Product Composer System Business Use Case Guide - Pega ...

Product Composer System Business Use Case Guide

Version 2.3 SP 2

October 2013

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Product Composer System

Document: Implementation Guide Software Version: 2.3 SP2 Updated: October 2013


Contents About This Document .................................................................. i

Intended Audience .................................................................................... i

Guide Organization .................................................................................... i

Chapter 1: . Product Composer Overview .................................. 1-1

Business Challenges ..................................................................................... 1-1

Product Composer Overview .......................................................................... 1-1

Product Lifecycle Management Benefits ........................................................... 1-2

Product Composer Features ........................................................................... 1-3

Ensure Payment Accuracy and Operational Readiness ....................................... 1-3

Maximizing Reuse with Pega’s “Layer Cake” .............................................. 1-4

Product Composer maximizes reuse with our Product structure ................... 1-5

Product Composer also maximizes reuse within each Product...................... 1-6

Single Repository for Product, Policy and Benefit information ...................... 1-7

Product Composer Concepts .......................................................................... 1-9

Overview.............................................................................................. 1-9

Codes & Code Sets ................................................................................ 1-9

Code Groups ....................................................................................... 1-10

PCS Product Tree ................................................................................ 1-11

Benefits ............................................................................................. 1-11

Variation Rules.................................................................................... 1-12

Benefit Sets ........................................................................................ 1-13

Product Composer Hierarchy ................................................................. 1-13

Product Templates ............................................................................... 1-13

Products ............................................................................................ 1-14

Plans ................................................................................................. 1-14

Quotes ............................................................................................... 1-14

Policies and Policy Terms ...................................................................... 1-14

Technical Overview ..................................................................................... 1-15

Chapter 2: . What is New in PCS ................................................ 2-1

Benefit/Grouper Mass Add / Remove ............................................................... 2-1

Overview.............................................................................................. 2-1

Plan Bundles ................................................................................................ 2-3


Adding Standalone Groupers / Benefits ........................................................... 2-4

Add a Grouper / Benefit Directly to a Product Template .............................. 2-4

Adding a Grouper / Benefit Directly to a PCS Product ................................. 2-4

Plan Level Enhancements .............................................................................. 2-4

Ability to Create a Plan from a DRAFT Product .......................................... 2-4

Enhancements for Viewing Plans Compared to the Base Product ................. 2-5

Plan Export ........................................................................................... 2-5

Master Variation List on Plan ................................................................... 2-5

Quick Entry Screens to Plan Level ........................................................... 2-6

Benefit Tier Configuration ....................................................................... 2-6

Copying Configured Networks / Groupers / Benefits .......................................... 2-7

Copy Fully Configured Benefits from One Product to Another ...................... 2-7

Copy Configured Groupers ...................................................................... 2-8

Copy Configured Networks ..................................................................... 2-8

Product / Plan Export Enhancements ............................................................... 2-8

Pega Survey Enhancements ........................................................................... 2-8

Tagging Benefits .......................................................................................... 2-9

Chapter 3: . Getting Started ...................................................... 3-1

PCS Users IDs, Passwords and Funtions .......................................................... 3-1

PCS Configuration ........................................................................................ 3-3

PCS Configuration ................................................................................. 3-3

Selecting a PCS Run Mode ............................................................................. 3-4

Claim System Configuration.................................................................... 3-7

Benefit Configuration ............................................................................. 3-8

PCS Document Generation ........................................................................... 3-10

Manage Document Template................................................................. 3-10

Document Generation Rules ................................................................. 3-11

Glossary of Terms ............................................................................... 3-14

PCS Integration Services Option ............................................................ 3-15

Using the Product Architect Portal ................................................................. 3-17

Displaying the Portal ............................................................................ 3-17

Portal Components and Functions .......................................................... 3-17

Product Explorer (left panel) ................................................................. 3-17

Getting Started ................................................................................... 3-17


To Do List .......................................................................................... 3-18

Tags and Recently Resolved ................................................................. 3-18

Chapter 4: . Policy Configuration .............................................. 4-1

Policy & Policy Term Overview ........................................................................ 4-1

Directly Configuring Policy Information on Product Templates ..................... 4-4

Policy variation rules .............................................................................. 4-5

Searching for Policy Terms ............................................................................ 4-6

Creating Policy Terms ................................................................................... 4-7

Create Policies ........................................................................................... 4-10

Overview of Policy ............................................................................... 4-10

Inheriting Policy Configuration ..................................................................... 4-15

Chapter 5: . Product Template Configuration ............................ 5-1

Stand-alone mode compared to using Benefit Sets ........................................... 5-1

Searching for Benefits, Benefit Sets and Product Templates ............................... 5-3

Creating Benefits .......................................................................................... 5-4

Creating Groupers ........................................................................................ 5-9

Creating Benefit Sets .................................................................................. 5-10

Creating Product Templates ......................................................................... 5-14

Configuring the Product Tree ....................................................................... 5-22

Navigating the Product Tree ................................................................. 5-23

Configuring a Network from the Tree ..................................................... 5-24

Configuring Groupers from the Tree ...................................................... 5-25

Configuring Benefits from the Tree ........................................................ 5-25

Configuring Cost Share Variations on Product Templates .......................... 5-26

Product Template, Configure Product Tree, Policy View.................................... 5-29


Policy & Policy Term Overview ...................................................................... 5-31

Directly configuring policy information ................................................... 5-34

Inheriting Policy Configuration ..................................................................... 5-37

Master Variation List – Policy view (coverage tabs) ......................................... 5-38

Use Case: Visit limit and usage level varies by Specialty................................. 5-39

Use Case: Benefit comparing dollar and usage limits ...................................... 5-42


Chapter 6: . Product Configuration ............................................ 6-1

Searching for Products .................................................................................. 6-2

Creating New Products .................................................................................. 6-3

Adding Standalone Networks, Groupers and Benefits ........................................ 6-7

Copying Configured Benefits into Product ........................................................ 6-8

Configuring Cost Shares on the Product Tree ................................................... 6-9

Navigating the Product Tree ................................................................. 6-10

Configuring the Product Tree ................................................................ 6-10

Product configuration tabs .................................................................... 6-11

Quick Entry Screens for Cost Shares (product view)........................................ 6-14

Configuring Cost Share Variation Rules ......................................................... 6-15

Use Case: Copay varies by inpatient vs. outpatient ................................. 6-18

Use Case: Copay varies when seeing PCP vs. Specialist............................ 6-20

Use Case: Comparing copay to coinsurance and selecting lowest member liability ............................................................................................... 6-21

Use Case: Authorization required – higher copay if not found ................... 6-23

Configuring Policy Terms on Products ............................................................ 6-26


Directly configuring policy information ................................................... 6-27

Copying a Master Product ............................................................................ 6-30

Quick Entry Screens for Coverage (policy view) .............................................. 6-31

Benefit Tier Configuration Tab ...................................................................... 6-32

Chapter 7: . Plan Configuration ................................................. 7-1

Searching for Plans ....................................................................................... 7-2

Creating New Plans ....................................................................................... 7-3

Configuring Cost Shares on the Product Tree ................................................... 7-6

Creating Plan Bundles ................................................................................... 7-8

Exporting Plan Data ...................................................................................... 7-8

Chapter 8: . Draft Mode Use Cases ............................................ 8-1

Draft Mode Overview .................................................................................... 8-1

Enabling Draft Mode ..................................................................................... 8-3

Creating Draft Benefits .................................................................................. 8-4

Creating Draft Benefit Sets ............................................................................ 8-7

Creating Draft Product Templates ................................................................... 8-8


Creating Draft Products ................................................................................. 8-9

Creating Draft Policy Terms & Policies ........................................................... 8-10

Changing Benefit Mapping or Description ....................................................... 8-11

Adding/Removing Benefits in a Set ............................................................... 8-14

Changing a Product Template – No Benefit Set Change ................................... 8-15

Finalizing a Product Template or Product ....................................................... 8-16

Chapter 9: . Quote, Compare Configuration ............................... 9-1

Run a Quote Request .................................................................................... 9-1

Comparing Products ...................................................................................... 9-4

Chapter 10: Pharmacy Benefits & Products .......................... 10-1

Creating a Pharmacy Benefit ........................................................................ 10-2

Creating a Pharmacy Grouper ...................................................................... 10-2

Adding a Pharmacy Grouper to a Medical Benefit Set ...................................... 10-2

Creating a Pharmacy Benefit Set .................................................................. 10-3

Creating a Pharmacy Product Template ......................................................... 10-3

Creating a Pharmacy Product ....................................................................... 10-4

Chapter 11: Tags, Reports & Common Processes ................. 11-1

Assigning Tags in PCS ................................................................................. 11-1

PCS Reports............................................................................................... 11-3

Common Work Processes ............................................................................ 11-5

Chapter 12: Mass Update Benefits ....................................... 12-1

Overview ................................................................................................... 12-1

Mass Update Benefit Sets to Product Templates ............................................. 12-2

Initial Configuration of Benefit Sets, Templates and Products .................... 12-2

Mass Update Benefits in Dependent Templates ............................................... 12-3

Configure New Benefits in Product Templates ......................................... 12-6

Mass Update Product Templates to Products .................................................. 12-6

Mass Update Products to Plans ..................................................................... 12-7

Mass Update Agent Processing ..................................................................... 12-7

Mass Update Error Processing ...................................................................... 12-8

Mass Update Action Menu ............................................................................ 12-9


Chapter 13: Benefit Configuration Examples ........................ 13-1

1. Quick Entry Cost Share Configuration using Master Variations ...................... 13-2

Quick Entry Screens for Cost Shares (product view) ................................ 13-3

2. Copay varies by inpatient vs. outpatient .................................................... 13-5

3. Copay varies when seeing PCP vs. Specialist .............................................. 13-8

4. Visit limit and usage level varies by Specialty – Mental Health ...................... 13-9

5. Coverage restricted by age ranges - Colonoscopy ..................................... 13-12

6. Benefit comparing dollar and usage limits – Wigs ..................................... 13-13

7. Comparing copay to coinsurance and selecting lowest member liability ........ 13-15

8. Authorization required – higher copay if not found .................................... 13-17

9. Configuring Mental Health carveout product ............................................. 13-20

10. Habilitation OT – Vary visits by Age ....................................................... 13-21

11. In Vitro Fertilization – Compare Unit and Dollar Limits ............................. 13-24

12. Preventive Routine Care – Benefit Age Tiers ........................................... 13-27

13. Partial Hospitalization Professional – Visit Tiers ....................................... 13-31

14. Skilled Nursing Facility – Compare Cost Shares ....................................... 13-33


i

About This Document This guide is designed to provide you with an overview of the Product Composer System (PCS) including business use cases to help orient you to the solution and its processes.

Intended Audience This guide is intended for business users who are looking to gain an understanding of the business processes delivered in the Product Composer System and how to use PCS to define the requirements for extending the processes.

Guide Organization This guide contains the following chapters:

Chapter 1: Overview Provides an overview of the Product Composer System.

Chapter 2: What is new in PCS An overview of the new features of Product Composer.

Chapter 3: Getting Started Introduces tools and concepts users need to begin using and learning the system including landing pages and the functions of the user portal.

Chapter 4: Policy Configuration Describes the review, creation and configuration of Policy Terms.

Chapter 5: Product Template Configuration Describes the review and creation of Product Templates.

Chapter 6: Product Configuration Describes the review, creation and configuration of Products.

Chapter 7: Plan Configuration Describes the PCS business processes for creating Plans in PCS.

Chapter 8: Draft Mode Use Cases Describes use cases for Draft mode operation of Product Composer.

Chapter 9: Quote, Compare Configuration Describes the PCS business processes for running a quote request and comparing products.

Chapter 10: Pharmacy Benefits & Products Describes the PCS business processes for creating Pharmacy Benefits, Groupers, Sets, Templates, Products and Plans.


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Chapter 11: Tags, Reports and Common Processes

Describes the tags, reports and common processes in PCS.

Chapter 12: Mass Update Benefits Describes the business process for adding or removing Benefits from a Benefit Set after Product Templates, Products and Plans have been created and configured.

Chapter 13: Benefits Configuration Describes the PCS business processes to enable your understanding of the available features and functionality.


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Chapter 1: Product Composer Overview

Business Challenges Over the past 40 years, the ability of Health Plans to deliver customer centric solutions has been constrained by rigid and single purpose applications. Antiquated legacy systems create barriers when bringing new Products to market and accurately administering them. These business challenges include:

From a large Health Plan, discussing the business challenges of Product creation from design through claim adjudication:

“The specific problems to be solved are to provide a single-source for product information, reduce set-up errors and resulting payment errors, confusion, re-work and delays resulting from limitations and redundancy of the current product definition, Benefit configuration and related processes that impact all product setup.”

Specific business issues include:

Inconsistent and inaccurate answers to Product, Policy and Coverage queries.

Mismatch of the sold Product terms to the Claim adjudication rules processed leading to significant payment errors.

Siloed Product, Policy and Claim departments working separately with non-aligned definitions of benefits and coverage making the creation of mandated documents such as Summary Benefit Coverage a technical and business interpretation challenge.

Unmanageable number of replicated Plans overwhelming users and systems.

Inflexible, siloed systems incapable of adapting to change restricting Health Plan’s ability to create innovative products and rapidly bringing them to market.

Product Composer Overview Pegasystem’s Product Composer System (PCS) is an enterprise wide Healthcare solution that addresses the root cause of these issues with innovative capabilities designed to solve these challenges with the flexibility to adapt to future changes.

PCS’s unique capabilities are powered by Pega’s unified technology foundation PRPC. A single unified environment organically developed over 30 years with industry leading Business Process Management (BPM), Business Rules Engine, Dynamic Case Management, Predictive and Adaptive Analytics and Decision Management capabilities.

PCS offers an agile solution allowing development and management of innovative healthcare Products that support design, approval, operational readiness and execution. Pega PCS provides a robust Product, Policy and Coverage repository designed for use across a Health


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Plan. The system brings transparency and speed to Product development efforts, while driving accurate Product delivery along with a high-quality customer experience.

Additionally, the common Product repository provides consistent information to all users in your company in the language and format best suited to their needs. This unique capability fortifies your ability to fulfill Product promises and increase customer satisfaction as it supports accurate, consistent and transparent customer interactions across Product design, Underwriting, Sales, Enrollment, Medical Policy and Claims.

Deployed on the cloud or on-premise, PCS makes it easy to dramatically reduce time to market, introduce innovative Products at lower cost, achieve traceable, defensible compliance and grow and retain your customer base in an increasingly competitive healthcare market.

PCS provides enhanced capabilities to deliver the following value:

What you sell is what you administer

90% reduction in product data and specific data on client customizations

Coordinated configuration of product, policy and claim information for a single source of truth across departments

Accurate and consistent product information for multiple consumer inquiries

Extensible and capable of rapidly adapting to new business challenges

Product Lifecycle Management Benefits For Product Composer to become an enterprise repository it must first deliver business for the Product design department.

PCS streamlines product design and approval lifecycle drastically reducing time to market for new Products.

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

PCS simplifies product management with component-based, re-usable product logic.

PCS becomes the single source for product, policy and benefit information supplying the information necessary to generate the Uniform Summary of Coverage (SBC) documents required by the government.

PCS delivers significant business value to downstream business areas with direct impact on customer satisfaction, net promoter scores, retention and market share by delivering a powerful product nucleus which provides authoritative, detailed, easily- searched, -accessed & –understood Product, Rates, Policy, Coverage & Benefit information.

PCS integrates easily to legacy systems and interoperates with other Pega solutions for Service, Sales, Enrollment, and Claims & Care Management for enterprise-wide agility, efficiency & control.


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Product Composer Features Pega’s Product Composer System (PCS) supports an expanded product lifecycle for modern healthcare products - from design, regulatory submissions and approval processes, product setup and management to sales material generation, web sales enablement, quote processing and benefit loading.

Multi-user, Multi-channel Enterprise Single Source Product Repository – Enterprise repository for Product, Policy and Coverage information with capability to customize responses for members, providers, brokers to provide information across multiple channels including web, social media, SQL and direct access by applications

Multi-level Reuse of Product Information - When a Health Plan client requests customizations to a base product, only the specific information changed by the client will be captured and stored. All remaining data will be reused from the base product. Maximizing reuse of product information will reduce product data by over 80% and substantially reduce the time to load product and Benefit information to back end systems

Ability to support downstream generation of documents such as Summary Benefit Coverage (SBC). Document generation features custom configuration for each document type.

Web-based Group, Individual and Exchange Sales support – PCS is a run time engine designed to supply product, benefit and policy information to web sales and enrollment systems

Code-group Driven Healthcare Terms – Product Composer mapping logic, Authorization requirements, Coverage notes, Benefit descriptions, SPD text 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, FitBits, guardrails in homes and smoking cessation, etc.

Ensure Payment Accuracy and Operational Readiness Product Composer 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 Code and Term Definers, Product designers, Benefit Configurators and Claim Calculation IT employees to work shoulder to shoulder to deliver a unified solution.

In a single environment, PCS enables:

Collaboration of product design, medical policy, benefits configuration and IT.

Code and Term Definers to assemble Healthcare codes into manageable groups and terms that form the foundation for benefit coverage notes, cost share definitions and


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exclusions. These terms form the building blocks for PCS to generate the paragraphs contained in the Summary Plan Descriptions and other documents.

Product designers to organize Benefits, Groupers and Networks into the structure of Products. To this structure, the contractual terms between Networks and Benefits are assigned.

Benefit configurators map the codes and terms from incoming claims to the most appropriate Network and Benefit.

The claim calculation IT staff assigns the parameters and calculations to the Networks and Benefits to connect the product terms and paragraphs to the actual claim adjudication calculations.

Maximizing Reuse with Pega’s “Layer Cake” A typical Health Plan will have a handful of products that result in hundreds of contracts with large accounts and thousands of contracts with small groups and individuals. To load these contracts, Plans are often required to copy or replicate all of the coverage rules, cost share parameters and exclusion logic for each contract even for contracts with little to no variations from the base Product.

Replicating all of that information exposes Health Payers to retesting the entire product for each sale substantially increasing the time and effort to load benefits.

With Pega, there is no need to load, configure or test the entire product. Changes are identified and a guided process leads the Benefit loader through the few changes required.

Product reuse 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.

Pega is able to do this because at the core of all our technology is a world class business rules engine, Pega Rules Process Commander, PRPC.


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Product Composer maximizes reuse with our Product structure

Product Templates - Typically a Health Plan will have less than 10 lines of business that would require a separate Product Template. Templates are created with Underwriting to specify the ranges of cost shares, rates and overall guardrails for sales. Examples would be HMO, Commercial PPO, Medicare Supplemental, etc.

Products - Products are created from Product Templates. For example a PPO template can be the basis for several PPO Products such as PPO preferred, PPO-80 and PPO-90. Products undergo DOI approval and are marketed to clients.

Standard and Non-standard Plans – These are the agreements signed with clients including their specific customizations to the Products they have selected. There may be hundreds or even thousands of Plans due to the number of clients requesting customization. Product Composer maximizes reuse during the Quote approval process by capturing and storing ONLY the client variations not the entire replicated Plan.

A typical Healthcare Payer will have a few hundred Products that result in potentially thousands of Plans with large groups, small groups and individuals. To load these signed quotes, Payers are often required to copy or replicate all of the coverage rules, cost share parameters and exclusion logic for each contract even for Plans with little to no variations from the base Product. Replicating all of that information exposes Payers to retesting the entire Product / Plan for each signed quote. This substantially increases the time and effort required to configure benefits into the claim system.

With Pega, there is no need to load, configure or test the entire Product. Changes are identified and a guided process leads the benefit loader through the few changes required.

Plans

Business ExamplesWhat is configured

Cost shares, coverage rules, descriptions, guidelines are selected

from Template ranges.

Standard and non-standard Plans. Only the variations from base Product are stored. All other information is

inherited from base Product.

PCS Configuration Level

Product Templates

Setting the structure and guidelines for Products in a LOB or Jurisdiction.

Benefit Set, Networks, Cost share ranges, pricing, sales guardrails,

claim calculation methods.

ProductsPPO 90 vs PPO 80

Metallic Plans(Typically 10 – 20 per Template)

Specifics for market reasonsLarge Account customizations(Typically thousands of Plans)

HMO / PPO / HIXJurisdictions such as states or regions to align with DOI filing

regulations (Typically under 5 per jurisdiction)


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Product reuse reduces the amount of effort required to load and tests Products by at least 75% and captures the changes requested during the sales process for precise analysis.

Product Composer also maximizes reuse within each Product Within a typical Product design, information such as the list of benefits, cost shares and calculation methods (how to calculate copay for example) are generally consistent for the Products associated with a common Template. The product customizations requested by large groups or for DOI mandates in States generally only affect a small number of Benefits. PCS optimizes the configuration of customizations by storing only the client changes on the Plans. All other Benefit information is shared or inherited from the base Product.

In the example below, the Plan level represents the changes configured for specific groups. The DOI mandates for coverage are represented by State DOI mandate level. These changes are stored as exceptions to the base Products (PPO-90). PCS does not require PPO-90 to be copied and modified. PCS reuses the base Product and processes only the changes requested. Example illustrated below:

In the example below, the Product has 3 Network levels. For the “Emergency Room” benefit the Copay values are inherited from the “In Network” level. Inheritance is indicated by the blue bent arrow in the copay column. However, on the “Inpatient” Benefit, the copay amounts were manually changed to be $100 - $200 as indicated below.


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Typically only a few Benefits will vary the cost share values from the Product. Product Composer stores only the overridden values and shows the user exactly which Benefits have been changed, increasing accuracy and minimizing configuration effort.

Single Repository for Product, Policy and Benefit information Product Composer is a single collaborative environment enabling multiple departments to configure their product related information into a single repository. A single configuration environment with a common Benefit structure to provide consistent communications, rules and information across the following departments:

Product design Member cost shares

Descriptions for SPD, DOI approvals, EOC

Sales guardrails

Network assignments

Underwriting Rates and relativity factors

Sales Individual rates and options

CSR & Web Inquiry Multi-consumer notes (information varies by Provider, member, etc.)

Multi-channel (web, chat, email, etc.)


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Compliance Federal and state coverage mandates

USBC documentation mandates

Exchange integration

Medical Policy Authorization requirements

Exclusions and limits

Coverage policy

Benefit Claim System Configuration Mapping codes to Benefits

Benefit coverage rules

Accumulator and limit processing

Claim system instructions


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Product Composer Concepts

Overview

Codes & Code Sets Code sets are work objects in PCS that store specific claim codes. PCS has the following objects and supports an import from Excel to load the code sets:

Bill Type

CPT

DRG

GCN

HCPCS

ICD9 Diagnosis

ICD10 Diagnosis

ICD9 Procedure

Product Templates

Products

Standard Plans

Benefits

Benefit Set

Non-Standard Plans

Variation Rules

Code Groups

Codes

Setting the structure and guidelines for Products in a LOB or Jurisdiction.Benefit Set, Networks, Cost share ranges, master variation list, coverage rules, pricing, sales guardrails, claim calculation methods. Approx 20 – 40 per year.

The products Health Plans take to market. DOI approval for Products and/or Templates. Typically 10 -20 per Template.

Fixed list of Benefits. Claim mapping configuration. Provides consistent definition and meaning of Benefits across the Health Plan.

Medical building blocks for Products, Policy, Benefits and Rates. The objective is to share the same list of Benefits across the entire Health Plan.

The context rules of Benefits such as seeing PCS, Inpatient, with Authorization, ,etc. Ability to configure cost shares, coverage and limits.

Combinations of code ranges to create Healthcare terms based on codes.

CPT, HCPCS, ICD-9, 10 etc codes. Ability to combine codes by ranges.

