e g a P C S -D a ta -C o n tra c t+ C o n tra c tC h a n g e s : E m b e d -H C -P C S -C o n tra c tD e lta -+ C o s tS h a re s : E m b e d -H C -P C S -C o s tS h a re -+ G ro u p e r : R u le -H C -P C S -G ro u p e r+ M e th o d s : R u le -H C -P C S -M e th o d+ N e tw o rk : R u le -H C -P C S -N e tw o rk+ O rg P ro d u c t : R u le -H C -P C S -P ro d u c t+ P ro d u c t : R u le -H C -P C S -P ro d u c t+ p y W o rk P a rty : D a ta -P a r ty+ C o n tra c tN a m e+ C o n tra c tP la n T y p e+ C u rrQ P a g e In Q u e s tio n S c re e n F lo w+ C u rre n tQ u e s tio n+ C u s to m e rN a m e+ E ffe c t iv e D a te+ F irs tN a m e+ G ro u p ID+ L a s tN a m e+ L a s tQ u e s tio n+ L a s tQ u e s tio n P a g e+ P ro d u c tN a m e+ T e m p la te F la g C o n tra c t+ T e rm D a te+ n e x tIn d e x O rF in is h In d e x

1

0 ..*

1

0 ..*

0 ..*

1

1

1

0 ..*


E m b e d -H C -P C S -C o s tS h a re -

E m b e d -H C -P C S -P r ic in g -+ B e n e fitA d ju s te d B a s e R a te+ C a te g o ry+ Is S e n io rP ro d u c t+ M e m b e rO O P+ N e tw o rk R e s tr ic t io n+ P M P M B a s e R a te+ P ro d u c tF a m ily+ P ro d u c tT y p e C o d e+ T re e C o s t

R u le -H C -P C S -+ C h a n g e s A p p lie d : D a ta -A u to T e s t-R e s u lt-C a s e

1

E m b e d -H C -P C S -R e g io n s


$ A N Y

P e g a P C S -D a ta -D ic t io n a ry+ *D ic t io n a ry T y p e+ P ro to ty p e ID

D a ta -P a r ty+ *p y W o rk P a rty U r i

P e g a P C S -D a ta -P a r ty -S u b s c r ib e r+ *p y W o rk P a rty U r i

P e g a P C S -D a ta -P a r ty -T P A+ *p y W o rk P a rty U r i


In d e x -H C -P C S -R u le+ *p x In d e x C o u n t+ *p x In d e x P u rp o s e+ *p x In s In d e x e d K e y

P e g a P C S -D a ta -P a r ty -P la n S p o n s o r+ *p y W o rk P a rty U r i

P e g a P C S -D a ta -P a r ty -B ro k e r+ *p y W o rk P a rty U r i

P e g a P C S -D a ta -P a r ty - In s u re r+ *p y W o rk P a rty U r i



Work object naming conventions

The naming convention for the names of the flow actions and their sections are derived from the step being processed. For example, flow action for the Commercial, Medical, Product Template Tree Review is ComMedPTemplateTreeReview. The association activities that occur before and after processing have pre- and post-suffixes. The Work type pyID prefixes are listed below.

Prefix Work Object Applies To Class BEN- Benefit PegaPCS-HC-USA-Work-Accelerator-Benefit BENS- Benefit Set PegaPCS-HC-USA-Work-Accelerator-BenefitSet GRP- Grouper PegaPCS-HC-USA-Work-Accelerator-Grouper PLCY- Policy PegaPCS-HC-USA-Work-Accelerator-Policy TERM- Policy Term PegaPCS-HC-USA-Work-Accelerator-Term PLAN- Plan PegaPCS-HC-USA-Work-Commercial-Medical-Contract PRD- Product PegaPCS-HC-USA-Work-Commercial-Medical-Product PRDT- Product Template PegaPCS-HC-USA-Work-Commercial-Medical-Ptemplate NET- Network PegaPCS-HC-USA-Work-Accelerator-Network BUNDLE- Plan Bundle PegaPCS-HC-USA-Work-Accelerator-Bundle MU- Mass Update PegaPCS-HC-USA-Work-Accelerator-BulkUpdate-BST


Pega Product Composer for Healthcare system roles Pega Product Composer for Healthcare supports key roles generally associated with Product Lifecycle Management.