Standard Plans to take to market. Non-standard Plans are base Products to be customized by large Groups. Plans ONLY store the data changes from the base Product. Can be thousands.


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ICD10 Procedure

Modifier

NDC

Place of Service

Provider Taxonomy and Revenue

Code Groups Health Plans use standard terms such as “Psychiatric Specialists”, “Mental Health Services” and many more to communicate with members, Providers and Brokers. In Product Composer, these Healthcare terms can be created based on specific codes and rules. For example, the term Psychiatric Specialists can be supported by the specific taxonomy codes Health Plans defines.

The diagram below illustrates an example configuration of code ranges for CPT and HCPCS to map to Assisted Reproduction benefit.


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By supporting Healthcare terms with codes, code ranges and rules, PCS creates an auditable connection between the words and the codes that define them. In PCS, code groups can be used to configure coverage, benefit mapping and authorization requirement rules creating a traceable and auditable connection from terms to the actual codes used in downstream systems.

PCS Product Tree PCS Product Tree is a structure of Product / Networks / Groupers / Benefits displayed in the diagram at right.

Product Composer has a base structure for Templates / Products / Plans. Within a Product there can be unlimited Networks such as In-Network, Mental Health Carve outs and Accountable Care networks. Under each Network is a full or partial list of benefits. Groupers are used to organize the Benefits into classifications such as Surgery, Mental Health, etc. Groupers are used to accumulate visits, units and dollars assigned to each Benefit and provide the ability to configure limits that span the dependent Benefits.

Groupers are also used to configure cost shares that are reused for the Benefits. For example, if a Physician Services Grouper was configured with a $ 10 copay, each of the dependent Benefits would inherit the $10 copay without further configuration. If the user wishes to change one of the Benefits to a $ 20 copay, that Benefit must be manually configured.

Benefits A Benefit is the basic building block of PCS. In most Health Plans, Benefits can have broad medical descriptions such as “Emergency Room” or very limited descriptions such as “Infertility Treatment Outpatient setting”. The definition of the list of Benefits is dictated by the cost share, coverage or policy differences to be specified.

Networks

Benefits

Groupers

Variation Rules

Coverage rules & guidelines• Coverage• Exclusions• Limits• Authorization• Medical Policy• Related Services

Product Tree

Variation Rules

Policy Terms

Cost shares and notes• Copay• Deductible• Coinsurance• Admission Copay• Out of Pocket maxs• Carryover

Product view Policy view


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PCS allows users to assign many attributes to Benefits. See the illustration at the right above for information that is configured on PCS Benefits.

One of the interpretation challenges facing Health Plans is the varying list of Benefits. The Product design department may use a list and definition of Benefits that is different from the Medical Policy or Claim configuration list of Benefits. Different lists and Benefit definitions can lead to interpretation, data mapping and basic communication challenges. This can result in difficulty answering simple coverage questions from Members or Providers. It can also result in significant interpretation challenges between product description and claim configuration which can drive large payment errors.

One of the factors leading to different lists of Benefits is the context of the service performed. For example, Infertility Treatment” is a Benefit while “Outpatient setting” is the context of where the service is rendered. PCS provides the ability to configure the context rules separately from the medical Benefit definition. These rules are called variation rules.

Variation Rules Variation rules provide the ability to configure cost shares, coverage, authorization requirements and limits differently based on the context of the service provided.

PCS allows the user to use a common list of Benefits across Templates with the capability of varying cost shares by the following:

Network – This feature is part of PCS 2.3 SP2. The Product tree concept provides the ability to set cost shares based on “In-network” vs. “Out of network”.

Place of Service – inpatient, outpatient, SNF, etc. can all have different cost shares for the same Benefit in the same Network.

Provider Specialty – Vary the cost shares based on seeing a Specialist, Internist or Nurse.

Service Group – Vary the cost shares based on the service provided. For example, the Benefit Mental Health may have a $10 for group counseling and $50 copay for individual counseling. Also vary cost shares based on bed type using revenue codes.

Age band and Gender – Vary cost shares by age and sex of the patient. Includes the ability to vary cost shares by months for newborns.

Service by – Vary cost shares when going to your PCP or Patient Centered Medical Home.

Authorization or Referral – Vary cost shares if referred to a specialist or authorized to have surgery. Lack of authorization will result in higher copay for example.

Provider Ranking – Ability to rank Hospitals and other providers and vary cost shares to drive member steerage to preferred facilities.

Jurisdiction – Ability to vary cost shares by location such as State. As government mandates of copay increase, this feature enables the user to vary cost shares for the same Benefit based on State rather than creating an entire new Product.


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The diagram below illustrates the configuration of a Habilitation Outpatient Therapy benefit with different copays for PCP, Outpatient, Specialist and Inpatient.

Benefit Sets The list of Benefits associated with PPP Products is essentially the same. Some Benefits may be optional while others are standard to each PPP based Product. Product Composer allows users to create this common list of Benefits into a Benefit Set. The Benefit Set is then used to create the PPP Product Template and all associated PPP Products.

Product Composer Hierarchy The list of Benefits (Benefit Sets) is used as the basis for the Product Template. The Product Template is the foundation of all of the Products within a line of business. Templates contain cost share ranges and associated underwriting relative values, coverage rules, networks, authorization requirements and guardrails for creating Products in a consistent approved process.

Product Templates Product Templates contain definitions for various aspects of an Insurance product and serve as the base rules and guardrails for Product creation. During Product Template construction, provider Networks are selected together with the Benefits each Network will cover. 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:


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Coverage Levels, Eligibility Rules, Cost Share range values, Guardrail rules, and general questions and answers 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 / Grouper / Benefit.

Products Products are 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 presented to make other selections. Again, the Product tree facilitates inheriting Network values when none are defined on a specific Benefit.

Plans Contracts are defined from Products as type Group or Individual; relevant parties are defined accordingly. During Contract Configuration, values may be edited, when edits are within acceptable ranges, Approval is bypassed; otherwise there is Exception processing to request Approval.

Quotes Quotes are used to support external requests for product and benefit data. Quote rules are temporary and do not create work in PCS, they are used simply to support the product request by a system such as an external quoting tool that needs to present product data.

Policies and Policy Terms PCS has a new Policy process to allow for configuration of coverage, exclusions, limits, authorization requirements and medical policy information. Policy information is configured for Product families and provides the default values for all associated Product Templates.

Policies are linked to Benefits within the Product Tree. When necessary to specify coverage more specifically, called policy terms and are associated to a specific Benefit. Associated with a policy term are sections as follows:

Policies – Configuration of coverage, exclusions, etc.

Maximum Reached – If a limit is reached, instructions for the next step for coverage or limits.

Client Instructions – A section for clients to add attributes and rules

Notes – Multiple consumer notes

Within the Policies flow the following sections are provided to configure the rules, parameters and instructions for each Policy term:

Coverage – Specific rules specifying when the Term is covered


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Exclusions – Specific rules specifying when the Term is not covered or excluded.

Limits – Configuration of specific dollar, visit and unit limits.

Authorization – When are authorizations and referrals required and what are the coverage rules if found or not found

Medical Policy – Text sections to allow the user to configure the policy paragraphs for use by customer service and inquiries.

Related Services – For a Policy Term what other services should also be covered. For example, lab is included with a surgical procedure.

PCS also provides the capability for multiple variation rules for a Policy Term.

Technical Overview PCS consists of flows and processing that create custom rules within the Rule-HC-PCS- hierarchy for:

Benefits

Benefit Sets

Groupers

Policy Terms

Policies

Product Templates

Products

Plans

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. PCS employs Work Objects to define, save and associate rules with one another, and save these custom rules. PCS V2.2 implements filtered selections for Medical, Dental, and Vision; for each of the custom rule definitions to ease tailoring. Each custom rule is designed and implemented for extensibility - Chapter 2 of this guide describes extending various aspects of PCS.

Benefit rules — collects and contain all the Healthcare Code Groups and Code Sets that are covered by the Benefit, this data inherent in the Benefit is referred to as Benefit proper mapping data. Refer to the Healthcare Common Codes Implementation Guide for further detail on Code Groups and Code Sets. Benefits also contain notes, a required indicator and optionally wellness data.

Benefit Set rules — contain a set of Benefits that are managed as a single unit – they can be selected for inclusion in Product Templates; can be tested for Benefit mapping conflicts, and can be tested for coverage of specific combinations of CodeGroups and CodeSets. When Benefits are included in a Benefit Set they are said to be locked by


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that Benefit Set and can only be changed after being copied to a new Benefit. Benefit Set construction also allows for the definition of Groupers. PCS V2.2 employs Benefit Set testing functionality to test Benefit Mapping to Claims matching logic.

Groupers — group Benefits within a Benefit Set or Network; changes to Grouper properties permit the contained Benefits to inherit those values. PCS implements two types of Groupers - permanent and temporary. Temporary Groupers can only be created 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 PCS’ configuration mode stipulates optional Benefit Sets.

Network rules — represent a Provider Network contracted to provide medical coverage for the Benefit child items under the Network. Networks in PCS are light weight objects whose properties are expected to be obtained by interacting with an external system. As such, creating Network rules is a simple manual operation.

Product Template rules — contains 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 will cover. 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, Eligibility Rules, Cost Share range values, Guardrail rules, and general questions and answers 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 rules — are 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 presented to make other selections. Again, the Product tree facilitates inheriting Network values when none are defined on a specific Benefit.

Contracts — are defined from Products as type Group or Individual; relevant parties are defined accordingly. During Contract Configuration, values may be edited, when edits are within acceptable ranges Approval is bypassed; otherwise there is Exception processing to request Approval.

Reusability — PCS rules implement reusability through copying and references. Any rule can start from a copy of a similar rule and all objects refer to defined base, for example new Contracts refer to a defined Product.

Extensibility — Cost Shares, Limits and Exclusions, as well as Eligibility rules are implemented with page lists to improve their extensibility. PegaSurvey facilitates Q&A extensibility for Product Templates. Benefit Mapping rules are defined based on a PCS Configuration setting so that Benefit Mapping could be disabled. Benefit Set functionality can be disabled with a PCS Configuration change.


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Chapter 2: What is New in PCS This PCS release contains the following features: Benefit/Grouper Mass Add / Removal: Adding or removing Benefits to a Benefit Set

and mass updating to Templates, Products & Plans Plan bundles Standalone Groupers / Benefits Plan level enhancements Copying configured Networks / Groupers / Benefits Product / Plan export enhancements Pega Survey enhancements Tagging Benefits

Benefit/Grouper Mass Add / Remove

Overview

This feature provides the ability to add or remove Benefits and/or Groupers from a draft Benefit Set and automatically add / remove the Benefits and/or Groupers to all associated Product Templates, Products and Plans.

The process provides for adding or removing entire Benefits and/or Groupers to the product tree, not the ability to mass update the attributes of existing Benefits or Groupers such as a date sensitive copay change. This capablity will be delivered in future PCS releases.

To begin, the user manually adds or removes Benefits or Groupers from a draft Benefit Set. The Mass Add/Removal process will schedule a batch job to apply the Benefit Set changes to the associated Product Templates as non-configured Benefits/Groupers in the product tree. The process can be scheduled immediately or during off hours when Templates and Products are not locked for configuration.

The Mass Add/Removal will not change the configuration of the Template’s existing Benefits. Configuration of added Benefits is accomplished in Configure Tree of Product Template creation process.

After configuring the Benefits/Groupers in the Product Template, the user then has the ability to Mass Add/Remove the Benefits/Groupers to all associated Products. The process is similar to creating a Product from a Template. The Benefits/Groupers will be configured with Template cost share ranges, etc. The user will then be required to complete the configuration for the new Benefits/Groupers by entering the Product cost share and coverage values.

The ability to update Plans associated with a Product is also provided in this release.

Notes:

Requires Benefit Sets to be in draft mode.


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Mixed or Claim Centric. Mapping is not required.

Plans can be created from draft Products effective.

Process Steps:

Create a Benefit Set as Draft.

Create a Product Templates and Products from the Benefit Set. Complete the configuration as required. Save as draft.

From user’s home page, select draft Benefit Set for revision.

Add / remove Groupers and/or Benefits from Set - Groupers or Benefits must first be created. Mapping is optional.

After the Benefit Set approval flow, when changes are made and there are dependent Product Templates; the screen shown below appears. This screen prompts the user to select “perform edits” on all Product Templates associated with the Benefit Set. This process will add or remove the new benefits/groupers updated to the set.

When should edits occur? – The options are to update the selected Templates

immediately, now, or to schedule the updates for off hours. The user has control of the time and date.

Detect conflicts – If the new Benefits already exist in any Product Templates the user has an option of not adding the Benefits or replacing the configured Benefit with the new non-configured Benefit.

The Benefits/Groupers will be automatically added or removed to each full Network in the Template. Carveout Networks must have the benefits manually added or removed.

Template owner pushes changes to associated Products.


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If the new Benefit was previously added to the Product using the standalone benefit feature, the system will indicate a potential conflict. The Product owner can elect to not override the configured Benefit.

The Product owner will then configure the new Benefits on a Product. If they wish, the Product owner can copy the fully configured Benefit to the remaining Products.

Plans are data instances of the Benefits that are manually changed from the base Product. Plans automatically inherit (not copy) the new Benefits from the Product.

Plan Bundles On the Plan level, this feature provides the ability to group or bundle multiple selected Plans into a single offering called a bundle. For example, if an individual selects specific Medical, Vision and Pharmacy Plans, the system will provide the ability to create a Plan bundle. The Plan bundle will be created during the Plan creation process. This functionality is within the Plan Data expandable section as shown here:

On the Plan creation process, the ability to enter multiple Products / Plans will be provided on the metadata screen. In addition, an automated service will be available to allow the sales process to automatically call the PCS Plan creation flow.

The Plan bundle will be the input to the client’s SBC process. PCS will provide the ability to bundle Plans and export the information to client’s external SBC configuration module.


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Adding Standalone Groupers / Benefits

Add a Grouper / Benefit Directly to a Product Template

This release provides the ability to add a Grouper / Benefit directly to a Product Template. This feature allows users to manually add Benefits to a Network within a Template without changing the Benefit Set.

First, the Grouper / Benefits must be created. Then the user can select from the list of available Groupers / Benefits to add to the product Template.

As shown in the illustration at right, the user positions the cursor on a Network right clicks and selects Add Benefit. A window appears allowing the user to select a Benefit from the available list of Benefits.

Adding a Grouper / Benefit Directly to a PCS Product

The ability to add a Network / Grouper / Benefit directly to a PCS Product. This feature allows users to manually add Benefits to a Network within a Product without changing the Benefit Set.

The user positions the cursor on a Network, right clicks and selects Add Benefit. A window appears allowing the user to select a Benefit from the available list of Benefits.

The ability to add new Networks to a PCS Template or Product is restricted to Carve out Networks only.

Plan Level Enhancements

Ability to Create a Plan from a DRAFT Product

PCS provides the ability to create standard and non-standard Plans from a draft Product. These Plans will not be in draft status! Once approved, the user will not be allowed to modify their configuration.

If a change is made to a draft Product and has not been overridden at the Plan level, Plans created from draft Products will continue to inherit from the base Product.

The ability to manually modify Plans will be available in a later release of PCS.


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Enhancements for Viewing Plans Compared to the Base Product

PCS will enhance the ability to view the manually overridden changes to Plans compared to the base Products.

Plan Export

The current Product information export utility will be added to the Plan level of PCS. The Plan export will contain all of the information of the Product export overlaid by the Plan changes. This combined export can be used to support client downstream systems.

Master Variation List on Plan

The Master Variation list feature provides the ability to configure consistent variation rules for all cost shares. A consistent list of cost shares provides the ability to directly map to claim system benefit rules.

Benefit variations for both cost shares (product view) and member coverage (policy view) are often used to configure Benefit context such as Inpatient / Outpatient, PCP / Specialist, etc. in PCS 2.3 SP2. This feature provides the ability to create a common or master list of variations for a Benefit across all cost shares and coverage tabs.

Master variations provide a consistent list for a Benefit on all levels of PCS.

Master variations are configured on the Product Template and automatically inherited to the Product and Plan levels.

Master variations enable the use of the Quick Entry screens on the Product and Plan.


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Quick Entry Screens to Plan Level

On the Plan level of PCS, the cost share “quick entry” screen has been added to allow for configuration of common cost shares and coverage information. A single screen allows the user to configure all cost share amounts for a Benefit and corresponding variations.

On row 1 of the quick entry screen shown above are the benefit default cost share amounts entered on the Product flow. The next 3 rows are variation rules for this Benefit configured on the Template and inherited to the Product and Plan levels.

By clicking in the PCP row as shown, the user can configure all of the cost share amounts shown on a single screen without the need to select each cost share tab. This screen significantly streamlines the configuration process on Products and Plans.

Benefit Tier Configuration


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The Benefit tier screen shown below has been added to the Plan level of PCS. This screen provides the ability to configure complex Benefits that vary cost shares based on limit and age ranges. The Benefit tier screen appears in the policy view because of the ability to configure by limit ranges. (Limits are configured on policy view)

The Benefit Tiers tab provides the following capabilities:

A screen with limits, age ranges and cost share values provides a single source for configuration of complex benefits such as wigs which typically are limited to one per year or $300 of coverage.

Inter row cost share comparisons – Setting the inter row calculation value allows for comparison of two cost share values. For example, $50 copay could be compared to an 80% coinsurance with the system taking the amount that is the “greater member liability”.

Intra or multiple row comparisons – Setting the inter row value to “OR” or “AND” instructs the system to compare multiple rows of configuration against each other. In the example shown below, row one will calculate a $ 20 copay and 0% coinsurance. Row 2 will calculate $ 0 copay and 70% coinsurance. The system will take the resulting value that is the “greater member liability”.

This screen can also work with the other policy screen configurations. For example, a Benefit can have a limit of $300 coverage (configured on limit tab) with $30 copay configured on the Benefit Tier tab.

The user should configure cost shares either on the product view (quick entry or individual tabs) or on this benefit tier screen but not both.

Copying Configured Networks / Groupers / Benefits

Copy Fully Configured Benefits from One Product to Another

On the Product level, select a Benefit from the Product tree (configure mode). Right click to display the window as illustrated at right. The “copy with values” option will copy both the manually configured and inherited values for the Benefit to the new Product. For example, if a Benefit inherits $10 copay from the Network in the original product, the “copy with values” option will configure a $10 directly on the Benefit (not inherited).

The copy as is option copies the actual values of the Benefit. If a Benefit inherits a $ 10 copay from the Network there is no value stored directly on the Benefit. When copied “as is”, the Benefit will inherit from the Network of the new Product.


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Copy Configured Groupers

A fully configured Grouper and all associated Benefits can be copied from one Product to another. Both the “with values” and “as is” options are available for Grouper copy. This feature is ideal for copying a pre-configured Dental or Mental Health Grouper and all Benefits to target Products.

Copy Configured Networks

A fully configured Network and all associated Groupers / Benefits can be copied from one Product to another. Both the “with values” and “as is” options are available for Network copy.

Product / Plan Export Enhancements PCS SP2 will add two new XML over HTTP services:

Example of the Product / Plan XML output shown at right.

Ability to invoke a PCS service to return the product tree for a given Product or Plan.

Ability to invoke a PCS service to return the information on the Benefit within a product tree.

Pega Survey Enhancements On the Product Template flow, the Pega framework, Pega Survey, is used to configure questions and responses configured for the product sales process. Using Pega Survey, these questions and decision trees are configurable. However, the answers recorded were not available for export outside of the framework.


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With PCS, the information captured by the survey questions will be available as part of an inquiry and for export to downstream systems.

Tagging Benefits A feature of PCS is the ability to assign tags to the entities of PCS. This allows users to search for all products, benefits, etc that are tagged with a similar word. For example, a customer service person may want to see all of the Benefits in a Product tagged with Surgical_Benefits to display the available list of Benefits related to surgery.

Steps to utilize tags:

On the PCS architect portal, select >

Process and Rules > Social > Tag Configuration. This step allows the PCS user to configure the available tags.

On the PCS screens the tag icon, , allows the user to assign tags during the standard PCS process flows of Benefit, Set, Template, etc.

Tags can then be used to search PCS work items. A list of matches will appear to the user.

Also a tag report is available to list all work items such as Products that match a tag search.


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Chapter 3: Getting Started This chapter introduces tools and concepts that help you get started using PCS once it is installed.

PCS User IDs, passwords and functions

• PCS Configuration

•

Selecting a PCS run mode

•

Claim System Configuration

Benefit Configuration

PCS Document Generation

PCS Integration Services

PCS Users IDs, Passwords and Funtions

Using the Product Architect Portal

PCS ships with seven pre-configured primary users that can be used to access the system and perform product development functions after the install. The following lists those user names, their user IDs, and the functions they have access to perform. Each account uses install for a password.

User Function

User Name: Product Architect User ID: ProductArchitect@MyHealthPlan

Creates and manages Benefits, Benefit Sets and Product Templates

Manages document templates and rules used to build the correspondence output

Creates the Prototype rules that support the Data Dictionary

Creates rules, decision maps, decision tables/trees, uses the graphical tools to create product template structures

Very technical and highly specialized


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User Function

User Name: Product Designer User ID: ProductDesigner@MyHealthPlan

Creates and manages Products based on the Product Templates

Requests product template changes from the Architect

Interacts with Sales & Underwriting

User Name: Contract Loader User ID: ContractLoader@MyHealthPlan

Creates and manages Contracts based on the Products

Requests product template changes from the Architect

Interacts with Sales & Underwriting

User Name: Policy Specialist - User User ID: ContractLoader@MyHealthPlan

Creates and manages Policy Terms and Policies

Associates Policy Terms to Benefits in the Product Tree

Interacts with Medical Policy and Product Architect

Interprets Medical Policy and configures coverage, exclusions, limits, authorization requirements and medical policy notes.

User Name: Product Manager User ID: ProductManagerPCS@MyHealthPlan

Approves new Benefit Sets, Product Templates, Products and Contracts

Accesses PCS Reporting Manages Work

User Name: Business Analyst User ID: LegalManagerPCS@MyHealthPlan

Approves new Product Templates Accesses PCS Reporting Manages Work

User Name: State Mandate Specialist User ID: StateMandateSpecialist@MyHealthPlan

Approves new Product Templates Accesses PCS Reporting Manages Work


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PCS Configuration This topic describes the options and functions available from the Product Composer Landing page such as setting the overall configuration parameters, managing the rules used to generate documentation and integration services. These are available to users who have privilege to access the Designer Studio – typically these are users who perform the roles of system administrator, system architect and business architect.

Accessing the landing page 1. Log in as

administrator@pegapcs; password is install.

2. From the Designer Studio, click on the top left corner of the portal to display the Product Composer landing page and its associated menus and options.

3. Select PCS Configuration.

PCS Configuration Use this option to:

Establish Application Settings Select system Run Modes Configure claim systems Define Benefit Mapping categories and Benefit Consumer notes

Steps 1. From the PCS landing page, select the Product Composer > PCS Configuration

option. The PCS Configuration page displays.

2. The Save Configuration buttons set the configuration settings as either the System Configuration which impacts everyone logged into the system as an end user or the Personal Configuration for an individual user logged in.

When you save as personal, the settings only apply to you and other users continue to use the system configuration.


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3. The Application Settings section allows you to establish the settings that control where and how your rules are saved. Settings are:

• The base Application the PCS solution is built on and the Application version - PCS is built on the HC USA Product Composer application.

• The default Class and Offering are used when rules are saved.

• The RuleSet and RuleSet Version are where users save new rules.

• PCS Release version is the level of release of PCS

Note: The RuleSet defined with the PCS Configuration is critical for PCS to function correctly as there are rules created during almost every user interaction. The RuleSet Name and Version must be available and open for PCS to function correctly.

4. The Export PCS Rules button saves the rules configured in PCS to enable moving rules to another instance of PCS.

Selecting a PCS Run Mode The PCS operating modes control many of the processes and screens of PCS. These have been simplified in PCS 2.3 SP2:

Standalone mode Standalone mode is best when PCS is used primarily to design and publish Products. Standalone has the following features:

Groupers and Benefits can be added at any time in the Template, Product or Plan processes. Standalone mode does NOT require Benefit Sets.


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Benefit mapping is not utilized.

Pros:

• Best used by clients that want freedom to change the list of benefits used by Products and Plans.

• If PCS is NOT used as an enterprise repository of product, policy and claim information, standalone mode provides the highest degree of flexibility.

Cons:

• When the list of benefits varies from Product to Product, the interpretation and meaning of benefits change. This causes confusion for downstream systems, customer service and inquiries.

Mixed mode

Mixed mode is an optimal choice when PCS is used to create an enterprise repository of product, policy and claim information. Mixed mode provides the flexibility for optionally using Benefit Mapping.

Mixed mode requires Benefit Sets to be used. When configuring Benefit Sets, PCS has added several features to allow for flexibility in benefits for each Product / Plan.

Benefits in a Benefit Set can be configured as required or optional. Optional benefits allow selecting these benefits during a sales cycle if desired. If an optional benefit is purchased, the user will change the setting of the benefit from “Not Covered” to “Covered”.

Benefit mapping can be set to optional or required in mixed mode. If optional, the user will see the screens in the process but are not required to configure mapping.

Pros:

• Best used by clients ultimately wanting an enterprise repository of product, policy and claim data. Mixed mode allows for using Benefit Sets but provides flexibility for mapping and adding Benefits outside of the Set.

• The ability to add Benefits and or Groupers to Products and Plans independent of the Benefit Set.

• The ability to add entire Networks to Products and Plans.


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Cons:

• Optional Benefit Mapping could result in Products which will not support adjudicating claims.

Claim Centric

Claim Centric mode is the same as mixed mode except that Benefit mapping is required.

Pros:

• Benefit mapping is configured in Product Composer. Claim information is captured for populating downstream claim systems

Cons:

• Benefit mapping is complex. Claim centric mode requires mapping to be completed before Templates are created.

It is important to finalize Benefit Sets as much as possible before building Templates and Products.

Benefit Mapping Mode

Benefit Mapping Mode is not used for Standalone and is required for Claim Centric. The user has an option when using Mixed Mode to select “Optional” or “Not Used”. If optional is selected, the Benefit Mapping screens will appear and must have at least one mapping entry configured. If “Not Used” the benefit mapping screens will not appear in the process.

The benefit mapping for each Benefit can be changed after a benefit is used in a Benefit Set, Product Template, etc. providing it is Approved as Draft.

Benefit Set Mode Benefit Sets are not used for Standalone mode. Benefits Sets are used for Mixed and Claim Centric modes.

Effective with PCS 2.3 SP2, Benefits can be added to a Benefit Set after the set is used to create Templates and Products. The ability to mass add / remove benefits from a used benefit set is available in PCS 2.3 SP2.

The user may add standalone Networks, Groupers and Benefits to established Templates, Products and Plans. Effective in PCS 2.3 SP2, the user can position the cursor on a Network on the product tree and right click to expose these options.


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Draft Mode Enabled Draft Mode enables the user to configure Benefits, Benefit Sets, Product Templates and Products in “Draft” mode. Draft mode allows the user to change any of these objects after Draft approval. For example, when Products are created from Product Templates, Draft mode enables the user to change the original Product Template.

Benefit Set Category Benefit Set Category enables the user to categorize a Benefit Set, Product Template and Product as Medical, Dental, Pharmacy or Vision. PCS does not use specific UI process flows for each category; rather a Product Category is selected on respective metadata screens.

Policy Flow Enabled Policy Flow Enabled set to “true” will enable a user to create Benefit Policy Terms during the Product Template creation process. Benefit Policy Terms allow the user to specify Policy information per Benefit such as coverage, limits, authorization requirements and medical policy notes. Policy Flow Enabled is usually set to false because Policy information can be set per Benefit within the Product Template and Product creation processes.

Claim System Configuration

PCS is designed to support the configuration of claim instructions for multiple claim systems. The name of the claim system and a brief description can be configured as illustrated below.

The user can configure the claim system name as shown in row one above. By selecting the +/- button, multiple claim systems can be configured. Multiple claim

systems will result in multiple UI sections on the Claim Instruction tabs.


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Benefit Configuration

Benefit Mapping categories define the code groups and code sets that are used to define a Benefit as well as the collection of code groups and code sets that further define when a benefit is covered or not covered. These code groups and code sets are described in greater detail in the Healthcare Common Codes Solution Business Use Case Guide. Adding new Benefit Mapping categories is described in detail in the Product Composer System Implementation Guide.

The Benefit Mapping section enables the user to specify the names displayed on the mapping screens and the Code Set Class. For example, if a user has a custom Provider Specialty class, the name of the class can be entered on this screen.

5. The Benefit Configuration section allows you to define Benefit Mapping categories and Benefit Consumer Notes.

PCS contains five Benefit Mapping categories that default on the page.

• Service Groups include individual or ranges of codes from CPT, HCPCS, ICD9 Procedure, ICD10 Procedure, Revenue, NDC, GCN and Modifier codes

• Diagnosis Groups include individual or ranges of codes from ICD9 and ICD10 Diagnosis codes

• Bill Type Groups include individual or ranges of codes from Bill Type codes

• Place of Service Codes include individual codes that define where a service is rendered such as a hospital or office


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• Provider Specialty Groups include individual codes that map to the Provider Taxonomy codes

6. Benefit Consumer Notes defines the number and type of Note tabs available to the end user when defining the benefit.

PCS contains five types of Consumer Notes that default on the page.

• Summary Plan Description Notes - typically used in the Guide to Benefits to describe a benefit to a member

• Member Service Notes - typically made available to a Customer Service system and are used by a call center representative to describe a benefit to a member

• Provider Service Notes - typically made available to a Customer Service system and are used by a call center representative to describe a benefit to a provider

• Web Service Notes - typically made available to a Health Plans web site and are used to describe a benefit to consumers out on the web

• SBC Benefit Description – Description of Benefit in the Product Tree used for printing on Summary Benefit Coverage (SBC) document


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PCS Document Generation Document configuration requires a significant level of expertise with developing PRPC solutions. The information below provides an overview of the capabilities of PCS document generation.

Manage Document Template

This document option displays the rule types that are used to generate Word document output from PCS. PCS ships with two preconfigured documents.

Summary Plan Description or Guide to Benefits document Department of Insurance Filing document

Steps

1. Select Product Composer > Document Generation > Document Generation Rules.

The Document Generation page displays with the Document Generation Rules tab open.

2. From this page you can:

• Enter a keyword in the Filter Rules By field to filter the display by only those rules containing that keyword

• Under Show Rules Categories select the checkbox next to Correspondence, Message, Paragraph or Section to display those rule type(s) when you click Go.

• Click a column header to sort the displayed data in the rows in descending order


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• Click the icons next to a Type or in the Versions column to display a snapshot of details about the rule or the rules versions in a pop-up

• Double click a rule to open it and view the rule details

The document rules can have multiple versions as they change from year to year and can also be designed to be used under a number of circumstances such as different product types or different regions of the country. The documents are supported by four categories of rules.

Document Generation Rules Correspondence rules - generally used to organize the other type of rules in a manner that makes sense to the business user. For example, a single correspondence rule may reference a number of paragraph or message rules and organize them into a section of a document. The correspondence rules are referenced in the Word templates that define all the sections of chapters that make up the entire document. The Word templates are described in greater detail in the Manage Document Template use case.

A user can double click a correspondence rule in the list to open the rule. This is an example of a correspondence rule.


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Message rules - used to put together sentences that reference PCS properties and static text define in the message rules. PCS message rules are used to build the generated text that describe the Benefit definition description, the Benefit coverage description, etc.

This is an example of the message rules that can be created.

Paragraph rules - typically used to store a specific sentence or paragraph as the name indicates. The paragraph rules are generally available for a number of reasons. This paragraph example illustrates how the rules typically are configured with static text to be used under various circumstances and on multiple documents or consumed by multiple consumers.

Section rules - primarily used to build a table or manage a specific display in the PCS documents such as the Summary Plan Description or Department of Insurance Filing documents.

For instance, the section rules are used to build the tables that display the Product Template, Group and Benefit tables in the DOI document.


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This section rule is used to build the Benefit table. It defines the display and always relies on references to other PCS properties for the generation of a table.


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Glossary of Terms This document option displays a list of commonly used Healthcare Terms along with their description. These are configured in PCS as Paragraph rules available to any consumer of PCS data. Typically, a glossary term would become a section in the Summary Plan Description or Guide to Benefits as well as a page on the Health Plan website.

Steps

1. Select Product Composer > Document Generation > Glossary of Terms.

The Document Generation page displays with the Glossary of Terms tab open.

2. From this list you can:

• Enter a keyword in the Filter Rules By field and click Go to search for a term

• View the name and description of each paragraph rule

• Click the icon to display summary details about the term or its versions in a pop-up

• Double-click a row to open a rule and make changes or create new versions and circumstances of the rule

This is an example of the Calendar Year paragraph rule in the Glossary.


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PCS Integration Services Option Use this page to test the services that have been configured to retrieve and display a list of Products and Plans based on an input parameter. Services are sorted by the type that identifies the object the service is configured for and display a link to the actual service rule.

Steps 1. Select the Product Composer > PCS Integration Services option.

The PCS Configuration page displays.


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2. Click a link to access the service and display the service rule for parameter entry.

In this example, the Get Product service displayed is set up to fetch a list of products based on the input parameter of product Effective Date. When run, PCS retrieves list of products where the date entered is greater than the Product effective date and less than the product end date.

3. To test a service, enter the parameter in the Value field and click Execute. A results page is returned and displayed.


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Using the Product Architect Portal This section describes the components and functions of the PCS Product Architect portal and how they can be used to expedite learning and system configuration.

Displaying the Portal Log in as ProductArchitect@MyHealthPlan; password is install.

Portal Components and Functions

Product Explorer (left panel) Located on the left side of the portal, a section displays a list of core PCS components. Selecting a component such as Product Templates, Networks, etc. the system will display the full list of available entities. From this view, the user can sort, filter and search for a specific entity.

Getting Started Located in the center workspace of the portal, this section gives you access to tools and processes authorized for the specific persona. The illustration next shows the home page for the Product Architect with links for creating new benefits, groupers and product templates.

Many of the processes are set up to guide you through the process using a series of tabs and include a list of actions you can perform on the process.


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To Do List This section lists the user’s current work assignments. For example all benefits, sets, etc created in draft mode will appear in this list to allow the user to select and re-configure by cycling through the create process when the component is Approved Draft.

Tags and Recently Resolved On the right side of the screen (shown below) is an automatic feed that lists work that has been recently resolved. In addition, a Tag Search facility allows searching for tagged components and several tags used most frequently.


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Chapter 4: Policy Configuration This chapter describes the PCS business processes for creating member coverage, limits, medical guidelines and authorization requirements in PCS. Use cases included are:

PCS Policy & Policy Term Overview

Direct Configuration of Policy in a Product Template

Searching for Policy Terms

Creating Policy Terms

Creating Policies

Inheriting Policy Information

Policy & Policy Term Overview Member coverage policy is typically created and maintained in the medical department of a Health Plan. However, the member coverage, limits, guidelines and authorization requirements specified by the medical office must ultimately be configured into the claim processing system. Often it is a manual effort to translate the text based medical guidelines and coverage rules into the coded structures of the claim system. This translation is complex, subjective and multi-step. With medical payments in the billions of dollars, even small translation mistakes in member coverage rules can lead to massive payment errors.

Networks

Benefits

Groupers

Variation Rules


Product Tree

Variation Rules

Policy Terms



Policy

Policy Configuration


Variation Rules

Policy Terms

Policy view

Policies can be configured independently from PCS Templates and Products. In this case, the Policy Term / Variation configuration is inherited by the Template .

The user can also directly configure Policy for each Template / Product or override the inherited information from the Policy

Inherited by PCS Template

Policy attached to Benefit


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Limitations, Coverage and Authorization Requirement Rules Medical policy defines the specifics of when a Benefit is covered / not covered, usage limitations and authorization requirements. Often these specifics are text not rules. PCS provides the capability of configuring these limitations with user friendly business rule forms. Once configured, PCS can generate consistent text descriptions as well as accurate, code based instructions to the back end claim system.

A single configuration provides accurate and consistent information to customer service, web users and downstream systems.

Member Medical Policy descriptions PCS provides options for capturing coverage and medical guidelines. The first option is to enter the text directly into PCS member policy screens. The benefit of this option is the capability to generate the Policy documents directly from PCS. (Document generation requires customization during implementation.)

A second option is to attach the pre-defined medical policy Word or PDF guideline documents into PCS. With this option the guidelines can be associated with the appropriate Products and Benefits, connecting the Policy text to the configured Benefit rules in PCS. Connecting policy guidelines to coverage and limit rules provides custom service, web users and downstream systems with a single source of Product, Policy, Benefit and Claim information.

Policy and Policy Terms are connected to a Benefit Policies are comprised of Policy Terms. For example a Mental Health policy may be linked to the Mental Health Benefit in a Product. However, more specific sub-benefits called Policy Terms can be configured for detox, alcohol rehab, etc. See example at right listing the 4 Policy Terms associated to the single Mental Health Benefit.

Policy Terms allow for configuration of specific coverage rules or authorization requirements without requiring additional Benefits added to the Product Tree.

Inheriting policy information to Products Medical policy is often created prior to configuring Product Templates and Products in PCS. Policies also change during the Product creation process. To ensure medical policy is accurately configured and maintained, PCS provides the capability for Products to inherit policy information. When creating a Product Template, PCS looks for Policies associated with Benefits. If found, the coverage, limits, authorization requirements and guidelines are linked in the Product Template to the Policy. The information is not copied, it is linked – Policy Terms identify a Benefit; when that Benefit is included in the Product Template tree, the Benefit’s Policy is inherited. Linking allows revisions to Policy to automatically update to the Product Templates and Products.


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When to use Policy / Policy terms? There are two methods for configuring coverage rules and guidelines within PCS:

Inheriting member policy information from Policy / Policy Term. Configuring member policy information on Template / Product.

Creating Policy / Policy Terms The first option for configuring member policy is to create Policy and Policy terms first, outside of the Template creation process. In PCS, the Policy is directly connected to a Benefit. Within the Policy are Policy Terms which are sub-benefits. For example, Colonoscopy may be a Benefit while screening, diagnostic and surveillance colonoscopy would be sub-benefits or Policy Terms. Policy Terms are configured with additional rules for defining each term using claim codes within the Colonoscopy policy.

This method begins by creating the Policy Terms and specific mapping rules. These Terms are then linked to a Policy in the Policy creation process. The Policy is connected to a single Benefit.

The Policy configuration process allows the user to configure coverage, exclusions, limits (dollar, unit and visit), authorization requirements and medical policy notes.

When a Product Template is created, the Benefit, if connected to a Policy, will inherit the Policy Terms and corresponding coverage, limits, authorization and guideline information. This information can then be manually overridden if necessary.

Pros – This method is best used when the member medical policy for a specific Benefit is very common across all Products. For example, if the Wigs benefit is consistent across all products, it will be helpful to configure Wigs once as a Policy and push the configuration to all Templates. This reduces configuration time and improves consistency.

Cons – If coverage, limits etc. for Benefits do vary for most Products it is an extra step to configure Policy and will not result in substantial reuse.

Configure Policy directly on Templates and Products This option begins in the Product Template creation process. Policy and Terms are not created in advance. This is accomplished by selecting the policy view from the product tree and creating a policy term “on the fly” by selecting the “create policy term” link. Once selected, the user can directly configure coverage, limits, etc. within the Template. Most clients will elect this method because Benefits do have different coverage, limits and authorization requirements across Products. The configuration of the Product Template will be copied to each subsequent Product.

Pros – Typically only 15% of Benefits require specific configuration of coverage, limits or authorization rules (typically authorization / referral rules are set at the Network

Networks

Benefits

Groupers


Product Tree – Policy View

Variation Rules

Policy Terms

Policy view


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level). Of those Benefits, it is common for the configuration to vary across Templates / Products. In this case, it is an unnecessary step to create Policy Terms outside of the Template.

Cons – There will be no ability to reuse Benefit configuration across Templates

Directly Configuring Policy Information on Product Templates PCS provides the capability to support the following:

Policy Terms are linked to Benefits within the Product Tree. Associated with a policy term are the following sections:

Policies – Configuration of coverage, exclusions, etc. Maximum Reached – If a limit is reached, instructions for the next step for coverage

or limits. Claim Instructions – Ability to assign pend codes to downstream claim systems. Client Configuration – A section for clients to add attributes and rules Tags – Ability to assign search tags to each Policy Term. Useful to assist customer

service in filtering and searching for Policy Terms. Within the Policies flow the following sections are provided to configure the rules, parameters and instructions for each Policy term:

Coverage – Specific rules specifying when the Policy Term is covered Exclusions – Specific rules specifying when the Policy Term is not covered or excluded. Limits – Configuration of specific dollar, visit and unit limits. Authorization – When are authorizations and referrals required and what are the

coverage rules if found or not found Medical Policy – Text sections to allow the user to configure the policy paragraphs for

use by customer service and inquiries. Related Services – For a Policy Term what other services should also be covered. For

example, lab is included with a surgical procedure. (Not available in PCS 2.3 SP2)


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Policy variation rules PCS also provides the capability for multiple variation rules for a Policy Term. See illustration below. Variation rules for policy terms are similar to variations for Product cost shares. The illustration below shows the configuration screen for configuring limits.

1. Variation rules are ranked to instruct the claim system which rule should take precedence. These rules are also date sensitive.

2. Limit Results – Policy terms can be configured to limit dollars, visits or units. For example, “one colonoscopy screening per year for male patients over 50”. There are multiple limit types.

3. Limit Conditions – These are the rules specifying when to apply the limit results. For example, screening colonoscopy is limited to one per year only when inpatient.

4. Client Configuration – A section for clients to add their custom attributes and rules.

5. Coverage Description – A generated description based on the configuration. A consistent description used for customer service and inquiries.

6. Coverage Guidelines – Ability to manually enter the specific guidelines for this policy term.


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Searching for Policy Terms This use case describes the ability to search for the major objects in PCS such as the Policy, Policy Terms, Benefit, Benefit Set, Product and the Product Template.

The left navigation panel contains links to the major objects in PCS. To view a list of all Policy Terms, click on the Policy Term link. The following screen will display:

Steps 1. Click on the Policy Term link in the left navigation panel

2. A screen will display with a list of all Policy Terms. See example above:

3. The columns displayed include:

• Custom Name • Availability of the Policy Term • Effective date • End date • Variation rule instance • Category (medical, dental, vision, Rx) • Created by • Last modified by • Last modified date For each of these columns, PCS provides the ability to filter and select using partial matches. For example to select all Policy Terms with “healthy” in the title the user can enter “health” as the filter. PCS will select all Policy Terms with the letters “health” in the name field.

This capability is the same for all items displayed on the left navigation panel.


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Creating Policy Terms A Policy Term is paragraph in the Policy description. A Policy connects to a Benefit in PCS so a Policy Term becomes a sub-benefit containing policy configuration.

Steps

1. There are two options for creating Policy Terms. When logged in as a Policy Specialist, from the Get Started section of the portal, click Create Policy Term. The second option is to click on the Policy Terms link on the left navigation panel to display the list of available Policy Terms. If the user permissions allow, a Create Policy Term button will appear at the right side of the screen. Either option starts the Policy Term creation process.

2. Upon selection, a window displays in the workspace with the Create New Policy Term process. The process starts with the Enter Metadata tab.

3. On the Enter Metadata tab, the user can create a new Policy Term or to choose to copy it from an existing one.

4. Benefit – A Policy Term is directly connected to a Benefit. Select this field and press the down arrow to display a filtered list of Benefits. Once assigned, the Policy Term will be linked to a specific Benefit. This linking is the key to the inheritance from Policy to Products.


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5. The Draft indicator allows the user to work on a Policy Term, save it temporarily then return to resume configuration. See the Draft Mode Use Case chapter.

6. When complete click Next>> to display the Define Mapping tab.

7. On the Define Mapping tab, select the appropriate code groups from the available code group categories. Each of these categories maps to the standard codes submitted on a Healthcare claim form. Each code group contains a single code or a range. These selected codes define how the policy term maps to the claim on an incoming claim. The code groups and supporting sets of codes are described in detail in the Healthcare Common Code Solution Business Use Case Guide.

8. The user selects code groups to configure the logic for determining the most appropriate Policy Term for a given claim line. If several groups are specified, the determination logic was as follows:

• If Service Group - Service Group A OR - Service Group B

• AND - Provider Specialty A OR - Provider Specialty B OR - Provider Specialty C

9. The Override selection instructs the determination logic to “override” the Policy Term selected on other lines of the claim and override those lines with this Benefit. For example, a claim may include a line for Lab and Surgical Tray. The determination logic may assign those claim lines Benefits based solely on the information on the


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line. However, if the next line of the claim is a surgical service, the most appropriate Benefit for the first two lines should be Surgery. The override indicator would instruct the logic to change the original Benefits on those lines to Surgery.

10. After selecting the code groups that define the policy term and the override code groups, selecting the Generate Description button automatically creates the language that describes the policy term in English terms. This auto-generated description is available to be used in the Summary Plan Description document or any other external system looking for a description of the policy term.

11. After selecting the desired code groups, click Next>> button to display the Enter Notes tab.

12. On the Notes tab, enter text that describes the policy term for the external consumers of PCS:

• Summary Plan Description document • Member Services • Provider Services • Web Services • SBC Policy term Description

13. After completing the tab, click Next>> to display the Review term tab.

On the Review term tab, review the Policy term definition and can click <<Back to go back to previous screens and make changes or click Finish to display a confirmation message.


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Create Policies

Overview of Policy PCS has a new Policy process to allow for configuration of coverage, exclusions, limits, authorization requirements and medical policy information.

Policies are linked to Benefits within the Product Tree. When necessary to define coverage more granularly, “sub-policies” called policy terms can be associated to a specific Benefit.

Policy Terms are linked to Benefits within the Product Tree. Associated with a policy term are sections as follows:

Policies – Configuration of coverage, exclusions, etc. Maximum Reached – If a limit is reached, instructions for the next step for coverage

or limits. Claim Instructions – Ability to assign pend codes to downstream claim systems. Client Configuration – A section for clients to add attributes and rules Tags – Ability to assign search tags to each Policy Term. Useful to assist customer

service in finding Policy Terms. Within the Policies flow the following sections are provided to configure the rules, parameters and instructions for each Policy term:

Coverage – Specific rules specifying when the Term is covered Exclusions – Specific rules specifying when the Term is not covered or excluded. Limits – Configuration of specific dollar, visit and unit limits. Authorization – When are authorizations and referrals required and what are the





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Steps

1. There are two options for creating Policies. When logged in as a Policy Specialist, from the Get Started section of the portal, click Create Policy. The second option is to click on the Policies link on the left navigation panel to display the list of available Policies. If the user permissions allow, a Create Policy button will appear at the right side of the screen. Either option starts the Policy creation process.

2. Upon selection, a window displays in the workspace with the Create New Policy process. The process starts with the Enter Metadata tab.