This matrix describes each of the roles shipped with the Pega Product Composer for Healthcare application, their default portal, and key dashboard features.

Roles, portals, and dashboards

Role Description Default portal Key dashboard features Product Development

Standard Pega Product Composer for Healthcare portal for creation and configuration of Pega Product Composer for Healthcare components such as Product Templates or Networks. Current work assignments and workbaskets are shown as well as tagged components and recently resolved work. This is the primary workspace for a Product or Benefit Configuration user.

Product Development Portal

• Worklist • Workbaskets • Search Tags • Configuration tools to

create/edit work such as plan bundles, plans, products, product templates, networks, benefit sets, groupers, benefits, policies, policy terms

• Reports

Product Manager

This portal enables monitoring of resolved activities, work volumes, worklists, workbaskets, execution of reports, and final approval of work objects.

Product Manager Portal

• Dashboard • Explorer review list • Recently open items • Team worklist sorted according

to SLA • Pega pulse • Work per team member • Workbaskets.

Legal, State Mandate Specialist, DOI Specialist

There is a standard case worker (pyCaseWorker) portal for the Access Groups associated with these Roles. The operators associated to this access group have the ability to process the work that is assigned to them.

• Process assigned work



Product development portal The Product Development Portal provides the main Pega Product Composer for Healthcare for both Product and Benefit Configuration users to create, edit, and review Pega Product Composer for Healthcare components. Current work assignments and workbaskets are shown, as well as tagged components and recently resolved work.

Product manager portal The Product Manager Portal provides similar capabilities as the Product Development Portal, but is targeted for managers. The manager portal permits easy access to: Pega Product Composer for Healthcare References, Pega Product Composer for Healthcare Work Analysis, and Pega Product Composer for Healthcare Work Monitoring.

Super User Super users are those users who can configure the benefits/entities without going through the approval process. Meaning that these are the users who bypass the approvals.

Product Development Portal

• Worklist • Workbaskets • Search Tags • Configuration tools to

create/edit work such as plan bundles, plans, products, product templates, networks, benefit sets, groupers, benefits, policies, policy terms

• Reports • Recently resolved




Life cycle management overview Pega Product Composer for Healthcare has a rich concept of life cycle management. Pega-provided case management features are extensively used to achieve this feature. Each Pega Product Composer for Healthcare entity (for example, Benefit, Product Template, and so on) undergoes this life cycle process. A typical health care benefit configuration, for example, undergoes various stages in its life cycle before it is available for consumption in the actual salable/marketable health plans. This progression of a benefit (or any Pega Product Composer for Healthcare entity) through various stages typically starts with a concept/idea and traverses through various internal and external reviews and approvals for it to be available in production (salable) before being finally retired when it is no longer used. Similarly a product template, product, or plan etc. undergo this life cycle.

Rather than being a linear, serialized process, a plan/product configuration is made up of many processes, tasks, policies, and supporting content. Depending on the context of the plan/product, elements and the way that work is accomplished change. Furthermore, a plan as a whole continues to change throughout its life cycle due to both internal and external events. Adding to the challenge, there are often several configurators, product managers, and other internal and external parties collaborating on any given plan/benefit configuration.

Therefore, this customizable stage based life cycle management provides better control over the business process and improves the consistency, effectiveness, and visibility of process handling which, thereby, decreases cost and improves quality.

Life cycle stage configurations like changing the stage names, skipping the stages, jumping across the stages and skipping approvals etc. are highly business friendly. These can be achieved by the business by just tweaking some business friendly rules like ‘When rules’, ‘Decision rules’, and ‘Flow rules’ etc. These are easily configurable and highly extendable. In short, life cycle stage configurations are Built For Change®. Refer to the implementation guide for more details on the business rules driving the life cycle process.