3. On the Enter Metadata tab, the user can create a new Policy or choose to copy it from an existing one.

4. Benefit – A Policy is directly connected to a Benefit. Select this field and press the down arrow to display a filtered list of Benefits. Once assigned, the Policy to Benefit link is the key to the inheritance from Policy to Products.

5. The Draft indicator allows the user to work on a Policy, save it temporarily then return to resume configuration. See the Draft Mode Use Case chapter.

6. When complete click Next>> to display the Policy Terms screen. Configuration is necessary for every Policy Term associated with the Policy.


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7. The policy term is now ready to configure. Select the Add Rule button to display the following screen:

8. Coverage Results - Enter a description, effective and end dates.

9. Select Coverage Conditions. On the coverage tab, these are specific rules governing when the Benefit is covered. Multiple conditions can be selected from the following list:

• Place of Service • Service Group – Services configured into groups

using the Code Manager framework. Services sets include CPT, Revenue, ICD-9, ICD-10, and HCPCS.

• Age Band – multiple age bands. For example a Benefit may only be covered for people over 18 years old

• Gender – Benefit only covered for males • Service By – Benefit only covered when the

patient sees their PCP or ACO • Authorized – Benefit is only covered when

Authorization is available • Provider Ranking – Health Plans can rank

Providers and use the rank to specify coverage. For example, a Benefit may only be covered when admitted to a “Gold” hospital

• Jurisdiction – Benefit may only be covered in specific States

• Referral – Benefit is only covered when referred by PCP


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• Bill Type – Benefit only covered for specific Bill types.

10. Select Generate Description to produce a text description of the rule.

11. Select Save

12. From the menu select Exclusions.

13. Exclusions – Configuration of exclusions is the same as coverage. Exclusion rules specify when a Benefit is not covered or excluded.

14. After creating the limit rule, select Save

15. From the menu select Limits.

16. Limits – Limits include visit, unit and dollar limits or coverage maximums.

17. Each limit type may require additional parameters. For example Visit with Age Ranges will display age range fields. The types of limits available in PCS include:

• Dollar limit – Coverage up to $ 300 based on allowed amount

• Visit limit – 10 counseling sessions

• Unit limit – 1 Wig • Dollar amount with age ranges • Visit with age ranges • Unit with age ranges • Floating period limits – 5 PT

visits every 3 months for one year

• Limits after event – 2 office visits 14 days after surgery

18. Limits can be compared using the Compare radio button. This feature allows for configuration of 2 limits and a comparison action. For example Wigs are covered 1 per year or a maximum of $300 per benefit year.

19. Calculation methods provide additional information about how the limit is to be calculated. For example, a dollar limit may be based on the allowed amount or the final paid amount.


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20. Generate Description – This button generates an English description of the configured rule. Typically clients will customize these descriptions. Once implemented these descriptions provide consistent and accurate information to customer service, web users and benefit loaders.

21. From the menu select Authorizations. This tab provides the configuration of when authorizations / referrals are required. The same condition rules can be configured to create rules.

22. After creating Authorization / Referral rules Generate Description and save.

23. From the menu select Medical Policy notes. Medical policy notes are date sensitive. To associate a Policy Word or PDF document with a Policy Term, browse the network to locate the Policy and upload it.

24. Save Medical Policy notes.

25. Related Services. Related Services are not available on PCS.


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26. When complete select Review and Complete.

27. Select Summary View to return to the Product Tree.

Inheriting Policy Configuration If a Policy is created with Policy Terms that specify a particular Benefit and Product Line; and, that Benefit is included in the Product Template also configured for that Product Line, the Policy Term information will be inherited automatically.

1. Select Product view, Configure and a specific Benefit

2. If a Policy with Policy Terms associated with the Benefit is active, the following policy information will display automatically. If the configuration is sufficient, no additional steps are required.

3. If the policy configuration is different for this Policy Term Template and Benefit, select Edit to “override” the medical policy. Once overridden, the inheritance of future changes in policy is stopped, the Override value takes precedence.

4. In the Product view of the Template shown above, note where policy information is inherited from the higher level medical policy and where the user has overridden the configuration.

5. A dash in the column indicates that there is no pre-defined, or policy override - the user has not manually configured policy for the Benefit.


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Chapter 5: Product Template Configuration This chapter describes the PCS business processes for creating Product Templates in PCS. Use cases included are:

Creating Benefits Creating Groupers Creating Benefit Sets Creating Product Templates Configuring Product Tree Configuring Cost Share Variations on Product Templates Master Variation List – Product view (cost shares) Policy View on Product Tree Configuring Policy information on Product Templates Inheriting Policy ConfigurationMaster Variation List – Policy view (coverage tabs)

Product Templates contain definitions for various aspects of an Insurance product and serve as the base rules and guardrails 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, Eligibility Rules, Cost Share range values, Guardrail rules, and general questions and answers 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 / Grouper / Benefit.

Stand-alone mode compared to using Benefit Sets A very important decision affecting the implementation of PCS is whether to use Benefit Sets or to select the stand-alone mode of operation.

Plans







Product Templates










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Stand-alone mode is best when PCS is used primarily to design and publish Products. Stand-alone has the following features:

Benefits can be added at any time in the Template, Product or Contract processes. Stand-alone mode does NOT require Benefit Sets. Benefit mapping is not utilized.

Pros:

• Best used by clients that want freedom to change the list of benefits used by Products and Plans.

• If PCS is NOT used as an enterprise repository of product, policy and claim information, stand-alone mode provides the highest degree of flexibility.

Cons:

• When the list of benefits varies from Product to Product, the interpretation and meaning of benefits change. This causes confusion for downstream systems, customer service and inquiries.

Mixed mode is best used when PCS is to be used to create an enterprise repository of product, policy and claim information. Mixed mode provides the flexibility for optionally using Benefit Mapping.

Mixed mode requires using Benefit Sets. When configuring Benefit Sets, PCS has added several features to allow more flexibility in benefits for each Product / Plan:

Benefits in a Benefit Set can be configured as required or optional. Optional benefits allow groups to select these benefits during the sales cycle if they wish. If an optional benefit is purchased, the user will change the setting of the benefit from “not covered” to “covered”.

Benefit mapping can be set to optional or required in mixed mode. If optional, the user will see the screens in the process but are not required to configure mapping.

Pros:

• Best used by clients that ultimately wants an enterprise repository of product, policy and claim data.

Cons:

• Important to finalize Benefit Sets as much as possible before building Templates and Products.

Claim centric mode is the same as mixed mode except full Benefit mapping is required.

Pros:

• Benefit mapping is configured in Product Composer. Claim information is captured for populating downstream claim systems

Cons:

• Benefit mapping is complex. Claim centric mode requires mapping to be completed before Templates are created.


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Important to finalize Benefit Sets as much as possible before building Templates and Products although PCS 2.3 SP2 offers much more flexibility in correcting mistakes and automatically updating dependent components when changes occur.

Benefit Mapping is not used for Stand Alone and is required for Claim Centric. The user has an option when using Mixed Mode to select “optional” or “not used”. If optional is selected, the Benefit Mapping screens will appear; but the mapping configuration is optional. Errors will not occur if Benefit Mapping data is not entered. If “not used” the benefit mapping screens will not appear in the process.

Benefit Sets are not used for Stand Alone mode. Benefits Sets are required for Mixed and Claim Centric modes. PCS 2.3 SP2 now allows adding or removing a Benefit or Grouper to a Benefit Set - the prelude to Mass Update. Further, enhancements were made to the Product Template creation process so that re-generating the Product Tree optionally preserves existing configuration data – on the Build Structure screen “Update Only” accomplishes this. See Product Template use cases for further information.

Draft Mode enables the user to configure Benefits, Benefit Sets, Product Templates and Products in “draft” mode. Draft mode allows the user to change any of these objects after draft approval. For example, although Products are created from a Product Template, draft mode enables the user to change the original Product Template.

Searching for Benefits, Benefit Sets and Product Templates This use case describes the user’s ability to search for the major objects in PCS such as the benefit, Benefit Set, product and the Product Template.

The left navigation panel contains links to the major objects in PCS. To view a list of all Product Templates, click on the “Product Template” link. The following screen will display listing all Product Templates.

Steps 1. Click on the Product Template link in the left navigation panel

2. A screen will display with a list of all Product Templates. See example below:


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• Custom Name • Availability of the Product Template • Retired • Effective date • End date • Version • Category (medical, dental, vision, Rx) • Created by • Last modified On • Last modified By For each of these columns, PCS provides the ability to filter and select using partial matches. For example to select all Product Templates with “healthy” in the title the user can enter “health” as the filter. PCS will select all Product Templates with the letters “health” in the name field.


Creating Benefits This use case describes the user’s ability to create a new benefit and select the parameters that define the benefit.

A benefit defines a set of code groups that make up the benefit definition as well as general parameters that describe the benefit such as its name, effective date and end date. This definition includes the Code Group mapping data which will map to elements received on a claim. When a benefit is mapped to a specific network within a Product Template, additional data elements of the benefit such as cost share values to apply are defined. This functionality is described in the Product Template use case. The benefit is available to be used within a defined timeframe and can be retired. Retired Benefits are not removed, but cannot be selected for new development.

Steps

1. There are two options for creating Benefits. From the Get Started section of the portal, click Create Benefit. The second option is to click on the “Benefits” link on


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the left navigation panel to display the list of available Benefits. If the user permissions allow, a “Create Benefit” button will appear at the right side of the screen. Either option starts the Benefit creation process.

A tab opens in the workspace and the Create New Benefit processing screen displays. This screen starts the guided process to walk the user through the steps of creating the benefit. The process starts with the Enter Metadata tab.

On the Metadata tab, the user can create a new Benefit or to choose to create by copying from an existing Benefit.

Selecting an existing benefit pre-fills the screens with the data from the selected benefit and gives the user the ability to make changes. The list of Benefits displayed includes all Benefits that saved and have not yet been approved and locked.

Note: Required properties are marked with an asterisk. It is also required that the name of the Benefit be unique within the effective and end dates selected.

2. After entering the Metadata, click Next>> to display the Define Mapping tab.

3. On the Define Mapping tab, select the appropriate code groups from the defined code group categories available. Each of these categories maps to the categories of codes submitted on a Healthcare claim form. Each code group contains a single code or a set of codes defined as a range, these selected codes define how the benefit maps to the claim on an incoming claim. The code groups and supporting sets of codes are described in detail in the Healthcare Common Code Solution Business Use Case Guide.


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Note: When operating in Stand-Alone mode (Benefit Mapping Mode – Not Used), this tab is by-passed as the mapping to code groups is not necessary.

4. The user selects code groups to configure the logic for determining the most appropriate Benefit for a given claim line. If several groups are specified, the determination logic was as follows:

• If Service Group Service Group A OR Service Group B

• AND Provider Specialty A OR Provider Specialty B OR Provider Specialty C

5. The Override selection instructs the determination logic to “override” the Benefit selected on other lines of the claim and override those lines with this Benefit. For example, a claim may include a line for Lab and Surgical Tray. The determination logic may assign those claim lines to Benefits based solely on the information on the line. However, if the next line of the claim is a surgical service, the most appropriate Benefit for the first two lines should be Surgery. The override indicator would instruct the logic to change the original Benefits on those lines to Surgery.


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6. After selecting the code groups that define the benefit and the override code groups, selecting the Generate Description button automatically creates the language that describes the benefit in English terms. This auto-generated description is available to be used in the Summary Plan Description document or any other external system looking for a description of the benefit.

Note: At least one code group must be selected to define the benefit and continue. The Override is optional and the benefit definition description will automatically be generated when the user selects Next, if not generated manually.

7. After selecting the desired code groups, click Next>> button to display the Enter Notes tab.

8. On the Notes tab, enter text that describes the benefit for the external consumers of PCS:

• Summary Plan Description document • Member Services • Provider Services • Web Services • SBC Benefit Description

9. After completing the tab, click Next>> to display the Review Benefit tab.

10. On the Review Benefit tab, review the Benefit definition and can click <<Back to go back to previous screens and make changes or click Finish to display a confirmation message.


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Note: At this point, PCS runs Approval flows for the Benefit. Upon successful approval (Approved Draft or Approved Final), PCS saves the benefit as a rule and sets the status of the benefit accordingly. Otherwise, Be where it is removed.


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Creating Groupers This use case describes how to create a Benefit Grouper. As the name implies, a Grouper contains multiple Benefits. The purpose of Groupers is to provide the following capabilities:

• Organization of Benefits in a common medical area. For example, all Dental Benefits may be organized under a Dental Grouper

• Across Benefit Accumulators – Mental Health group counseling and inpatient Psychiatrist visits are two separate Benefits but they may have a limit of 20 overall visits that are a combination of the two.

Steps

1. There are two options for creating Groupers. From the Get Started section of the portal, click Create Groupers. The second option is to click on the “Groupers” link on the left navigation panel to display the list of available Benefits. If the user permissions allow, a “Create Groupers” button will appear at the right side of the screen. Either option starts the Benefit creation process.

2. The first screen in the process is the Grouper metadata screen. Enter the name of the Grouper, the category (Medical, Dental, Pharmacy, Vision), effective dates and if the Grouper is to be created new or copied from an existing Grouper.

3. Click next to advance to the Benefit selection screen. On this screen, the user selects the Benefits to be associated with the Grouper. Entering a partial name in the selection field and pressing the down arrow will list the available Benefits. PCS requires that a Benefit object is selected from the list requiring the user to double click on an entry, or highlight it and select with Return.

4. The required flag indicates if a Benefit in the Grouper is to be sold as a required part of the Product. If a group or individual wants to purchase a “non-required” Benefit

the sales system should present them as optional or “riders”. For example, if Dental benefits are optional, these benefits should be indicated as not required or

unchecked in the Benefit selection process


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5. To avoid ambiguity, The Grouper is not configured as required or optional. If all of the Benefits contained in the Grouper are marked as non-required, the sales system should indicate the entire Grouper structure as an optional rider.

6. The info icon next to the required column allows reviewing the Benefit’s Mapping and Note rules.

7. To change the order of the Benefits in a Grouper, position the cursor over the number at the front of the row. The four corned icon appears and allows the user to move the selected Benefit up or down in the order.

8. When the list of Benefits is completed, the user then selects Next to proceed to the approval processes.

9. Approval processes should be configured during implementation to align to the requirements of each client.

Creating Benefit Sets This use case describes how to create a new Benefit Set, select the Groupers and Benefits that are to be included in the Benefit Set and specify how claims should determine the most appropriate benefit.

The purpose of the Benefit Set is to define a list of benefits that collectively map to the potential claims submitted to the Health Plan.

Benefit Sets may be created anew, or can be created by copying from an existing Benefit Set. This paradigm is implemented for all larger-scale PCS components except Plans.

The function is accessible from a link on the Get Started section of the user portal. This function allows for the following:

• Enter Benefit Set metadata • Select the benefits that make up the Benefit Set • Test the Benefit Set against sample claim data and submission • Obtain approval of the product manager

Note: When operating in Stand-Alone mode (Benefit Set Mode – Not Used), this use case is not available and the link to Create Benefit Sets on the portal is removed.

Steps

1. There are two options for creating Benefit Sets. From the Get Started section of the portal, click Create Benefit Set. The second option is to click on the Benefit Set link on the left navigation panel to display the explorer list of available Benefits. If the user permissions allow, a Create Benefit Set button will appear at the right side of the screen. Either option starts the Benefit Set creation process.


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2. The create Benefit Set process begins with the enter metadata screen as shown below:

On the metadata tab, the user can create a new Benefit Set or to choose to create by copying from an existing Benefit Set. Selecting Copy From an existing Benefit Set pre-fills the preceding screens with the data from the selected Benefit Set and gives the user the ability to make changes. The list of Benefit Sets displayed includes all saved Benefit Sets of the specified Category that are not Retired.

After entering the Metadata, click Next>> to display the Select Groupers and Benefits tab.


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3. Select the category of Benefits to be selected. Medical, Dental, Pharmacy and Vision Benefits are then displayed when pressing the down arrow in the Benefit entry box. The user can also enter partial information such as “Emergency” to reveal all Benefits with the word “emergency” in the name.

4. After selecting the benefits, click Add -> to add the Benefit to the Benefit Set display area.

5. The “Add Grouper” panel provides the capability to add Groupers and all of the associated Benefits to the Benefit Set. To select a Grouper, choose the category of first; the list of available Groupers will be filtered by the category.

6. Enter the full or partial name of the Grouper then press the down arrow key. The system will present a list of the available Groupers matching the criteria.

7. Click on the Grouper in the list. The Grouper name will appear in the box.

8. Click the Add -> link to add the Grouper and all associated Benefits to the Benefit Set.

9. When complete, press the Next to move to the test and submit screen.

10. On the Test and Submit tab, the user can perform two tests. The user can test for conflicts between benefits in the set or run a single claim test.

Testing for conflicts In the Detect Conflicts section, click Detect Conflicts to see if conflicts exist in the benefit determination rules configured for all Benefits in the set. Conflicts exist when one of the benefits has the same definition of another benefit. Click Clear Results to clear the test results. The purpose of clearing the conflicts is that a claim should never map to more than a single benefit and conflicts prohibit this process.


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Testing Single Claims

In the Single Claim Test section, the user can enter professional claim parameters and test the mapping to the benefits.

The user can enter all of the claim parameters available on the display. The Provider Specialty, Place of Service, Service Codes and Diagnosis Codes are all potential codes that would come in on a professional claim. After entering the desired codes, click Test to run a test and display the results. The claim test relies on the ranking of the benefits to find a single match if a set of codes matches to multiple benefits. This logic is explained in greater detail in the Product Composer System Implementation Guide.

On the Test and Submit tab, to review the test results and can click <<Back to go back to previous screens and make changes.

11. Click Finish to display a confirmation message and submit the Benefit Set for product manager approval.

Note: Logging in as the Product Manager provides the ability to approve the Benefit Set, described in the General Approval Process use case.


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Creating Product Templates Product Templates define the Network structure, list of Benefits, cost share ranges, sales guardrails, default medical policy rules, notes and descriptions used to create Products and Plans. A Product Template is typically created to support all the Products in a line of business and jurisdiction. For example, a Product Template would be created to be the base for creating PPO products for a specific State.

Cost share ranges and associated pricing form the guardrails for Product creation and sales. For example, the Product Template may define the allowed copayment cost shares to be between $5 and $100 in increments of $5. A Product built using this template would allow the user to select a specific copayment cost share within this defined range. If the Product configuration requires a cost share out of these guardrails, PCS provides an exception approval process called Policy Override.

The Product Template process provides for the following configuration:

• Create a new Product Template or a copy of an approved one • Enter Product Template metadata • Select the Networks and Benefit Set used to build the structure of the template • Select coverage levels and pricing parameters • Set cost share ranges • Define network and cost share guardrail rules for associated Products and Plans • Define claim processing parameters through a series of questions • Configure cost share and coverage definitions for specific benefits within selected

networks • Configure coverage, exclusions, limits, authorization/referral requirements and

medical policy notes • Process approvals through Underwriting, Legal and Product Management


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Steps

1. There are two options for creating Product Templates. From the Get Started section of the portal, click Create Product Template. The second option is to click on the Product Templates link on the left navigation panel to display the list of available Product Templates. If the user permissions allow, a Create Product Template button will appear at the right side of the screen. Either option starts the Product Template creation process.

2. Upon selection, a window displays in the workspace with the Create New Product Template process. The process starts with the Enter Metadata tab.

3. On the Enter Metadata tab, the user can create a new Product Template or choose to copy it from an existing template. Selecting an existing template pre-fills the preceding screen with the data from the selected template and provides the ability to make changes.

4. The Benefit Set category is used to define the Product Template and all associated Products as Medical, Dental, Vision or Pharmacy products.

5. Copy From this Product Template provides the capability of copying a previously defined and approved Product Template. This capability substantially accelerates


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the creation of new Product Templates and ensures consistency across templates and Products.

6. The Draft indicator allows the user to work on a Product Template, save it temporarily then return to resume configuration. See the Draft Mode Use Case chapter.

7. On the lower section of the metadata screen are the attributes available to assign to this Product Template. Attributes are organized into the following categories:

• Main: These properties categorize the business terms of this Product Template. The Product Line attribute is very important to connect the PCS Policies to the corresponding Benefits in the Product Template.

• The Product Features section provides attributes for defining the type of Product, specific coverage areas and indicators. In this section, all fields default to blank or no. For example a blank by the HDHP indicator specifies this Product Template is not a high deductible plan.

• CDH Properties specify the Consumer Directed Health attributes

• SBC Properties specify the Summary of Benefit Coverage parameters necessary for printing the SBC for Products and sold Plans.

• Exchange Properties provide the attributes necessary for selling products on the public and private exchanges

• ID Properties provide for the configuration of the copay amounts to be printed on ID cards for this Product Template and associated Products.

• All attributes with the star indicator are required fields. The fields with the radio box are defaulted to blank or no.

8. After entering the Metadata and attributes, click Next>> to display the Build Structure screen. This screen has three sections: Select networks, Select Benefit Set and Generate Product Tree.


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9. Create Networks –Networks must first be created using the Networks link on the left navigation panel.

10. Select Networks – this section provides the capability of selecting the Networks to support the Product Template. All available Networks will appear. To select the Networks to support this Product Template, the user clicks on the box to the left of the Network icon and name.

11. Changing the order of Networks – Position the cursor over the small circle at the left of Network. The four pointed star icon will appear providing the user the ability to drag the Network up or down in the list. When generating the product tree the order of Networks will appear as they do in this list.

12. Carve-out? – If a Network such as “New England Mental Health Network” is contracted to support only a few Benefits, it should be marked as a carve-out Network. When generating the product tree, carve-out Networks will not automatically be configured with the entire list of Benefits and Groupers. The user must manually assign the appropriate Benefits / Groupers to carve-out Networks.

13. Select Benefit Set – The user selects the Benefit Set that becomes the foundation for the Product Template. The Benefit Set contains the list of Groupers and Benefits that will be generated to each full Network.

14. Click Build Structure to build the template structure. This action places all of the benefits from the selected Benefit Set into each of the selected full Networks. If the Network is flagged as a Carve Out network, the system does not automatically insert the benefits. The user must configure carve-out Networks manually.

15. Right-clicking a carve-out Network in the structure displays the Add Benefit action as shown at right.


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16. Selecting the Add Benefit link displays a window for selecting the appropriate Benefits for this carve-out Network. In PCS, only Benefits can be added to carve-out Networks.

17. For full Networks, PCS does not provide the capability for removing Benefits from the product tree. In mixed or claim centric mode, Benefits are not removed from the product tree they should be set to non-covered.

Note: At least one Network and a single Benefit Set must be selected to continue. If the user selects continue without building the structure, the system creates it automatically. If the Product Template contains only a Carve out Network, at least one Benefit needs to be added.

18. After completing the Build Structure tab, click Next>> to display the Pricing tab.

19. The Pricing tab provides for selection of Coverage Levels that will be supported by the template. Select from the available Eligibility Rules to configure when products are built using the template.

In addition, this tab provides for configuration of Pricing parameters that are used to support rating at the product and benefit level. They also support when and how the template may be offered in the market and to build products.

Note: At least one Coverage Level must be selected to continue. The required parameters in the

Pricing section are marked with an asterisk and must be completed before the user can continue.

After selecting the Cover and Pricing parameters, click Next>> to display the Cost Shares tab.


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20. On the Cost Shares tab, the user enters cost share ranges for each cost share type. The PCS solution ships with seven configured cost share types. After entering a cost share Range and Increment, the user can generate the calculated specific values for the cost share by clicking Calculate.

Once the values are calculated, the user can enter a Relativity Factor that will be applied to the base cost of a benefit to adjust the pricing by a selected cost share value as well as a code that represents how this cost share selection could map to a claim adjudication code if possible.

The Set Default column sets the specific default cost share value for Products created from this Template.

21. Set Values – This link is provided to expedite the configuration of a Product Template for training purposes. During the implementation of PCS, some clients may elect to customize this action to set default values prevalent to their business.

Note: All share ranges and increments must be selected for each cost share type to continue.


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22. When the cost share ranges are entered for the cost share types, click Next>> to display the Guardrails tab. Define the Network Rules for each selected network. When set, these authorization and PCP rules become the default rules for the products built using this Product Template.

Cost Shares/Network Rules are applied when Products are created using this template as well as when the Template is used to support a quote request. In this example, the rule to be applied is that the Copay for the In Network must be less than or equal to Copay for the Out of Network. When a product is built using the template, this rule will be enforced during the cost share selection process.

23. When PCP Requirements are entered for Networks and Guardrails are entered for the cost share types, click Next>> to display the Rules Survey tab.


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24. The Rules Survey tab, asks the typical questions a claim system would need in order to process claims. In PCS, there are six sample questions asked on two screens to serve as examples.

It is expected that this section of the solution will be extended based on the claim adjudication system or for systems the PCS supports the product definition. In this example, the system asks additional second level questions based on a positive response to an initial question. The solution is using Pega Survey to display these questions. See the Pega Survey documentation to extend the questions.

25. The Out-of-Pocket maximum definition tab allows for configuration of dollar, visit and


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unit accumulations. It is expected that this section of the solution will be extended based on the claim adjudication system or for systems the PCS supports the product definition.

26. When the survey questions are answered, click Next>> to display the Configure Tree tab.

Configuring the Product Tree The create Product Template process provided configuration of the Product Template at the highest product level. On the Configure Tree screen, the user configures the cost shares, coverage, limits, authorization requirements, etc for the Network, Grouper and Benefit levels.

Maximize inheritance to accelerate configuration and increase consistency PCS provides the ability for Benefits to inherit values from levels higher in the Product Tree. For example if 90% of all Benefits in the Product Template have a $10 to $50 copay range, the user need only to configure the highest product level and allow all Benefits to inherit this copay range. Then the user configures the 10% of Benefits remaining with a different copay range.

When setting parameters such as Cost shares, PCS provides the capability of setting copay at a Network level. If all the Benefits in the Network share the same level of copay, this attribute need only be set on the Network level. All of the Benefits

On the Configure Tree tab, the top level node in the tree is the Product Template created through entry of data on the previous tabs. The tree displays the cost share ranges set for each of the cost share types display as columns.

Each node in the tree inherits or re-uses the cost share ranges set by either the template or the node above it if that node is modified. This reusability feature is important to supporting the ability to review and only make the changes necessary to complete the template. Each


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network, grouper and benefit displayed in the tree can be edited from this tab by right clicking the node in the tree.

Navigating the Product Tree The summary view of the Product Tree has two major views, Product and Policy view.

Product View – Displays the cost share configurations for the Product, Network, Grouper and Benefit levels. This view shows the inheritance icons described above.

Policy View – This view displays the coverage, exclusion, limit and authorization / referral requirement rules for the Benefit. It also provides tabs for medical policy guidelines and custom client configurations.

The summary view provides the user the ability to expand and collapse the tree by Network and Grouper. After the name column the next three columns provide critical information about the status of the configuration and about the Benefits:

Reviewed - For each row of the tree, the Reviewed column will display a green check mark for those rows that have been configured, reviewed and completed.

Required – When “yes” the Benefit is a required part of the Product coverage. When blank or “no”, the Benefit is optional or a rider. In the example below, the Dental benefits are optional benefits and must be selected separately during the sales process.

Covered – If “yes”, the Benefit is covered for that Network in the Product. If “no”, the Benefit is not covered.


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Configuring the Product Tree

1. The summary view does not allow editing of the Product Tree. To edit the elements of the Product Tree, select the Configure link. The configure tree screen will display.

2. Select a row in the product tree. When the configure tree view initially displays it will position to the Product level of the Tree. On this view the Product level is not configurable and a message will display requesting the user to position the cursor to a row in the tree.

Configuring a Network from the Tree

1. Click on a row in the Product Tree. If the row is a Network level, the following screen will appear.

2. The initial values displayed on the Network are the inherited values from the Product.

If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. If the values on the Network require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.


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4. After editing the Network row, all nodes under this Network will inherit or re-use the cost share ranges for the network unless specifically modified.

5. If all or most of the Benefits associated with this Network are not covered, select the Set all Benefits as Non-Covered link. This link will set the non-covered flag to “no” for all of the Benefits in the Network. For example, for Out of Network, if the only Benefit covered is Emergency Room, setting this flag will mark all Benefits in the Out-of-Network to be non-covered. The user then edits the Emergency Room Benefit to be “covered” to complete the configuration.

6. When complete and reviewed, move to the next row for configuration. If complete with all configurations or to see the summary view, select Summary View link to return to the product tree summary view.

Configuring Groupers from the Tree

1. Click on a Grouper row in the Product Tree.

2. The initial values displayed on the Grouper are the inherited values from either the Network or the Product. If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. If the values on the Grouper require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.

4. After editing the Grouper row, all nodes under this Grouper will inherit or re-use the cost share ranges unless specifically modified.


Configuring Benefits from the Tree

1. Click on a Benefit row in the Product Tree.

2. The initial values displayed on the Benefit are the inherited values from either the Grouper, Network or the Product. If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. A Benefit in the product tree has the following configuration tabs:

• Cost Shares – Each of these tabs provides the ability to configure a range of values for the amount, single maximum and family maximum.

Copay Deductible Coinsurance Out of Pocket


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Admission Copay – For example emergency room copay Maximums – Overall lifetime or annual maximums (note: these are

maximum accumulation values not dollar limits. Dollar limits are configured on the Policy view.

Carryover – Rules for carryover to next benefit year • Mapping – A view only display of the Benefit mapping rules • Notes – Ability to configure notes specific to the Benefit in the Network • Metadata – Additional attributes on the Benefit

4. If the values on the Benefit require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.


Configuring Cost Share Variations on Product Templates Product Templates are designed to contain cost share ranges not specific values. During Product creation, specific cost share values are selected from the range of values defined within the Product Template.


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For a myriad of reasons, cost share and policy values change - due to context, circumstances, member attributes like age, gender, etc. and more. For example, copayments may be suspended if the member has an office visit while pregnant. To address this need, Variations are defined to specify how cost share and policy values change under various conditions. Cost Share and Policy Variations are defined for Product Templates, Products and Plans at the Network (Product only), Grouper and Benefit levels.

Additionally, Product Template Benefits support a specialized form of variations called - Master List Variations. Master List Variations let the user create a list of variations and apply them to all cost share types selected. Master List Variations also enable the cost share quick entry screen for Product configuration.

Master List Variation – Product Template Cost Shares The Master List Variation feature provides the ability to configure consistent variation rules for applicable cost share and policy types.

Benefit variations for both cost shares (product view) and member coverage (policy view) are used to configure Benefits in PCS when conditions pertain. The Master List Variation feature provides the ability to create a consistent set of variations across all cost shares and coverage tabs.

Master List Variations are configured on the Product Template and automatically consumed by the Products and Plans created from that Product Template.

1. From the Product Template, Configure Product Tree screen…

2. Select Product View, then select Configure.

3. Select a benefit row.

4. Select the Variations tab.

5. Select Edit link.

6. Select the cost share types that will be configured with the master variation list.

7. Select Add Condition.


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8. Configure the condition type, dates and name. Use the plus icon to define multiple condition types if needed; use the trash can icon to remove them. Select OK to add the variation.

9. Add as many Master List Variation rules as necessary.

10. Click Apply. The check marks as noted below will appear for every variation rule.


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All cost shares tabs will appear with the prepopulated list of master variation rules.

Product Template, Configure Product Tree, Policy View Overview of Policy PCS 2.3 SP2 has a new Policy process to configure coverage, exclusions, limits, authorization requirements and medical policy information. Policy information can be configured as Inherited, as an Override or not configured at all. Inherited Policy serves as a default for all associated Product Templates. Policy Overrides are used within the product tree to set specific policy for the Network, Grouper and Benefits containing the Policy Override.

Policies are linked to Benefits within the Product Tree to qualify coverage more specifically; “sub-policies” or policy terms can be created for a specific Benefit in the Product Tree. The Policy View of the Product Tree indicates that Policy is defined for each Benefit with “Override”. For example, the policy for a Colonoscopy Benefit might have several policy terms for: Preventative Screening, Diagnostic, PreOp or PostOp.

Associated with a policy term are sections as follows:

Policies – Configuration of coverage, exclusions, etc. Maximum Reached – If a limit is reached, instructions for the next step for coverage or

limits. Claim Instructions – A section that details Pend Instructions for an Event which may

occur for each of the Cost Share types. Client Configurations – A section for clients to add attributes and rules.

Figure 1: Master List Variations


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Tags – The ability to tag the Benefit’s Policy configuration.








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Policy & Policy Term Overview Member coverage policy is typically created and maintained in the medical department of a Health Plan. However, the member coverage, limits, guidelines and authorization requirements specified by the medical office must ultimately be configured into the claim processing system. Often it is a manual effort to translate the text based medical guidelines and coverage rules into the coded structures of the claim system. This translation is complex, subjective and multi-step. With medical payments in the billions of dollars, even small translation mistakes in member coverage rules can lead to massive payment errors.

Policy and Policy Terms are connected to a Benefit Policies are comprised of Policy Terms. For example a Mental Health policy may be linked to the Mental Health Benefit in a Product. However, more specific sub-policy called Policy Terms can be configured for detox, alcohol rehab, etc. See example at right listing the 4 Policy Terms associated to the single Mental Health Benefit.

Networks

Benefits

Groupers

Variation Rules


Product Tree

Variation Rules

Policy Terms



Policy

Policy Configuration


Variation Rules

Policy Terms

Policy view

Policies can be configured independently from PCS Templates and Products. In this case, the Policy Term / Variation configuration is inherited by the Template .

The user can also directly configure Policy for each Template / Product or override the inherited information from the Policy

Inherited by PCS Template

Policy attached to Benefit


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Policy Terms allow for configuration of specific coverage rules or authorization requirements without requiring additional Benefits added to the Product Tree.

Inheriting policy information to Products Medical policy is often created prior to configuring Product Templates and Products in PCS. Policies also change during the Product creation process. To ensure medical policy is accurately configured and maintained, PCS provides the capability for Products to inherit policy information. When creating a Product Template, PCS looks for Policy associated with a Benefit for the Product Lines included in the Product Template. If found, the coverage, limits, authorization requirements and guidelines are linked to the Benefit in the Product Template. The information is not copied, it is linked. Linking allows revisions to Policy to automatically update the Policy for all associated Benefits in Product Templates and Products.

When to use Policy / Policy terms? There are two methods for configuring coverage rules and guidelines within PCS:

Inheriting member policy information from Policy / Policy Term. Configuring member policy information on Template / Product directly.

Creating Policy / Policy Terms The first option for configuring member policy is to create Policy and Policy terms first, outside of the Template creation process. In PCS, the Policy is directly connected to a Benefit. Within the Policy are Policy Terms which define policy for a Benefit with specific claim codes. For example, Colonoscopy may be a Benefit while screening, diagnostic and surveillance colonoscopy would be defined as sub-benefits or Policy Terms. Policy Terms are configured with additional rules for defining each term using claim codes (ie: Mapping Definitions) within the Colonoscopy policy.

This method begins by creating the Policy Terms and specific mapping rules. These Terms are then linked to a Policy in the Policy creation process. The Policy is connected to a single Benefit.

The Policy configuration process allows the user to configure coverage, exclusions, limits (dollar, unit and visit), authorization requirements and medical policy notes.

When a Product Template is created, the Benefit, if connected to a Policy, will inherit the Policy Terms and corresponding coverage, limits, authorization and guideline information. This information can then be manually overridden if necessary.

Pros – This method is best used when the member medical policy for a specific Benefit is very common across all Products. For example, if the Wigs benefit is consistent

Networks

Benefits

Groupers


Product Tree – Policy View

Variation Rules

Policy Terms

Policy view


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across all products, it will be helpful to configure Wigs once as a Policy and push the configuration to all Templates. This reduces configuration time and improves consistency.

Cons – If coverage, limits etc. for Benefits do vary for most Products it is an extra step to configure Policy and will not result in substantial reuse.

Configure Policy directly on Templates and Products This option begins in the Product Template creation process. Policy and Terms are not created in advance. This is accomplished by selecting the policy view from the product tree and creating a policy term “on the fly” by selecting the “create policy term” link. Once selected, the user can directly configure coverage, limits, etc. within the Template. Most clients will elect this method because Benefits do have different coverage, limits and authorization requirements across Products. The configuration of the Product Template will be copied to each subsequent Product.

Pros – Typically only 15% of Benefits require specific configuration of coverage, limits or authorization rules (typically authorization / referral rules are set at the Network level). Of those Benefits, it is common for the configuration to vary across Templates / Products. In this case, it is an unnecessary step to create Policy Terms outside of the Template.

Cons – There will be no ability to reuse Benefit configuration across Templates


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Directly configuring policy information

1. From the Product tree summary view, select Configure

2. On the configure product tree screen, click on a Benefit row. See example below:

3. If the Policy Term was not created previously (see Chapter 4 Policy Term Configuration), the screen above will appear. The Create Policy Term is the indication that there is no active Policy Term for this Benefit. If the Policy Term was already created, the system will display the values of the Policy Term.

4. Select Create Policy Term to display the following screen. Select Edit


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5. The policy information is now ready to configure. Select the Add Rule button to display the following screen:

6. Coverage - Configure coverage rule 1. Enter a description, effective and end dates.










• Referral – Benefit is only covered when referred by PCP Figure 2: Variation Conditions


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8. When multiple Coverage Conditions are specified the rule process as Condition 1 AND Condition 2.




• Dollar limit – Coverage up to $300 based on allowed amount


• Unit limit – 1 Wig • Dollar amount with age

ranges • Visit with age ranges • Unit with age ranges • Floating period limits – 5 PT






15. After creating the limit rule, select Save.


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16. Continue to configure additional rules by selecting other tabs or adding additional rules on the same tab. There is no limitation to the number of rules. When complete select Review and Complete.

17. Select Summary View to return to the product tree.

Inheriting Policy Configuration Refer to Chapter 4: Policy Configuration If a Policy is created with Policy Terms that link to a Benefit in the Product Template, the information will be inherited automatically.

1. Select Product view, Configure and a specific Benefit

2. If a Policy with Policy Terms associated with the Benefit is active, the following policy information will display automatically. If the configuration is sufficient, no additional steps are required.

3. If the policy configuration is different for this Product Template and Benefit, select Edit to “override” the medical policy.

4. In the Product view of the Template shown above, note where policy information is inherited from the higher level medical policy and where the user has overridden the configuration.

5. A dash in the column indicates that there is not a pre-defined policy and the user has not manually configured the Benefit.


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Master Variation List – Policy view (coverage tabs)

1. From the product tree, policy view and select Configure. Select a benefit row.

2. To create a master variation list, select the Variations tab

3. Select Edit.

4. Select the coverage types that will be configured with the master variation list


6. Configure the condition types and dates. Multiple condition types can be selected for every rule.

7. Add as many rules as necessary.


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Use Case: Visit limit and usage level varies by Specialty Use Case:

Mental Health visits

• Maximum of 10 visits to a Psychiatrist per benefit year. In this case the visits have a usage rate of 4 to 1. Example, 1 visit to a Psychiatrist equals 4 visits to Group counseling sessions

• Maximum of 20 visits to a Psychologist per benefit year. In this case the visits have a usage rate of 4 to 1. Example, 1 visit to a Psychiatrist equals 2 visits to Group counseling sessions

• Maximum of 40 group counseling visits per benefit year.

Steps:

1. In Product Template select the Mental Health Benefit.

2. Configure Benefit.

3. Add Policy term on the fly by selecting Create Policy Term. Policy Terms can be predefined and inherited during the Product Template creation process. This use case will describe the configuration of a Policy Term directly on the Benefit.


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4. Select Edit.

5. Select Add a Rule. See screen example above. Configure a Visit Limit of 10 maximum visits per benefit year with a usage rate of 4 – Four for One.

6. Configure Limit Conditions to specify this rule applies only to Psychiatric visits.

7. Create a second limit specifying a Visit Limit of 20 visits per benefit year with a usage rate of 2 – Two for one.

8. In the second limit rule, specific the limit conditions for all specialties other than Psychiatrists that are covered when performing individual sessions.

Configure the third limit rule to specify the 40 group counseling sessions per benefit year.

9. The limit conditions for the group sessions can be configured using a code group for Group Sessions in the limit conditions section as noted below.


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10. The result will be three limit variation rules as noted below.


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Use Case: Benefit comparing dollar and usage limits Use Case:

Wigs

• Maximum of 1 wig per benefit year

• Maximum of $300 coverage per benefit year

• Take which ever limit is reached first

Steps:

1. Create Benefit for Wigs. It can be a broad misc Benefit covering many items including Wigs.

2. In Product Template process on the Product Tree view select Configure.

3. On the detail view select the Wig Benefit.

4. Select Edit.

5. Add Policy term on the fly by selecting create policy term. Policy Terms can be predefined and inherited during the Product Template creation process. This use case will describe the configuration of a Policy Term directly on the Benefit.

6. Add a Rule. See screen example below.

7. Select Compare.

8. For Limit 1 configure a Dollar limit. Set to $300 per Benefit Year and a Calculation Method of “Coverage based on Allowed”.

9. For Limit 2, configure a Unit limit. Set number of units to 1 unit (Wig) per Benefit Year.


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Chapter 6: Product Configuration This chapter describes the PCS business processes for creating Products in PCS. Use cases included are:

Searching for Products

Creating New Products

Adding Standalone Networks, Groupers and Benefits

Copying Configured Benefits into Product

Quick Entry Screens for Cost Shares (product view)

Configuring Cost Shares on the Product Tree

Configuring Cost Share Variations • Use Case: Copay varies by inpatient vs. outpatient • Use Case: Copay varies when seeing PCP vs. Specialist • Use Case: Authorization required – higher copay if not found • Use Case: Compare copay to coinsurance, select lowest member liability

Configuring Policy Rules on the Product Tree

Copying a Master Product

Quick Entry Screens for Coverage (policy view)

Benefit Tier Configuration Tab

Products are defined from Product Templates or can be copied from other Products. During Product creation, Cost Share selections and Policy selections are required for each Network, Grouper and Benefit in the product tree. The Product tree facilitates inheriting Product, Network and Grouper values when none are defined on a specific Benefit.

Plans







Product Templates










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Searching for Products This use case describes the user’s ability to search for the major objects in PCS such as the Benefit, Benefit Set, Product and the Product Template.

The left navigation panel contains links to the major objects in PCS. To view a list of all Products, click on the Product link. The following screen will display listing all Products.

Steps 1. Click on the Product link in the left navigation panel

2. A screen will display with a list of all Products. See example below:


• Custom Name • Availability of the Product • Retired • Effective date • End date • Version • Category (Medical, Dental, Vision, Pharmacy) • Created by • Last Modified • Last Modified By For each of these columns, PCS provides the ability to filter and select using partial matches. For example to select all Products with “healthy” in the title the user can enter “health” as the filter. PCS will select all Products with the letters “health” in the name field.



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Creating New Products Product Templates define the Network structure, list of Benefits, cost shares. Products define the specific cost share values, medical policy rules, notes and descriptions. Products are defined as specific “Plans” to be sold.

The Product process provides for the following configuration:

• Create a new Product or a copy of an approved one • Enter Product metadata • Select the Networks and Benefit Set used to build the structure of the Product • Select coverage levels and pricing parameters • Set cost shares • Define network and cost share guardrail rules for associated Products and Plans • Define claim processing parameters through a series of questions • Configure cost share and coverage definitions for specific benefits within selected

networks • Configure coverage, exclusions, limits, authorization/referral requirements and

medical policy notes • Process approvals through Underwriting, Legal and Product Management

Steps

1. There are two options for creating Products. From the Get Started section of the portal, click Create Product. The second option is to click on the Products link on the left navigation panel to display the list of available Products. If the user permissions allow, a Create Product button will appear at the right side of the screen. Either option starts the Product creation process.


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2. Upon selection, a window displays in the workspace with the Create New Product process. The process starts with the Enter Metadata tab.

3. On the Enter Metadata tab, the user can create a new Product or to choose to copy it from an existing template. Selecting an existing template prefills the preceding screens with the data from the selected template and provides the ability to make changes.

4. The Benefit Set category is used to define the Product and all associated Products as Medical, Dental, Vision or Pharmacy products.

5. Copy from a previous Product provides the capability of replicating a previously defined Product. This capability substantially accelerates the creation of new Products and ensures consistency across Products.

6. The Draft indicator allows the user to work on a Product, save it temporarily then return to resume configuration. See the Draft Mode Use Case chapter.

7. Attributes – After entering the Product Template name, click on the Initialize from Template button to copy the values from the Product Template to the Product.

8. Attributes can now be modified as necessary. Attributes are organized into the following categories:


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• Main: These properties categorize the business terms of this Product. The Product Line attribute is very important to connect the PCS Policies to the corresponding Benefits in the Product.

• The Product Features section provides attributes for defining the type of Product, specific coverage areas and indicators. In this section, all fields default to blank or no. For example a blank by the HDHP indicator specifies this Product is not a high deductible plan.


• SBC Properties specify the Summary of Benefit Coverage parameters necessary for printing the SBC for Products and sold Plans.

• Exchange Properties provide the attributes necessary for selling products on the public and private exchanges

• ID Properties provide for the configuration of the copay amounts to be printed on ID cards for this Product and associated Products.


9. The Pricing tab provides for selection of Coverage Levels or premium tiers defining the different levels of coverage that can be selected. For example, individual and spouse + 2 tiers.

10. In addition, the pricing tab provides for configuration of pricing parameters that are used to support rating at the product and benefit level. They also support when and how the Product may be offered in the market.

11. After selecting the Cover and Pricing parameters, click Next>> to display the Cost Shares tab.

12. On the Cost Shares tab, the user selects amounts, single maximums and family maximums for all of the cost share types. The values in the dropdown boxes are configured on the Product Template as ranges. If the user wants to enter a cost share value that is not in the dropdown list, select the Other value.


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After selecting Other, a box will display to allow for entry of copay that is not within the Product Template predefined range. Entry of a value outside of the specified ranges can configure a special approval process. Approval processes are configured to meet client specifications during the PCS implementation effort.

13. Set Values – This link is provided to expedite the configuration of a Product for training purposes. During the implementation of PCS, some clients may elect to customize this action to set default values prevalent to their business.

Note: All share ranges and increments must be selected for each cost share type to continue. The

user must also select a minimum of 1 occurrence and calculation method to continue.

14. When the cost share values are selected for all Networks, click Next>> to display the Configure Tree tab.


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Adding Standalone Networks, Groupers and Benefits Add a Grouper / Benefit directly to a Product Template

PCS SP2 provides the ability to add a Groupers and Benefits directly to Templates, Products and Plans. This feature allows users to manually add Benefits to a Network within a Template without changing the Benefit Set.

First, the Grouper / Benefits must be created. Then the user can select from the list of available Groupers / Benefits to add to the product Template.

As shown in the illustration at right, the user positions the cursor on a Network right clicks and selects “Add Benefit”. A window appears allowing the user to select a Benefit from the available list of Benefits.

Adding a Network / Grouper / Benefit directly to a PCS Product

The ability to add a Network / Grouper / Benefit directly to a PCS Product. This feature allows users to manually add Benefits to a Network within a Product without changing the Benefit Set.

The user positions the cursor on a Network, right clicks and selects “Add Benefit”. A window appears allowing the user to select a Benefit from the available list of Benefits.