Stage based life cycle management



There are four stages in this life cycle, namely;

Development

Implementation

Production

Retirement

Stages are also displayed in approval screens:

This life cycle driven-capability allows the users to build/create the entities (Benefits, Groupers, Networks, and Product Templates, and so on) effectively by providing a consistent, repeatable processes for data definition, configuration options.

Development A Product, Plan, or Benefit that is being created and reviewed to become an offering by the organization that requires internal review and approval for next steps. In this stage the product



developer creates a concept for a new benefit/product etc. based on market need or regulatory requirements. Benefit Configuration may create a subset of benefits or a draft product template etc. based on the concept. The product manager reviews the concept and it is either rejected or approved or sent for rework. After approval product manager promotes the entity to implementation stage for further configuration.

Implementation A Product, Plan or Benefit that is fully developed and is intended to be an offering but needs the appropriate approvals prior to being available for production. An approved concept is sent to this stage for further configuration and review by the product manager. (Work flow steps can be defined here to seek some internal reviews and approvals before initiating the production stage). At the end of this stage product manager promotes the entity to production stage. Please read the Note section below.

Production A Product, Plan or Benefit can further be configured in the production stage and sent for product manager approval. After his review and approval the entity is ready for sale. Please read the Note section below.

Retirement When a Product, Plan or Benefit etc. is no longer required/offered it can be marked as retired so that further consumption is not allowed. Entities can also be marked as retired when they were created in error or when they were never sold. So in Pega Product Composer for Healthcare Production-Approved entities are moved to the retirement stage to complete the retirement process.

Note: an entity can be rejected in any stage (except the retirement stage, it has a separate processing) by the product manager. These entities are moved to rejection stage and marked as rejected.

Lifecycle process summary The below table explains all the work queues that are used in life cycle process with their usages. Some of the important work statuses are also shown. The table references a benefit through the life cycle, but the life cycle process applies to all Pega Product Composer for Healthcare entities.



Stage Work queue(WQ) (aka Work basket)

Work status Purpose/Usage

Development Dev_Initiation Dev-Initiation User picks the benefit from this WQ to start the work or rework in Development stage under the following scenarios:

• Generally when the manager promotes the benefit to the next stage it will be routed to this WQ.

• Or when the manager sends the benefit for rework it will be routed here.

Dev_PendingApproval Dev-PendingApproval

Product manager picks the benefit from this WQ to take approval actions.

Dev_Approved Dev-Approved Product manager picks the benefit from this WQ either to promote the benefit to the next stage or send it for rework, if rework action is available.

Implementation Impl_Initiation Impl-Initiation User picks the benefit from this WQ to start the work or rework in Implementation stage under the following scenarios:



Impl_PendingApproval Impl-PendingApproval


Impl_Approved Impl-Approved Product manager picks the benefit from this WQ either to promote the benefit to the next stage or send it for rework, if rework action is available.

Production

Prod_Initiation Prod-Initiation User picks the benefit from this WQ to start the work or rework in Production stage under the following scenarios:



Prod_PendingApproval Prod-PendingApproval


Prod_Approved Prod-Approved Product manager picks the benefit from this WQ either to promote the benefit to the next stage or send it for rework, if rework action is available.

Retirement Retire_PendingApproval Retire-PendingApproval

When Product manager retires the benefit from Prod_Approved WQ it will be routed to this WQ. From



Stage Work queue(WQ) (aka Work basket)

Work status Purpose/Usage

here another authorized manager picks this and finally retires the benefit.


Entity versioning introduction Entities like benefit, plan, etc. may undergo changes in their life cycle. Work flows of these entities generally progress in discrete temporal phases, with each phase often requiring the allocation of a different set of data or business rules to be enforced. This is often necessary and required in health care industry.

For example, a cardiac related benefit may undergo changes in its life cycle due to state mandated changes. This change may be due to the inclusion or exclusion of some codes or code groups, or may be due to changes to some of the cost shares, variation conditions, or may be a change to some of the plan data. In cases like these, versioning provides a capability to represent these changes to an entity in ‘time blocks’. So each ‘time block’ of an entity can be called a “version”.

This temporal representation of facts about an entity is very important from the auditing perspective too. The facts or history about a particular version is preserved in its entirety. This facilitates traceability at any point of time. This will also tell a story about the evolution of an entity over a period of time and provides valuable insights like:

Why some entities change more frequently and what caused these changes.

Why some entities do not change over a long period of time.

Why a particular version of an entity is the most used in some plans or products.

What kind of health care benefit or plan data most commonly undergoes changes.

Why some entities have versions but never been used (consider other options like retirement).

There may be other events, apart from state mandated changes, which trigger the versioning of an entity. For example, a benefit might have been created with some errors which would require a new version to correct. Other reasons could be benefit remapping, creation of new templates and plans, adding additional benefits into an existing plan, changing cost shares, introduction of new organizational level health care plan policies etc. There could be many more reasons like this.

Entity versioning



Pega Product Composer for Healthcare versioning Creation of default version All core Pega Product Composer for Healthcare have versioning support, which includes:

Benefit

Grouper

Benefit set

Network

Product Template

Product

Plan

Version number has two components in it. One is major version and the other is minor version as shown below.

The user can either create a major version or minor version. This will depend upon the changes to the effective and end dates that the user is making. If either effective or end dates changed a major version is created and if dates are not changed a minor version of the corresponding major version is created. While creating from the “Create” menu, the system will always create a default 01-01 as the starting original version. This can be considered as a base version.

Versioning enhancement With Pega Product Composer for Healthcare release 7.31, only changes to effective dates now drive versioning automatically. Changes to business properties, such as name and line of business, no longer drive versioning in Pega Product Composer for Healthcare.

Users can change the name of any business entity and the change will be reflected in real time throughout the application. No mass update of further processing is needed. This means that the user can change business properties of entities, but keep the same entity instance. A new version of the entity is not created. For example, if the user misspelled the name a benefit, the user can now modify the name without creating a new version of the benefit.

Users can create versions from the search results screen as shown below:



Users can also create versions from inside the search result screen after opening it:


Mass update overview Mass Update enables the user to Add, Update, and Remove both New and Used Benefits and Groupers into a set of selected target Benefit sets, Product Templates, Products and Plans. The Mass Update flows have three screens where the change is determined, union data is edited and targets are selected. After manager approval, an Execute screen lets the user push the mass update change to the selected targets.

Mass update operation is mainly performed via three screens.

Select benefit or grouper: Defining the source data

Configure data: Configuring the actual updates

Select targets: Selecting the target entities to push the mass update.

Source data is selected in the ‘Select benefit or grouper’ screen, updated in the Configure data screen (if Add/Update-Used operation) and pushed to the selected target entities in the Select targets screen. This is the mass update in essence.

The ‘Select benefit or grouper’ screen allows the user to select which Grouper or Benefit to be used as the source for the Mass Update change. Adding-New will add the benefit/grouper to the target entities (selected PTs, PRDs and PLANs). Updating-Used will update the benefit/grouper in the target entities and finally ‘Remove’ will remove the selected benefit/grouper in the ‘Select benefit or grouper’ screen from the target entities selected on the select target screen.

Below are some of the example screen shots:

Select benefit or grouper screen:

Mass Update



Configure data screen:

Select targets screen:

NOTE: Please refer to user guide for more details.


Multi-Channel, Enterprise Single-Source Product Repository – Under Documentation Support provides for messages/descriptions to be tailored based on audience and channel

Feature screen shots



Multi-Level Reuse of Product Information

Code Group Driven Healthcare Terms (CPT)



Code Group Driven Healthcare Terms (ICD-10 Diagnosis)



Product Lifecycle Management – Configurable approval processes



Flexible Configuration – Simple Coinsurance variation



Flexible Configuration – Complex Authorization variation with flat amount penalty

Flexible Configuration – Product Template hierarchy



Flexible Configuration – Product benefit tree



HCIF Code Sets

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Pega Product Composer for Healthcare – Product Overview · 2019. 5. 22. · Product lifecycle...

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