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The user also has the ability to add a new Carveout Networks. The Carveout Network will be added with no Groupers or Benefits. The user can then use the add Benefit feature to add Benefits to the Network.

Copying Configured Benefits into Product PCS SP2 has added the ability to copy a fully configured Benefit from one Product to another. This concept provides the ability to create “Master Products” with fully configured Benefits. These Benefits can then be copied from the Master Product to the target Product as shown below.

Steps 1. Configure Product A.

2. From the product tree, position the cursor on a Benefit.

3. Right click to expose the dropdown selections.

4. Copy with values – Select this option to copy this Benefit and its entire configuration.

5. Open Product B

6. From the product tree, position the cursor on the Network you desire

7. Right click and select “Paste Benefit”

8. The new Benefit will be added with its full configuration.


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Configuring Cost Shares on the Product Tree The create Product process provides configuration of the Product at the highest product level. On the Configure Tree screen, the user configures the cost shares, coverage, limits, authorization requirements, etc for the Network, Grouper and Benefit levels.

Maximize inheritance to accelerate configuration and increase consistency PCS provides the ability for Benefits to inherit values from levels higher in the Product Tree. For example if 90% of all Benefits in the Product have a $10 copay, the user need only configure the highest product level and allow all Benefits to inherit this copay. Then the user configures the 10% of Benefits remaining with different copay.

When setting parameters such as Cost shares, PCS provides the capability of setting copay at a Network level. If all the Benefits in the Network share the same level of copay, this attribute need only be set on the Network level.

On the Configure Tree tab, the top level node in the tree is the Product. The attributes of this level were created through entry of data on the previous tabs. As a result, the display reminds the user to select another row of the tree.

Each node in the tree inherits or re-uses the cost shares set by the Product or the node above it if that node is modified. This reusability feature is important to supporting your ability to review and only make the changes necessary to complete the Product. Each network, grouper and benefit displayed in the tree can be edited from this tab by right clicking the node in the tree.


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Navigating the Product Tree The summary view of the Product Tree has two major views, Product and Policy view.

Product View – Displays the cost share configurations for the Product, Network, Grouper and Benefit levels. This view shows the inheritance icons described above.

Policy View – This view displays the coverage, exclusion, limit and authorization / referral requirement rules for the Benefit. It also provides tabs for medical policy guidelines and custom client configurations.

The summary view provides the user the ability to expand and collapse the tree by Network and Grouper. After the name column the next three columns provide critical information about the status of the configuration and about the Benefits:

Reviewed - For each row of the tree, the Reviewed column will display a green check mark for those rows that have been configured, reviewed and completed.

Required – When “yes” the Benefit is a required part of the Product coverage. When blank or “no”, the Benefit is optional or a rider. In the example below, the Dental benefits are optional benefits and must be selected separately during the sales process.

Covered – If “yes”, the Benefit is covered for that Network in the Product. If “no”, the Benefit is not covered.

Configuring the Product Tree

1. The summary view does not allow editing of the Product Tree. To edit the elements of the Product Tree, select the Configure link. The configure tree screen will display.

2. Select a row in the product tree. When the configure tree view initially displays it will position to the Product level of the Tree. On this view the Product level is not


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configurable and a message will display requesting the user to position the cursor to a row in the tree.

Product configuration tabs The following tabs are available on the Product (cost shares) configuration screens:

Cost Shares – Each of these tabs provides the ability to configure a range of values for the amount, single maximum and family maximum.

• Copay • Deductible • Coinsurance • Out of Pocket • Admission Copay – For example emergency room copay • Maximums – Overall lifetime or annual maximums (note: these are maximum

accumulation values not dollar limits. Dollar limits are configured on the Policy view.

• Carryover – Rules for carryover to next benefit year Maximum Reached – Not available in PCS – In a future PCS release this screen will

provide configuration for what steps to take after a maximum is reached. For example, after reaching the $500 individual deductible a specific Benefit may change to a 90% coinsurance cost share.

Claim Instructions – Ability to assign Pend codes when cost share limits are reached. Configurable for multiple claim systems.

Client Configurations – A section for clients to add attributes and rules Metadata – additional attributes on the Network, Grouper and Benefit levels in the

product tree.

Configuring Product (cost share) information at the Network level

1. Click on a row in the Product Tree. If the row is a Network level, the following screen will appear.


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2. The Default initial values displayed on the Network are the inherited values from the Product. If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. If the values on the Network require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.

4. For each cost share type (copay, deductible, etc) PCS provides the ability to configure specific rules defining When copay varies from the default values on the Network. These are called Variation Rules.

5. See the next section, Configuring Cost Share Variation Rules for additional information.

6. After editing the Network row, all nodes under this Network will inherit or re-use the cost shares for the network unless specifically modified.

7. If all or most of the Benefits associated with this Network are not covered, select the Set all Benefits as Non-Covered link. This link will set the non-covered flag to “no” for all of the Benefits in the Network. For example, for Out of Network, if the only Benefit covered is Emergency Room, setting this flag will mark all Benefits in the Out-of-Network to be non-covered. The user then edits the Emergency Room Benefit to be “covered” to complete the configuration.


Configuring Product (cost share) information at the Grouper level

1. Click on a Grouper row in the Product Tree.

2. The initial values displayed on the Grouper are the inherited values from either the Network or the Product. If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. If the values on the Grouper require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.

9. For each cost share type (copay, deductible, etc) PCS provides the ability to configure specific rules defining when copay varies from the default values on the Grouper. These are called Variation Rules.



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11. After editing the Grouper row, all nodes under this Grouper will inherit or re-use the cost shares unless specifically modified.


Configuring Product (cost share) information at the Benefit level

1. Click on a Benefit row in the Product Tree.

2. The initial values displayed on the Benefit are the inherited values from the Grouper, Network or the Product. If these values are acceptable, select the Review and Complete link to complete the editing of this row.

3. If the values on the Benefit require changes, select the Edit link. The display will change to edible fields. Change fields as necessary. When done, select the Review and Complete link to save the changes and mark the row as completed.

4. For each cost share type (copay, deductible, etc) PCS provides the ability to configure specific rules defining when copay varies from the default values on the Benefit. These are called Variation Rules.


6. After editing the Benefit row, all nodes under this Benefit will inherit or re-use the cost shares unless specifically modified.



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Quick Entry Screens for Cost Shares (product view) Most of the configuration for a specific Benefit is maintained on the Product Template process. For example calculation methods, conditions, etc. are best configured on the Product Template

On the Product process, the cost share “quick entry” screen is provided to allow for configuration of common cost shares and coverage information. A single screen allows the user to configure all cost share amounts for a Benefit and corresponding variations.

On the Product process, use the screen shown above to enter the cost share amounts for each type. Typically, this configuration is sufficient for cost shares eliminating the need to visit and configure each cost share tab in the Product process.

Steps: 1. Create Product Template using master variation list feature.

2. Create a Product.

3. Access the Variations tab to view the cost share quick entry screen.

4. Edit.

5. Click on a row to active entry mode.

6. Enter cost shares. Entering on this screen automatically populates the cost share tab screens alleviating the need to configure each tab.

7. Apply and review complete.


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Configuring Cost Share Variation Rules Many products today vary the cost shares; particularly copay, if the patient is seen at an inpatient facility vs. outpatient. Others vary copay when a patient sees their PCP vs. a specialist.

PCS has a new feature called Cost Share Variation Rules. PCS allows the user to use a common list of Benefits across Templates with the capability of varying cost shares by the following:

Place of Service – inpatient, outpatient, SNF, etc can all have different cost shares for the same Benefit in the same Network.

Provider Specialty – Vary the cost shares based on seeing a Specialist, Internist or Nurse.

Service Group – Vary the cost shares based on the service provided. For example, the Benefit Mental Health may have a $10 for group counseling and$50 copay for individual counseling. Also vary cost shares based on bed type using revenue codes.

Age band and Gender – Vary cost shares by age and sex of the patient. Includes the ability to vary cost shares by months for newborns.

Service by – Vary cost shares when going to your PCP or Patient Centered Medical Home.

Authorization or Referral – Vary cost shares if referred to a specialist or authorized to have surgery. Lack of authorization will result in higher copay for example.

Provider Ranking – Ability to rank Hospitals and other providers and vary cost shares to drive member steerage to preferred facilities.

Jurisdiction – Ability to vary cost shares by location such as State. As government mandates of copay increase, this feature enables the user to vary cost shares for the same Benefit based on State rather than creating an entire new Product.

Cost Share Variation Rules provide the capability to change cost shares on a Network, Grouper or Benefit based on user defined rules. This capability is critical for managing the variations of Benefit cost shares without requiring the creation of additional Benefits.

To create Cost Share Variation Rules, Edit a Network, Grouper or Benefit. Click on the Add Rule button to display the following screen:


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Cost Share Variation Screen

Steps

1. Select the Add Rule button.

2. Enter a description of this variation rule. For example, “Inpatient copay”, to define the difference in copay when the patient receives this Benefit in an inpatient setting.

3. Cost share variation rules can be short or long in duration. Enter the effective and expiration dates.

4. Fixed – Specifies only one cost share amount

5. Compare – specifies two cost share amounts with the ability to calculate both and take the lesser or greater based on member liability. See Use Case Comparing copay to coinsurance and selecting lowest member liability.


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6. Amount – the amount of cost share depending on the specific tab. If a Benefit has a Deductible and copay, configure the copay amount on the copay tab and the deductible amount on the deductible tab.

7. Single and family maximum amounts. The maximum amount of this type of cost share that can be taken in a benefit year.

8. Calculation Methods – How the cost share should be calculated. For copay, see the list to the right for the options on the calculation methods.

9. Copay Conditions – see description above of the optional conditions available to vary copay. If several conditions are specified the rule is processed as follows:

• POS – Outpatient AND • Serviced by PCP



12. The variation rule screen can be compressed by clicking on the small arrow next to the rule number. Example below:




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Use Case: Copay varies by inpatient vs. outpatient Use Case:

In-Network, Mental Health Counseling Inpatient

• $50 copay

In-Network Mental Health Counseling Outpatient

• $20 copay

Out of Network Mental Health Counseling

• NOT COVERED

Steps: 1. Create Mental Health Counseling Benefit.

2. Create a Benefit Set with Mental Health benefit.

3. Create a Product with In-Network and Out-of-Network Networks.

4. Configure Product with $50 copay for In-Network Mental Health Counseling.

5. For Out-of-Network, Mental Health Counseling set the “Service is covered” to blank. This indicates that the Benefit is NOT covered.

6. When reviewing the Product, the Out-of-Network, Mental Health Counseling benefit will appear with blank in the “covered” column indicating this Benefit for Out-of-Network is NOT covered. This satisfies the not covered bullet in the use case.

7. When creating the Product, select the Mental Health Counseling for In-Network and “configure”.

8. Select “Add Rule” to create a Cost Share Variation.

9. Enter the Amount of $50 in the Amount field.

10. Select “Per Visit” to indicate the $50 would be charged for each visit to the Counseling sessions if at an Inpatient facility.

11. Under Copay Conditions select “Place of Service”. Enter “Inpatient”. (Optionally, the dropdown will access the POS codes to allow for selection of POS codes.


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12. Generate Description to view the results of the rule configuration.

13. To configure the “Outpatient” copay of $20 there are two options.

14. Use the Default value of $20. In this case there are no additional “rules” to configure

15. Create a rule for “Outpatient”.


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Use Case: Copay varies when seeing PCP vs. Specialist

Use Case:

Office Visit Benefit

• $25 copay for visiting Specialist

• $20 copay for visiting PCP

Steps: 1. Select Configure when on the product tree screen

2. On the detail screen, select the Office Visit benefit for In-Network and select Edit.

3. Select Add Rule to create a Cost Share Variation.


5. Select “Per Provider per Visit” to indicate the $25 would be charged for each visit to a specific Provider.

6. Under Copay Conditions select “Service By”. Select “Specialist”.

7. Generate Description to view the results of the rule configuration

8. Save

9. To configure the “PCP” copay of $20 there are two options.

10. Use the Default value of $20. In this case there are no additional “rules” to configure

11. Create a rule for “PCP” copay with $20 copay specified. Create a second variation rule configured with $20 copay per visit with a Condition of “PCP”

12. Save variation rule

13. Review and complete

14. Return to summary view


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8. See screen illustration below for an example of a cost share variation rule.

Use Case: Comparing copay to coinsurance and selecting lowest member liability

Use Case:

Mental Health Visit Benefit

• $25 copay for visiting Specialist

• 80% Coinsurance

• Select the calculation that results in the lowest member liability

Steps: 1. Select Configure when on the product tree screen

2. On the detail screen, select the Mental Health benefit

3. Select “Add Rule” to create a Cost Share Variation.

4. Select the “compare” button. When selecting compare two independent cost share configuration areas will appear. The user will configure each cost share type independently then select the comparison method from the list shown at right.

Figure 1: Copay Configuration for Speicalist


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5. For the Compare two cost share types and choose, select the option “Whichever is the lesser member liability”

6. For Cost Share type 1, select Copay and enter $50 in the amount field

7. Select the calculation method of “Per Visit” to indicate the copay will be taken for each visit to the Provider

8. For Cost share 2, select Coinsurance and the amount of 80%.

9. For the cost share type 2 calculation method select “Standard Coinsurance’

10. For Apply to Accumulators select Apply to Accumulators.

11. In this use case there are no specific condition rules.

12. Generate Description and save the variation rule.

13. Select “review and complete” to save

14. Select “summary view” to return to the Product Tree view


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Use Case: Authorization required – higher copay if not found

Use Case:

Out of Network, Emergency Room Benefit

• Authorization is required

• If authorization is not found, raise admission copay to $250

Steps 1. Proceed to the Product Tree configuration screen. Select Policy view and configure

2. On the detail screen, select the Emergency room Benefit under Out of Network. benefit

3. Under the Authorization tab, select “edit”

4. Select “Add Rule” to create a policy term variation rule.

5. Select the “Authorization required prior to service”

6. If additional conditions are required such as authorization ONLY for specific services, these can be configured by selecting a condition type and “Service Group”. Service groups are configured by each client. They represent specific ranges of codes such as CPT, HCPCS, Revenue codes, ICD-10, etc.

7. Generate the description and save

8. Select “review and complete” then return to summary view

9. The screen below illustrates the configuration requiring an authorization for Out of Network Emergency room services.

10. The second part of the use case requires configuring copay to be higher if the authorization is not available. From the Product tree view, select “configure”

11. From the detail view select the Emergency room Benefit for Out of Network

12. Select the Admission Copay tab and “edit”

13. Enter $250 amount

14. On Admission Copay Conditions select the “Authorized” type then the “Authorization is required but not found” entry.

15. This configuration specifics that if a claim is an Out of Network Emergency room claim and no authorization is found, raise the admission copay to $250 per visit.


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16. The screen below is an illustration of this configuration in PCS

17. Save the configuration.

18. Select Review and Continue

19. Select Return to Summary view


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Configuring Policy Terms on Products

Overview of Policy PCS has a new Policy process to allow for configuration of coverage, exclusions, limits, authorization requirements and medical policy information. Policy information is configured for Product families and provides the default values for all associated Product Templates.

Policies are linked to Benefits within the Product Tree. When necessary to specific coverage more specifically, “sub-policies” called policy terms can be associated to a specific Benefit.

Associated with a policy term are sections as follows:

Policies – Configuration of coverage, exclusions, etc. Maximum Reached – If a limit is reached, instructions for the next step for coverage or

limits. Client Instructions – A section for clients to add attributes and rules Notes – Multiple consumer notes








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Directly configuring policy information

1. From the Product tree summary view, select Configure

2. On the configure product tree screen, click on a Benefit row. See example below:

3. If the Policy Term was not created previously (see Chapter 4 Policy Term Configuration), the screen above will appear. The Create Policy Term is the indication that there is no active Policy Term for this Benefit. If the Policy Term was already created, the system will display the values of the Policy Term.

4. Select Create Policy Term to display the following screen. Select Edit


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5. The policy information is now ready to configure. Select the Add Rule button to display the following screen:

6. Coverage - Configure coverage rule 1. Enter a description, effective and end dates.










• Referral – Benefit is only covered when referred by PCP


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8. When multiple Coverage Conditions are specified the rule process as Condition 1 AND Condition 2.




• Dollar limit – Coverage up to $300 based on allowed amount


• Unit limit – 1 Wig • Dollar amount with age

ranges • Visit with age ranges • Unit with age ranges • Floating period limits – 5 PT








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Copying a Master Product Products can be copied. When copied, all the values will be replicated to the target Product.

Steps:

1. Create Product.

2. Select Copy from this Product.

3. Enter the name of the master product.

4. Click on the blue initialize button to copy all values to the new Product.

5. Proceed with configuration of the new Product.


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Quick Entry Screens for Coverage (policy view) Most of the configuration for a specific Benefit is maintained on the Product Template

process. For example calculation methods, conditions, etc. are best configured on the Product Template

On the Product process, policy view, a new “quick entry” screen is provided to allow for configuration of common coverage information.

Steps:

1. Create Product Template using master variation list feature.



4. Edit.





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Benefit Tier Configuration Tab The Benefit tier screen shown below has been added to the Plan level of PCS. This screen provides the ability to configure complex Benefits that vary cost shares based on limit and age ranges. The Benefit tier screen appears in the policy view because of the ability to configure by limit ranges. (Limits are configured on policy view)

The screen provides the following capabilities:

A screen with with limits, age ranges and cost share values provides a single source for configuration of complex benefits such as wigs which typically are limited to one per year or $300 of coverage.

Inter row cost share comparisons – Setting the inter row calculation value allows for comparison of two cost share values. For example, $50 copay could be compared to an 80% coinsurance with the system taking the amount that is the “greater member liability”.

Intra or multiple row comparisons – Setting the inter row value to “OR” or “AND” instructs the system to compare multiple rows of configuration against each other. In the example shown below, row one will calculate a $20 copay and 0% coinsurance. Row 2 will calculate $0 copay and 70% coinsurance. The system will take the resulting value that is the “greater member liability”.

This screen can work with the other policy screen configurations. For example, a Benefit can have a limit of $300 coverage (configured on limit tab) with$30 copay configured on the Benefit tier tab.

The user should configure cost shares either on the product view (quick entry or individual tabs) or on this benefit tier screen but not both.

Steps:



3. Policy view, configure

4. Access the Benefit Tier tab.

5. Select limit type.

6. If the Benefit Tier is based on limit usage ranges select the limit range check box. For example if the Benefit visits 1 – 7 have $10 copay while visits 8 – 15 have $20 copay.

7. If the Benefit has cost share or coverage variations based on age, select the Age Range check box.

8. In the example below, the age range was selected. A window appears to allow for configuring the age range bands. Select the +/- button to add as many age ranges as necessary.


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9. Select the apply button.

10. On the lower window select the +/- button to add new rows.

11. In the example below, select the appropriate age range.

12. The Inter Row Compare column provides the capability to configure two or more rows for the same age range to create a comparison rule. For example, the first row would be created with the “OR” selection. This row may have $20 copay and 70% coinsurance. Create a second row with the “END” selection. This row may have $40 copay and 60% coinsurance. This configuration allows for comparing the two rows. The determination is based on the last column. In the example below the calculation resulting in the “Greater Member Liability” will be selected.

13. Complete Benefit Tier screen for each variation.

14. Review complete.


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Chapter 7: Plan Configuration This chapter describes the PCS business processes for creating Plans in PCS. Use cases included are:

Searching for Plans

Creating New Plans

Configuring Cost Shares on the Product Tree

Creating Plan Bundles

Exporting Plan Data

The Plan process creates sold “Plans”

Plans are the agreements signed with clients including their specific customizations to the Products they have selected. There may be hundreds or even thousands of Plans due to the number of clients requesting customization. Product Composer maximizes reuse during the Plan approval process by capturing and storing ONLY the client variations not the entire replicated Product.

A typical Health Plan will have a handful of Products that result in hundreds of Plans with large accounts and thousands of Plans with small groups and individuals. To load these Plans, Plans are often required to copy or replicate all of the coverage rules, cost share parameters and exclusion logic for each Plan even for Plans with little to no variations from the base Product. Replicating all of that information exposes Plans to retesting the entire Product for each sale substantially increases the time and effort to load benefits.

Offering(Pega

Framework)

Plans


Base rules for Commercial, Medicare, Medicaid, Canada, Europe

Current PCS is US Commecial






Product Templates




Products

US Commercial Plans

PPO 90 vs PPO 80Metallic Plans

Specifics for market reasonsLarge Account customizations


regulations


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With Pega, there is no need to load, configure or test the entire Product. Changes are identified and a guided process leads the Benefit loader through the few changes required.

Product reuse reduces the amount of effort required to load and tests Products by at least 75% and captures the changes requested during the sales process for precise analysis.

Searching for Plans This use case describes the user’s ability to search for the major objects in PCS such as the Benefit, Benefit Set, Plan and the Product Template.

The left navigation panel contains links to the major objects in PCS. To view a list of all Plans, click on the Plan link. The following screen will display listing all Plans.

Steps 1. Click on the Plan link in the left navigation panel

2. A screen will display with a list of all Plans. See example below:


• Custom Name • Availability of the Plan • Effective date


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• End date • Variation rule instance • Category (medical, dental, vision, Rx) • Created by • Last modified by • Last modified date For each of these columns, PCS provides the ability to filter and select using partial matches. For example to select all Plans with “healthy” in the title the user can enter “health” as the filter. PCS will select all Plans with the letters “health” in the name field.

Creating New Plans Product Templates define the Network structure, list of Benefits, cost shares. Plans define the specific cost share values, medical policy rules, notes and descriptions. Plans are defined as specific “Plans” to be sold.

Plans can be configured as “Standard” or “Non-Standard”. Typically Standard Plans are sold to small groups and individuals and do not allow for client changes. Non-standard plans are base Products that typically will accept changes from large Groups.

The flow for the Plan creation process is shown below:

Steps

1. There are two options for creating Plans. From the Get Started section of the portal, click Create Plan. The second option is to click on the Plans link on the left navigation panel to display the list of available Plans. If the user permissions allow, a Create Plan button will appear at the right side of the screen. Either option starts the Plan creation process.

2. Upon selection, a window displays in the workspace with the Create New Plan process. The process starts with the Enter Metadata tab.


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3. On the Enter Metadata tab, create a group or an individual Plan.

Plans are based on existing Products. When you copy an existing Product for a customer, values from that Product are copied into the Plan.

Note: Required properties are noted with an asterisk. It is also required that the name of the

Plan/Customer be unique within the effective and end dates selected.

4. On the Enter Metadata tab, the user can create a new Plan or to choose to copy it from an existing template. Selecting an existing template prefills the preceding screens with the data from the selected template and provides the ability to make changes.

5. Attributes – After entering the Product Template name, click on the Initialize from Template button to copy the values from the Product to the Plan.

6. Attributes can now be modified as necessary. Attributes are organized into the following categories:

• Main: These properties categorize the business terms of this Plan. The Plan Line attribute is very important to connect the PCS Policies to the corresponding Benefits in the Plan.

• The Plan Features section provides attributes for defining the type of Plan, specific coverage areas and indicators. In this section, all fields default to blank or no. For example a blank by the HDHP indicator specifies this Plan is not a high deductible plan.



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• SBC Properties specify the Summary of Benefit Coverage parameters necessary for printing the SBC for Plans and sold Plans.

• Exchange Properties provide the attributes necessary for selling Plans on the public and private exchanges

• ID Properties provide for the configuration of the copay amounts to be printed on ID cards for this Plan and associated Plans.


After selecting Other, a box will display to allow for entry of copay that is not within the Product Template predefined range. Entry of a value outside of the specified ranges can configure a special approval process. Approval processes are configured to meet client specifications during the PCS implementation effort.

7. Set Values – This link is provided to expedite the configuration of a Plan for training purposes. During the implementation of PCS, some clients may elect to customize this action to set default values prevalent to their business.

8. After entering the Metadata, click Next>> to display the Collect Parties tab.

9. On the Collect Parties tab, enter the contact detail of all the parties involved. Group Plans identify a Plan Sponsor, Third Party Administrator (TPA), Insurer and Broker. For individual Plans enter the Subscriber ID rather than Plan Sponsor and TPA.

10. After entering the party information, click Next>> to display the Configure Plan tab.

11. If the Plan has been sold with no changes to the base Product, click Next to finalize the Plan.

12. If the individual / group requested changes, configure the changes in the product tree. The Configure Contact screen has the same capabilities as the configure Product. From this screen, the sales process can configure the customizations requested by the individual or employer group.


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Configuring Cost Shares on the Product Tree The product tree configuration process and screens on the Plan are identical as the Product. See Chapter 6 Product Configuration for additional information.

1. After configuring any client requested changes, click on set values to review and complete each row in the tree. Click Next.

2. On the Review Changes screen, the changes configured for this client will be displayed. These are the overrides to the base Product stored on the Plan record.

3. Click Next to advance to the finalization steps.


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Summary of changes to Plan The next step in the process is to display the differences captured during the Plan configuration from the original base Product. The screen below lists each property and the changes. For example at the bottom of the screen the copy for the Behavior Health benefit has been changed from $ 10 (on base product) to $ 25 on the Plan.

Plan approval process flow


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Creating Plan Bundles PCS SP2 has the ability to input or electronically receive a “bundle” of Products / Plans selected by an indvidual during the sales process. The sales system will record the person selecting the medical, vision, pharmacy and dental Plans as noted below. PCS will create a consolidated “Bundle” representing the combination of the 4 Plans.

This Plan Bundle can then be used to output Plan information to an SBC generation process.

Exporting Plan Data On the PCS Plan approval screens, select the blue Actions button to expose the “Export Plan Data” link. This link will submit a process to export the key information for all Plans in a Plan Bundle.


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Chapter 8: Draft Mode Use Cases This chapter describes the PCS business processes to enable your understanding of the available features and functionality.

Use cases included are:

Enabling Draft mode

Creating Draft Benefits

Creating Draft Benefit Sets

Creating Draft Product Templates

Creating Draft Products

Creating Draft Policy Terms & Policies

Changing Benefit Mapping

Adding/Removing Benefits in a Set – Rebuild Product Tree

Changing a Product Template

Draft Mode Overview

Finalizing a Product Template or Product

The Draft configuration enhancement enables users to create Benefits, Benefit Sets, Policy Terms, Polices, Product Templates and Products without requiring the finalization of the prior step. Each process can be completed by “approving as Draft”.

To modify a Product Template or Product after it has been approved as Draft, the user will review their work items on their Home page To Do List. By selecting on a work item, the system starts the item at the beginning of the update process.

Update of a Benefit Set

When a Product Template is created from a Draft Benefit Set the system records the date/time version of the Benefit Set on the Product Template. When a user attempts to modify a Benefit Set, the approval process flow lists all of the Templates and Products affected by the change. The user will then follow the Benefit Mass Update process to add/remove Benefits to these Templates and Products.

If only a few Templates are affected, the user may elect to not follow the mass update process and update each Template manually. In this case, the Product Template flow will display the following error messages:


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If the user is at the early stages of configuring a Template and wants to erase the existing configuration, set the “Update Only” check box to blank. When clicking the Re-generate Tree button, the system will erase the existing product tree and recreate a new version from the Benefit Set.

If the user prefers to retain the existing configuration and only add/remove Benefits from the tree, set the “Update Only” check box to on. When clicking the Re-generate tree, the system will add or remove the Benefits that are new in the Set.

What happens under the following situations?

Change Benefit Mapping or descriptions

• User can proceed with updating Product Templates and Products.

• A “refresh” link is provided to bring the new Benefit descriptions into the Product.

Change Benefit Set – Add/Remove Benefits

• Follow the mass update process initiated when modifying the Benefit set

• Elect to not follow mass update and want to re-generate Product Tree – deselect “Update Only” check box and regenerate tree. This will erase previous configuration.

• Manually add/remove Benefits by selecting “Update Only” and regenerating tree. This will add/remove Benefits to configured tree. This manual process will not automatically update associated Products. If Products are involved, follow the mass update process.

Change Benefit Set – No change to list of Benefits

• User will receive warning message but can ignore

• Updating of Product Templates and Products will successfully save

Changing Policy Term / Policy configuration

• Select “refresh” on each Benefit in the Product Tree / Product associated with the changed Policy Term / Policy


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Restarting a Finalized Item

When moving PCS to a different system, the approval processes may be lost. PCS provided the ability to restart a draft item so it may be assigned back to the original person. The button “Restart Draft” appears on all of the draft work item process flows.

Restart draft opens the Benefit work object and starts the Benefit configuration process flow with the metadata screen. This is a restart of the configuration process and not the create process. Only modifications to the existing Benefit will be available.

Important: Restart Draft should not be pressed without consulting with your Pega technical support team.

Enabling Draft Mode To enable Draft Mode:

1. Log in as administrator@pegapcs; password is install.

2. From the Designer Studio, click on the top left corner of the portal to display the Product Composer landing page and its associated menus and options.


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3. Select PCS Configuration.

4. For “Draft Mode Enabled” select true. This will allow the user to configure items in draft mode.

Creating Draft Benefits This use case describes the user’s ability to create a new benefit using draft mode and select the parameters that define the benefit.

Creating a Benefit using draft mode follows the same process as creating a standard benefit:

1. Follow the create benefit process.

2. Select draft on the Benefit metadata screen. The only change is selecting the “Draft” check box as noted below.

3. Complete the Benefit creation process.

4. When approving the Benefit, select “Approve as Draft” then click Submit.


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Selecting the “approve as draft” process changes the routing process for approval. The process flow is illustrated below:

The routing process assigns the Draft Benefits to the assigned user.

5. To update a Benefit, the assigned user finds the task by accessing their HOME page as follows:

6. The work item can be searched using the name or ID by clicking on the down arrow to the right of the column.


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7. When the work item is found, the user double clicks to start the update process for the item.

8. At the end of the update process the same series of approvals will be required. If the draft indicator was not selected on the metadata screen, the user can still approve as draft during the approval process. This will mark the Benefit as draft.

The approval process should be configured during the implementation of PCS.

If the Benefit was not marked as draft and was approved as selected the Benefit will be stored as non-draft.


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Creating Draft Benefit Sets This use case describes the user’s ability to create a new benefit using draft mode and select the parameters that define the benefit.

Creating a Benefit using draft mode follows the same process as creating a standard benefit:

1. Follow the create Benefit Set process.

2. Select “Draft” on the enter metadata screen

3. Both Groupers and draft and non-draft Benefits can be selected for the Benefit Set. Groupers do not have an Approve As Draft capability.

4. Complete the test and submit step.

5. Selecting the “approve as draft” process changes the routing process for approval.

If the draft indicator was not selected on the metadata screen, the user can still approve as draft during the approval process. This will mark the Benefit Set as draft


If the Benefit was not marked as draft and was approved as selected, the Benefit Set will be stored as non-draft.

Example of a Benefit Set used to create a product structure containing both draft and non-


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draft Benefits.

Creating Draft Product Templates 1. Follow the create Product Template process.

2. Select “Draft” on the Product Template enter metadata screen

Example of a Product Template structure with both draft and non-draft Benefits.

3. Complete the Product Template configuration as Draft.

4. For the first three approval steps (Underwriting, Legal and State Mandate Specialist) the Product Template is approved as selected.

5. For the final Product Manager approval, the user can select “approve as draft” process to complete the approval process but not finalize the Product Template.

6. The Product will be assigned to the user as a work item on the “To Do List”.

7. If the Product Manager “approves this selection”, the Product Template will be accepted as final.


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Product Template approval process flow diagram below:

Creating Draft Products 1. Follow the create Product process.

2. Select “Draft” on the Product enter metadata screen

3. Products can be created with a combination of draft and non-draft Benefits.

4. Complete the Product configuration as Draft.

5. For the first three approval steps (Underwriting, Legal and State Mandate Specialist) the Product is approved as selected.

6. For the final Product Manager approval, the user can select “approve as draft” process to complete the approval process but not finalize the Product. The Product will be assigned to the user as a work item on the “To Do List”.

If the Product Manager approves this selection, the Product will be accepted as final.



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Creating Draft Policy Terms & Policies

Policy Term

1. Follow the create Policy Term process.

2. Select “Draft” on the Policy Term enter metadata screen. See below:

3. Complete the Policy Term configuration as Draft.

4. For the first approval step the Policy is approved as selected.

5. For the final Policy Manager approval, the user can select “approve as draft” process to complete the approval process but not finalize the Policy Term. The Policy Term will be assigned to the user as a work item on the “To Do List”.

6. If the Policy Manager “approves this selection”, the Policy Term will be accepted as final.



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Policy

1. Follow the create Policy process.

2. Select “Draft” on the Policy enter metadata screen. See below:

3. Complete the Policy configuration as Draft.

4. For the first approval step the Policy is approved as selected.

5. For the final Policy Manager approval, the user can select “approve as draft” process to complete the approval process but not finalize the Policy. The Policy will be assigned to the user as a work item on the “To Do List”.

6. If the Policy Manager “approves this selection”, the Policy will be accepted as final.


Changing Benefit Mapping or Description 1. If the Benefit is approved in draft mode, the user should search for the Benefit work

item in their “To Do List” on their Home page.

2. Click on the work item to start the update Benefit process.

3. Click next to position to the Benefit Mapping screen. The mapping configuration can be changed at this time.


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4. Click next to position to the enter notes screen. Modify notes as required.

5. Submit for approval. If the Product Manager “approves this selection” the Benefit will be saved in its final form. It will be “finalized”. If the Product Manager approves as draft, the Benefit can be re-opened for additional configuration.

6. Submit for approval. If the Product Manager “approves this selection” the Benefit will be saved in its final form. It will be “finalized.

Below is a screen shot of the mapping changes and the Rule Details obtained from the “view” button.

In this example:

Mapping was changed adding two additional Bill Type Groups, “Hospital Swing Beds” and “Skilled Nursing Inpatient.


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A note was changed on the Benefit.

Refresh on Product Template to see Benefit changes

1. If the Product Template is approved as draft, the user searches their “To Do List” to find the Product Template work item.

2. Clicking on the work item starts the Product Template update process.

3. Click next through the Product Template configuration process until reaching the configure tab. Select Configure

4. When selecting the corresponding Benefit, the screen below illustrates the Benefit has inherited the mapping changes recently configured on the Benefit.

5. Select the notes tab to view the changes to the Benefit description. See Below:

When a Benefit is in draft mode, the mapping and descriptions are automatically inherited to the Product Template.


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Adding/Removing Benefits in a Set 1. Select a draft Benefit Set.

2. The user searches for the Benefit Set work item in the “To Do List”. Click on the work item to start the update Benefit Set process.

3. Add or remove a Benefit to Benefit Set as shown below:

4. After the approval flow, the Benefit Set work object will enter the Mass Update subflow.

5. If the Benefit Set has any associated Templates, they will be listed on the screen.

6. Select which Templates to be automatically updated.

7. Select to update immediately or to schedule the update process.

8. See Mass Update chapter for additional information.


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Changing a Product Template – No Benefit Set Change If the Benefit Set has not changed, restarting a Product Template that has been approved in draft mode but not finalized allows the user to re-configure the Product Template. The process is as follows:

1. Search for Product Templates work item in the user’s “To Do List”.

2. Click on the desired work item to start the update Product Template update process.

3. The warning message, “The Product Template Tree may be outdated. Consider regenerating the Tree before you continue” displays at the top of the screen.

4. It is up to the user to make sure the Benefit Set used as the basis for the Product Template has not added or removed Benefits.

5. If only Benefit mapping or descriptions have changed, the user is safe to proceed with updating the Product Template.

6. Continue with the Product Template update process.

7. Complete the Product Template configuration as Draft.

8. For the first approval step the Product Template is approved as selected.

9. For the final Policy Manager approval, the user can select “approve as draft” process to complete the approval process but not finalize the Product Template. The Product Template will be assigned to the user as a work item on the “To Do List”.


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Finalizing a Product Template or Product Attempting to finalize a Product Template with any draft elements will result in a screen such as the following:

To finalize a Product Template or Product, all Benefits, Benefit Sets, Policy Terms and

Policies must be finalized first.

Plan Composer System Business Use Case Guide

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Chapter 9: Quote, Compare Configuration This chapter describes the PCS business processes for running a quote request and comparing products. Use cases included are:

Run a Quote Request

Comparing Products

Run a Quote Request This use case describes how to request a quote based on a selected Product Template. This runtime tool gives you the ability to select cost shares for networks, groupers and/or benefits and submit a quote request.

This feature is designed so that the solution can support external systems looking to PCS as a tool that provides Plan comparison.

The function is accessible from a link on the Get Started section of the Product Architect portal. This function allows you to:

Select a Product Template Select cost shares from a tree structure Create a specific Quote

Steps

1. From the Getting Started section of the portal, click Run Quote Request. A tab opens up in the workspace and the New Quote processing screen displays that starts a guided process to walk you through the steps of running a quote request. The process starts with the Select Product Template tab.

2. On the Select Product Template tab, you can manually filter Product Templates by the Effective Date, to search for and display templates that fall in that desired range. Click Search to refresh the template display.


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3. Once the template list displays, choose a template from the list to use as the base for the quote request.

4. Click Next>> to display the Select Cost Shares tab.

5. On the Select Cost Shares tab the configuration process for Quote is identical to Product configuration cost share screens. See Chapter 6 Product Configuration for additional details.

6. After configuring the cost share and policy terms, click Review and Complete.

7. Click Set Values to complete the update of the product tree. Click Next>> to display the Configure Quote Request tab.


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8. On the Configure Quote Request tab, you can follow online instructions about selecting cost share values for the network, groupers or benefits listed in the tree.

To modify a cost share for a node, select the node. The display refreshes with the data for that node.

The system defaults the selections made at the network level for all sub-nodes below the network. You can select individual cost share values for each node in the tree.

9. After you make your selections, click Next>> to display the Review Selections tab.

10. On the Review Selections tab, you can review your selections for completeness and accuracy.

11. Click Finish to submit the quote request to a process defined by an external system in a Planion environment and display a confirmation screen.


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Comparing Products This use case describes how to compare two products.

This runtime tool gives you the ability to quickly drill down into the details of two products and compare them. It was designed so that the Solution can support external systems looking to PCS as a tool that provides product comparison.

The function is accessible from a link on the Get Started section of the user portal. This function allows you to:

Select products Compare the selected products

Steps

1. Log on as the Product Designer. From the Getting Started section of the portal, click Compare Products. A tab opens up in the workspace and the Compare Products processing screen displays that starts a guided process to walk you through the steps of comparing products. The process starts with the Select Products tab.

2. On the Select Products tab, you can filter products by the Effective Date to search for and display the products that fall in the date range. The expectation is that in a production environment when this is a service request by an external system, the effective date would be a parameter sent to PCS. Also, it is expected that additional parameters such as group size or location would be sent to further filter the products available for display.

3. Click Search to search for and display a list of products.


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4. Select two products from the list to compare.

5. Click Next>> to display the Compare Selected Products tab.


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6. The Compare Selected Products screen displays the product tree. Each product displays the networks, groupers and benefits available with the product. You can see and compare both products in a tree structure where every node can be clicked to display its network, benefits and grouper cost share information in read-only mode where it cannot be edited.

7. Click the network node for both products to refresh the screen and display the network level cost shares.

8. Click benefits under each product. You are not limited to compare the benefits belong to the same network. You can chose to compare benefits belonging to different network. It displays cost shares belonging to the chosen benefit irrespective of the network.

You also can choose different benefits under different networks – shown in the example above.

The compare product is a flexible tool that displays product details per your selection, even if they are not the same benefits, networks or groupers across products.

9. When you have compared the products, click Finish to end the process and display a confirmation screen.


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Chapter 10: Pharmacy Benefits & Products This chapter describes the PCS business processes for creating Pharmacy Benefits, Groupers, Sets, Templates, Products and Plans. Use cases included are:

Creating a Pharmacy Benefit

Creating a Pharmacy Grouper

Adding a Pharmacy Grouper to a Medical Benefit Set

Creating a Pharmacy Benefit Set

Creating a Pharmacy Product Template

Creating a Pharmacy Product

Product Composer has implemented the ablity to configure a Pharmacy Benefit. Additional condition types have been added including the following:

Cost shares, limits, coverage, authorization requirements can be configured using combinations of these types. For example, the copay for Preferred Brand drugs may be $50 while the equivalent Generic drugs ordered via mail order would have a copay of $ 10 per order.


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Creating a Pharmacy Benefit To activate the Pharmacy configuration when creating a Benefit, select the Category of Pharmacy.

The remainder of the configuration is the same as the Medical benefit process flow.

Creating a Pharmacy Grouper When creating a Grouper select the Category of Pharmacy.

Only Pharmacy Benefits can be selected in Pharmacy Groupers. On the Grouper creation screen the only Pharmacy Benefits will display in the dropdown list.

The remainder of the configuration is the same as the Medical Gruper process flow.

Adding a Pharmacy Grouper to a Medical Benefit Set PCS can configure Products with Pharmacy, Medical, etc. components. To add a Pharmacy Grouper or Benefit to a Product, add them to a Benefit Set as shown below:

Steps:

1. To select medical Benefits, set the Category to “Medical” and search for Benefits. Add them to the Benefit set.

2. To select Pharmacy Benefits, set the Category to “Pharmacy” and search for Pharmacy Benefits. Add them to the Benefit set.


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Creating a Pharmacy Benefit Set On the Benefit Set metadata screen, select the category of “Pharmacy”. Add Pharmacy Groupers and Benefits to the Set.

There are no restrictions from adding non-pharmacy Benefits or Groupers to the Benefit Set.

Creating a Pharmacy Product Template To create a Pharmacy Template, select the category “Pharmacy” on the metadata screen. This selection changes the dropdown lists on product and policy variation rules.

Pharmacy configurations on variation rules:

In the example above, the additional condition types allow the user to configure variation conditions aligned with Pharmacy benefits for cost shares, coverage, limits and authorization requirements.

The reminder of the Pharmacy process flow and screens are identical to Medical.

On the limit tab in the policy view, additional pharmacy limit type selections are available. Also added for Pharmacy are Waiting Period and Supply Days fields.


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Creating a Pharmacy Product To create a Pharmacy Product, select the category “Pharmacy” on the metadata screen. The condition types and variation rule configurations will change to align to pharmacy benefit requirements.


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Chapter 11: Tags, Reports & Common Processes

Assigning Tags in PCS Tags provide the ability to assign and search work items by user defined words or tags. For example, if a user assigns a tag of “HMO” to a Benefit Set, Templates and many Products, they can be searched, filtered and reported using the tag. Many tags can be assigned to a single work item.

Tags can also be effective assisting custom service search for the most appropriate benefit for a given caller.

The first step is to create tags in PCS:

Creating Seed Tags: Select > Process

and Rules > Social > Tag Configuration. Tags are free form text.

Assigning tags: Tags can be assigned to work objects such as Benefits, Sets, Templates, etc. On the work object creation process,

click on the tag icon, .


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The tag icon opens up the tag assignment screen. See example above of assigning tags to Benefits during the creation process:

Tags are assigned to work pools within PCS including: • Most Urgent — displays a list of open work items associated with the tag sorted

in descending priority order

• Recently Resolved — displays a list of recently resolved work items associated with the tag

• Top Resolvers — displays a list of resources who have resolved the most items associated with this tag

• Related Tags — displays a cloud of tags used in conjunction with the currently selected tag. Click one of these related tags to view the tag deck for that tag

Search Tags: After assigning tags to various work items, the search feature provides the ability to search across all work items (benefits, sets, templates, etc.) and list all work items linked to the specific tag.

The screen at right illustrates an example of tags assigned to various work items. The size of the font indicates the number of assignments. A tag with a large font is assigned too many work items while a small font indicates fewer assignments.

The screen below shows an example of a Benefit and a Benefit Set matching the tag search criteria.


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The “where referenced” feature also works with tags showing where a specific tag is referenced.

PCS Reports This section describes how to run and review PCS reports as well as the standard reports delivered with the PCS solution.

PCS ships with thirteen reports specific to the work and rules created in the PCS system. In addition to these reports, fifty+ standard PRPC reports are included. Each of these reports can be adjusted to provide additional data when necessary.

The function is accessible from a link on the Get Started section of the user portal. This function allows you to:

Select a report to review

Review the report data

Open rules of work objects depending on the type of report

Export report details to Excel depending on the type of report

Steps

On the left navigation panel, select Reports to open the report screen.

• PCS References Reports

• PCS Work Analysis Reports

• PCS Work Monitoring Reports

Selecting the PCS References reports from the list of standard reports displays the following list:

Open any report to review the report data and optionally export that data to an Excel spreadsheet.

Selecting the PCS Work Analysis Reports from the list of standard reports displays the following list:


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From any of these report lists, you can select and run an individual report. In this example, the Product Template by Status report is selected.

From this report you can manipulate the chart and drill down into any of the objects displayed to open a product template item by its status.


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Common Work Processes This use case describes the processes that are available to you to perform on the major objects such as the benefit, benefit set, product template, product and contract from the Actions icon.

The function is accessible when a work item displays on the user portal. The actions you can select and perform are:

Take Notes

Add Attachments

View History

Where am I

Steps

1. Display a work item such as a benefit, benefit set, product template, product or contract in the workspace of your portal. In this example, a benefit is displayed.

2. Select Take Notes from the Actions list. Enter the Subject and the Note text, and then click OK to save. The system saves the note and stores it with the object.

3. Select Add Attachments from the Actions list. Enter the Subject and Category for the attachment. Browse for the attachment and click OK when the desired attachment is found. The system saves the attachment and stores it with the object.

4. Select View History from the Actions list. You can review the history for the object as well as add or remove attachments in a separate


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window. Close the window when the review is complete to return to the previous screen.

5. Select “Where am I” from the Actions list. From this display you can review the flow in a new window and see the step in the flow that you are currently working on. Close the window when review is complete return to the previous display screen.


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Chapter 12: Mass Update Benefits This chapter describes the PCS business process for adding or removing Benefits from a Benefit Set after Product Templates, Products and Plans have been created and configured.

This Chapter includes:

Mass Update Benefit Sets to Product Templates Mass Update Benefits in Dependent Templates Mass Update Product Templates to Products Mass Update Products to Plans Mass Update Agent Processing Mass Update Error Processing Mass Update Action Menu

Overview PCS provides the ability to change the list of benefits in a Benefit Set and mass update the changes to all associated Product Templates, Products and Plans. After a Benefit Set is modified to include new Benefits or remove existing Benefits, those Benefit changes are propagated to all the Product Templates created from that Benefit Set. Removing benefits from a Set will result in those benefits being removed from the associated Product Templates - no additional configuration is necessary for removals. Once the updated Product Templates acquire the new Benefits, each of the template creation flows configures the new benefits and the templates are saved.

After templates are saved, once again, the Mass Update feature recognizes the Benefit structural changes and the process continues: adding / removing benefits from the template to the product; but this time, with Benefit configuration data. Again, this process continues propagating structural Benefit changes from Products to Plans including benefit configuration added in the product creation process.

Several import points were omitted above to convey the general notion of Mass Update, but are included here: Although Mass Update is described relative to Benefits; Groupers within a Benefit Set

are managed identically. Mass Update is predicated on being able to change the Benefit composition of a Benefit

Set; this can only be done by saving the Benefit Set as Draft and not Final. Saving as Draft, saves a version of the artifact and cycles back into the creation process as further changes are expected.

Mass Update is qualified here as conducting structural changes, meaning that whole benefits and their entire configuration are propagated. Changes to individual property values within existing benefits cannot be updated en-mass. This capability will be delivered in future PCS release.

The Benefit Set in PCS is “the source of truth” or foundation for Benefit composition in subsequent artifacts. Complexities arise between the features of Mass Update and Benefit Copy and Paste. These are discussed in following sections.


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Note: Benefit Mass Update will not erase or negatively impact the configuration of existing

Benefits in Product Templates, Products or Plans.

Mass Update Benefit Sets to Product Templates After configuring the Benefits in a Benefit Set and saving in Draft mode, the Benefit Set is available for construction of templates, products and plans. The number of these artifacts will depend on the core differences required in each for a company’s business. The number of Benefit Sets will depend on the needed differences in Benefits contained in them. The number of Product Templates will depend on the differences in cost share ranges and defined conditions required. For Products, the number will depend on the differences in cost share values and condition selections. Plan numbers will depend on the required changes to Products for interacting with the customers buying them. In general, expectations are that the numbers of artifacts will increase with each stage in the gestation of Benefit Sets to Plans.

Throughout this process, it should be evident that the Benefit Set is the foundation of an insurance Plan; Benefit Sets are therefore termed, “the source of truth” - an important concept in discussing the complexities of Cut and Paste.

As the Benefit Set is modified, Mass Update propagates those changes to the dependent Product Templates.

Notes: Requires Benefit Sets, Templates and Products to be in draft mode. PCS operating modes of Mixed or Claim Centric employ Benefit Sets. Benefit Mapping to claim codes does not influence Mass Update and is not required. Plans can be created from draft Products effective with the interim release of June 28,

2013.

Initial Configuration of Benefit Sets, Templates and Products

1. Create Benefits and Groupers using their Create processes.

2. Using the Create Benefit Set process; configure Groupers and Benefits into a Benefit Set, and save as Draft.

3. In Product Template creation flow, use the Benefit Set to create the product tree. Configure each Benefit in the process – Product for cost shares, Policy for conditions. Approve the Product Template as Draft.

4. Create Products from Product Templates; save as Draft.

At this point all dependent artifacts are arranged for Mass Update


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Mass Update Benefits in Dependent Templates

1. From the Product Architect’s home page, select a Draft Benefit Set for revision from the To Do List. Add or remove Groupers and or Benefits from the Set. In the example below, the “Emergency Room” benefit is added to a Benefit Set used as the foundation for our Mass Update example.

2. Approve the Benefit Set. After the approval process, when the revised Benefit Set is saved; the system recognizes that dependent Product Templates have been created from this Benefit Set. A link is presented to the Product Architect allowing entry to Mass Update. The Mass Update flow is executed starting with the Select Update Actions screen displaying available options.

3. Select Update Actions displays the template targets being updated with the edits being performed. Check Perform Edits for each template to be updated and Conflict Override to overwrite configuration data.

Edits are the same for each template target, the Benefit Set changes; shown by the Edit/Source panel (above right). Benefit conflicts are identified for each target and an option to override them can be checked (left panel).


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Benefit conflicts arise when a Benefit is copied from another template and pasted into the product template; and then that template is mass updated. Benefit copy/paste allows configuration data to be copied as one of the selections (Copy as is verses Copy with data). The Conflict Override option allows the user to overwrite that configuration data or not. In this instance, Benefit Set to Product Template Mass Update, configuration data would be removed because Benefits within a Benefit Set cannot have configuration data. Benefit (Grouper and Network) configuration commences in the Product Template. The interaction of Mass Update with Copy and Paste is the complexity mentioned previously.

Locking issues can be a common occurrence with mass update running together with users actively working on the same artifacts; therefore, it’s advisable to schedule mass updates for “off hours”. In early stages of product design, mass update can be deselected – uncheck Perform Edits. However, bypassing mass update will result in the previous benefit configuration of the Templates and Products to be left undone.

Mass Update is performed by an Agent process where changes are queued and executed when their schedule date times occur. The mass update process will add the new benefits automatically to each “full” Network in the Template. Carveout Networks must have benefits added or removed manually. Benefits removed from the Set will be removed from all full Networks. A Mass Update History report is available on the Action menu showing details of actions taken.


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4. Review Mass Update Actions and Edits and click Next. The Mass Update work item is now delivered to the Product Managers work list.

5. The Product Manager opens the Mass Update work item and reviews the Actions and Edits for the Product Template.

6. After submitting the Mass Update work item to the Agent, the following links are shown. This work object should be closed allowing the Agent to continue processing.


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Configure New Benefits in Product Templates

1. After the Template is mass updated, the affected Templates in the Product Architect’s work list can be selected and moved forward to the Configure Product Tree.

2. The Template owner configures all the new Benefits. The Example below shows the new Benefits added under each Network. The Emergency Room benefit has been added to the Template and configured:

Mass Update Product Templates to Products The process of mass updating Templates to Products is very similar to the previously described process.

1. After configuring the Product Template Benefits, follow the approve process flow.

2. If the system detects Products associated with the Template, the Mass Update process starts again.


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3. Select the mass update process link.

4. PCS advances to the Select Update Actions screen and provides the user with the same options described in the Benefit Set to Product Template Mass Update:

a. Perform Edits – a checkbox of which Products to update, check to update.

b. Override Conflicts – a checkbox to replace configuration data, check to replace.

c. Now or Scheduled – the date time to run Mass Update

As before, currently existing Conflicts are identified; this may change when Mass Update actually occurs.

5. Click Next to display the Review Update Actions screen.

6. Again, the mass update process will add the new benefits automatically to each “full” Network in the Product. Carveout Networks must have the benefits manually added or removed. Benefits removed from the Set will be removed from all full Networks.

Mass Update Products to Plans The process of mass updating Benefits from Products to Plans is identical in all respects to that previously described. There is one exception, Plans do not have Draft processing, they are saved final only; regardless, Benefit Sets are the “source of truth” changes to them ripple through the progression of artifacts so that Plans are updated as well.

Mass Update Agent Processing The Mass Update Agent runs with a defined frequency and delay between runs, specified in the Agent rule definition in PegaHC-USA-PCS. As processing occurs, the errors that can occur are parsed and fed into retry and manual intervention workbaskets that the Product Manager can use to analyze and resolve problems.


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Mass Update Error Processing The Mass Update Agent may encounter errors as it updates Product Templates, Products and Plans with changes from the Benefit Set. The errors parsed for Retry and Manual Intervention will be found in their respective workbaskets:

PCSMassUpdateErrors@myhealthplan PCSMassUpdateRetry@myhealthplan.

The Retry errors are retried for a number of iterations with a delay time separating the retries.

The following table describes the types of errors and their dispensation:

Error Status Value Parse Results Explanation

Pending-MUErrorTargetNotFound Manual Intervention Target rule not found

Pending-MUErrorWONotFound Manual Intervention Target work object not found

Pending-MUErrorWONotOpen Auto Retry Target work object could not be opened

Pending-MUErrorWONotSaved Auto Retry Target work object could not be saved

Pending-MUErrorTargetNotSaved Auto Retry Target rule could not be saved

Pending-MUErrorRulesetNotFound Manual Intervention Target ruleset was not found

Pending-MUErrorRulesetLocked Manual Intervention Target ruleset was locked

Otherwise Manual Intervention

Both the delay time between retries and the maximum number of retries is specified in the PCS Configuration:

When the retry count is exhausted, the Mass Update work item experiencing errors is placed in the Manual Intervention workbasket where it is available for closer inspection and analysis.


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Mass Update Action Menu Two entries were added to the Action menu to help with Mass Update:

Mass Update Synchronize — Allows Templates, Products and Plans to catch up with their Mass Updates in the event that Perform Edits was not checked, but the owner now deems it necessary to acquire the updates.

Mass Update History — Displays the Mass Update actions history.


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Chapter 13: Benefit Configuration Examples This chapter describes the PCS business processes to enable your understanding of the available features and functionality.

Use cases included are:

1. Quick Entry Cost Share Configuration using Master Variations

2. Copay varies by inpatient vs. outpatient

3. Copay varies when seeing PCP vs. Specialist

4. Visit limit varies by Provider specialty – Mental Health

5. Coverage restricted by age ranges - Colonoscopy

6. Benefit comparing dollar and usage limits - Wigs

7. Comparing copay to coinsurance and selecting lowest member liability

8. Authorization required – higher copay if not found

9. Configuring Mental Health carveout product

10. Vary visits by age - Habilitation OT 11. Compare Unit and Dollar Limits - In Vitro Fertilization

12. Benefit Age Tiers - Preventive Routine Care

13. Visit Range Tiers - Partial Hospitalization Professional

14. Compare Cost Shares - Skilled Nursing Facility


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1. Quick Entry Cost Share Configuration using Master Variations

Use Case:

85% of Benefits can be configured using only Cost Shares (Product view)

Most PCS clients will use variations to configure cost shares based on the context of Benefits such as Inpatient, PCP visit, with authorization, etc.

Steps:

Configuring Master List of Cost Share Variations on Product Templates

Creation of a master list of variations is configurable on the Product Template. Select the Variations tab and create the list of variations desired. Clicking Apply copies this list of variations to all the cost share tabs. This configuration enables the cost share quick entry screen on the Product configuration.

The Master List Variation feature provides the ability to configure consistent variation rules for all cost shares. A consistent list of cost shares provides the ability to directly map to claim system benefit rules.

• Benefit variations for both cost shares (product view) and member coverage (policy view) are often used to configure Benefits in PCS. This feature provides the ability to create a common or master list of variations across all cost shares and coverage tabs.

• Provides consistent variation list for a Benefit.

• Master variations are configured on the Product Template and automatically inherited to the Product and Plan process.

1. From the product tree, product view, select Configure. Select a benefit row.

2. To create a master variation list, select the Variations tab

3. Select Edit.

4. Select the cost share types that will be configured with the master variation list.



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6. Configure the condition types and dates. Multiple condition types can be selected for every rule.

7. Add as many rules as necessary.

8. Click Apply. The check marks as noted below will appear for every variation rule. See above:

Quick Entry Screens for Cost Shares (product view)

Most of the configuration for a specific Benefit is maintained on the Product Template process. For example calculation methods, conditions, etc. are best configured on the Product Template

On the Product process, the cost share “quick entry” screen is provided to allow for configuration of common cost shares and coverage information. A single screen allows the user to configure all cost share amounts for a Benefit and corresponding variations.

On the Product process, use the screen shown above to enter the cost share amounts for each type. Typically, this configuration is sufficient for cost shares eliminating the need to visit and configure each cost share tab in the Product process.


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Steps:




4. Select Edit.





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2. Copay varies by inpatient vs. outpatient

Use Case:

In-Network, Mental Health Counseling Inpatient

• $ 50 copay

In-Network Mental Health Counseling Outpatient

• $ 20 copay

Out of Network Mental Health Counseling

• NOT COVERED

Steps: 1. Create Mental Health Counseling Benefit.

2. Create a Benefit Set with Mental Health benefit.

3. Create a Product Template with In-Network and Out-of-Network Networks.

4. Generate product tree with Benefit Set and both Networks.

5. Configure Product Template with the range of $20 to $50 copay for In-Network Mental Health Counseling.

6. For Out-of-Network, Mental Health Counseling set the Service is covered to blank. This indicates that the Benefit is NOT covered.

7. When reviewing the Product Template, the Out-of-Network, Mental Health Counseling benefit will appear with blank in the “covered” column indicating this Benefit for Out-of-Network is NOT covered. This satisfies the not covered bullet in the use case.


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8. Create a Product from the Product Template. Product Templates role are to form the foundation for Product creation. Cost share variations are configured on the Product process. Cost Share variations are very specific to the Product and therefore not configured on the Product Template.

9. When creating the Product, select the Mental Health Counseling for In-Network and Configure.



12. Select Per Visit to indicate the $ 50 would be charged for each visit to the Counseling sessions if at an Inpatient facility.

13. Under Copay Conditions select Place of Service. Enter Inpatient. (Optionally, the dropdown will access the POS codes to allow for selection of POS codes.


15. To configure the Outpatient copay of $ 20 there are two options.

• Use the Default value of $20. In this case there are no additional “rules” to configure

• Create a rule for Outpatient.


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16. Complete. See screen sample below.


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3. Copay varies when seeing PCP vs. Specialist

Use Case:

Office Visit Benefit

• $ 25 copay for visiting Specialist

• $ 20 copay for visiting PCP

Steps: 1. Follow use case 1 to add an Office Visit Benefit to a Product Template and Product.

2. The Product Template creation process does not have cost share variations. Cost share variations are very specific values of cost share. Product Templates configure ranges of cost shares.

3. Cost share variations are configured on the Product creation process.

4. When creating the Product, select Configure on the product tree screen.

5. On the detail screen, select the Office Visit benefit for In-Network and select Edit.



8. Select Per Provider per Visit to indicate the $ 25 would be charged for each visit to a specific Provider.

9. Under Copay Conditions select Service By and Specialist.


11. Click Save.

12. To configure the PCP copay of $ 20 there are two options:

• Use the Default value of $20. In this case there are no additional “rules” to configure. Create a rule for “PCP” copay with $ 20 copay specified.

• Create a second variation rule configured with $ 20 copay per visit with a Condition of “PCP”.

13. Save variation rule.

14. Review and complete.

15. Return to summary view.


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16. See screen illustration below for an example of a cost share variation rule.

4. Visit limit and usage level varies by Specialty – Mental Health

Use Case:

Mental Health visits

• Maximum of 10 visits to a Psychiatrist per benefit year. In this case the visits have a usage rate of 4 to 1. Example, 1 visit to a Psychiatrist equals 4 visits to Group counseling sessions

• Maximum of 20 visits to a Psychologist per benefit year. In this case the visits have a usage rate of 4 to 1. Example, 1 visit to a Psychiatrist equals 2 visits to Group counseling sessions

• Maximum of 40 group counseling visits per benefit year.

Steps: 1. Create Benefit for Mental Health.

2. In Product Template select the Mental Health Benefit.

3. Select Configure Benefit.


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5. Select Edit.

6. Select add a Rule. See screen example above. Configure a Visit Limit of 10 maximum visits per benefit year with a usage rate of 4 – Four for One.

7. Configure Limit Conditions to specify this rule applies only to Psychiatric visits.

8. Create a second limit specifying a Visit Limit of 20 visits per benefit year with a usage rate of 2 – Two for one.

9. In the second limit rule, specific the limit conditions for all specialties other than Psychiatrists that are covered when performing individual sessions.


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10. Configure the third limit rule to specify the 40 group counseling sessions per benefit year.

11. The limit conditions for the group sessions can be configured using a code group for Group Sessions in the limit conditions section as noted below.

12. The result will be three limit variation rules as noted below.


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5. Coverage restricted by age ranges - Colonoscopy

Use Case:

Colonoscopy Screening

• Age 0 to 49 Only if authorized by PCP

• Age 50 to 55 1 Screening per 5 years

• Age 55 to 65 1 Screening per 2 years

Steps: 1. Create Benefit for Colonoscopy.

2. In Product Template select the Colonoscopy Benefit.

3. Select Configure Benefit.

4. Add Policy term on the fly by selecting Create Policy Term. Policy Terms can be predefined and inherited during the Product Template creation process. This use case will describe the configuration of a Policy Term directly on the Benefit. A second option is to create a policy term for screening colonoscopy within a Policy of Colonoscopy.

5. Create a policy term rule for age 0 to 49 a screening colonoscopy that is only approved with an authorization. In the example below, the authorization required prior to service is selected. The conditions when this rule applies are configured with an “Age Band” condition type. This type requires the configuration of age ranges indicating the ages that require authorization.

6. In the example below, an additional condition was added for gender.

7. This Authorization rule states that an authorization will be required for a Colonoscopy for women ages up to but not including 50 years. This covers the first bullet of the use case.


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6. Benefit comparing dollar and usage limits – Wigs

Use Case:

Wigs

• Maximum of 1 wig per benefit year

• Maximum of $ 300 coverage per benefit year

• Take which ever limit is reached first

Steps: 1. Create Benefit for Wigs. It can be a broad misc Benefit covering many items

including Wigs.

2. In Product Template process on the Product Tree view select Configure.

3. On the detail view select the Wig Benefit.

4. Select Edit.


6. Add a Rule. See screen example below.

7. Select Compare.

8. For Limit 1 configure a Dollar limit. Set to $ 300 per Benefit Year and a Calculation Method of “Coverage based on Allowed”.

9. For Limit 2, configure a Unit limit. Set the number of units to 1 unit (Wig) per Benefit Year.


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10. If the Benefit is broader than Wigs, user can configure a Limit Condition to specify the Code Group of Wigs. See below.

7. Comparing copay to coinsurance and selecting lowest member liability

Use Case:

Mental Health Visit Benefit

• $ 25 copay for visiting Specialist

• 80% Coinsurance

• Select the calculation that results in the lowest member liability

Steps: 1. Select Configure on the product tree screen

2. On the detail screen, select the Mental Health benefit



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4. Select Compare. When selecting compare two independent cost share configuration areas will appear. The user will configure each cost share type independently then select the comparison method from the list shown at right.

5. For the Compare two cost share types, select the option Whichever is the lesser member liability.

6. For Cost Share type 1, select Copay and enter $50 in the amount field.

7. Select the calculation method of Per Visit to indicate the copay will be taken for each visit to the Provider.

8. For Cost share 2, select Coinsurance and the amount of 80%.

9. For the cost share type 2 calculation method select Standard Coinsurance.

10. For Apply to Accumulators select Apply to Accumulators.

11. In this use case there are no specific condition rules.


13. Select Review and Complete to save

14. Select Summary View to return to the Product Tree view.


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8. Authorization required – higher copay if not found

Use Case:

Out of Network, Emergency Room Benefit

• Authorization is required

• If authorization is not found, raise admission copay to $ 250

Steps: 1. Follow use case 1 to add an Out of Network Emergency Room Benefit to a Product

Template and Product.

2. Cost share variations are configured on the Product creation process not during Product Template creation process.

3. Proceed to the Product Tree configuration screen. Select Policy view and Configure.

4. On the detail screen, select the Emergency room Benefit under Out of Network. Benefit.

5. Under the Authorization tab, select Edit.

6. Select Add Rule to create a policy term variation rule.

7. Select the Authorization required prior to service.

8. If additional conditions are required such as authorization ONLY for specific services, these can be configured by selecting a condition type and Service Group. Service groups are configured by each client. They represent specific ranges of codes such as CPT, HCPCS, Revenue codes, ICD-10, etc.

9. Generate the description and save.

10. Select Review and Complete then return to summary view

11. The screen below illustrates the configuration requiring an authorization for Out of Network Emergency room services.


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12. The second part of the use case requires configuring copay to be higher if the authorization is not available. From the Product tree view, select Configure.

13. From the Detail view select the Emergency room Benefit for Out of Network.

14. Select the Admission Copay tab and select Edit

15. Enter $ 250 amount.

16. On Admission Copay Conditions select the Authorized type then the Authorization is required but not found entry.

17. This configuration specifics that if a claim is an Out of Network Emergency room claim and no authorization is found, raise the admission copay to $ 250 per visit.


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18. The screen below is an illustration of this configuration in PCS

19. Save the configuration.

20. Select Review and Complete.

21. Select Summary View to return to the Product Tree.


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9. Configuring Mental Health carveout product

Use Case:

Configure a Mental Health carveout Network

• Create Network

• Configure as an “at risk” carveout

• Configure appropriate Benefits

Steps: 1. Select Networks from the left navigation area.

2. Select Create Network.

3. On the metadata screen select Per Member Per Month reimbursement method.

4. Submit and approve Network.

5. Create a Product Template.

6. On the build structure screen, select the new Network and indicate it as Carveout yes.

7. When building the product structure, a carveout network will not automatically insert Benefits under the network. The user must manually select the appropriate Benefits for the carveout network. To add Benefits to a carveout network, right click on the network in the build structure section.


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8. Add Benefits as appropriate. See screen illustration at right.

9. The Mental Health Network will now contain the benefits appropriate for the carveout contract.

10. Save the Benefit Set.

11. Configure the Product Template.

10. Habilitation OT – Vary visits by Age

Use Case:

Benefit: Habilitation – OT

• Provider Type: Facility Provider

• Place of Service: Outpatient

• Coinsurance: 100%

• Copay: $20 per provider per day

• Apply Deductible? N (Set Deductible to zero on this Benefit)

• Apply Stop-loss? Y (Set OOP limit)

• Effective Date: 1/1/2008

• Term Date: 12/31/9999

• If Age is between 0 and 18 years, then, allow a maximum of 999 visits, for 1 plan year;

• If Age is over 18, then, allow a maximum of 30 visits, for 1 plan year

Configuration approach The configuration will be in the following steps:


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• Product Template: Configure the master list of variation rules on the Product view and the Policy view. Go to Product to configure the copay and the visit amounts by age.

• Product: Configure the Product view, cost shares, Copay tab to set $20.

• Product: Configure the Policy view, Limit tab to configure the age ranges and maximum visits.

Create Benefits and Benefit Set:

1. Create Benefits with effective date of 1/1/2008 and expiration date of 12/31/2999.

Product Template: Create master list of variation rules:

2. On Product Template, select Configure on the product tree, product view. Configure and select the Benefit.

3. Edit the master list of variation rules and the corresponding cost share tabs. Select 2 condition types: Provider Type: for Facility Provider and Place of Service: Outpatient.

4. Variation rules need only be configured on the Product Template. The list is inherited to the Product level.

Product Level – configure copay

1. On the product tree, product view, select Configure. Select the Habilitation OT benefit under the appropriate Network.

2. Select the Copay tab and select, Edit.

3. For the Variation rule, configure Copay to $ 20 per provider per visit.

4. Select Apply to Accumulators.


6. Select the Coinsurance tab. Set to 100% on Benefit level and variation rule.

7. Select Review and Complete to save.

8. Select Summary View to return to the Product Tree view.


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Limits – Policy view to configure limits by age

1. Select the Policy view and select Configure.

2. Select Create Policy Term.

3. Select the Limits tab.

4. Select Edit.

5. Configure limits tab as shown below.

13. Generate description and save.

14. Select Review and Complete, return to summary view.


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11. In Vitro Fertilization – Compare Unit and Dollar Limits

Use Case:

Benefit: In Vitro Fertilization

• Provider Type: Institutional Provider

• Place of Service: Inpatient

• Coinsurance: 100%

• Copay: $ 0

• Apply Deductible? N

• Apply Stop-loss? Y

• PreAuth Required? Y


• Term Date: 12/31/9999

• Allow a maximum 3 attempts, for 1 week; AND

• Allow a maximum benefit limit of $100,000 for 1 Lifetime

Configuration approach The configuration will be in the following steps:

• Product Template: Configure the master list of variation rules on the Product view and the Policy view.

• Product: Configure the Product view, cost shares, Copay tab to be $0.

• Product: Configure the Product view, cost shares, Coinsurance tab to be 100%.

• Product: Configure the Product view, cost shares, Maximums tab to be $100,000 lifetime for both single and family.

• Product: Configure the Limit tab for the maximum 3 attempts for 1 week.

• Product: Configure the Authorization tab on the Policy view to require an authorization.

• The tabs in PCS work as “and” logic. By configuring the Maximums, Copay, Coinsurance, Limits and Authorization tabs PCS applies all three as “and” conditions.

Create master variations on Product Template

1. On Product Template, select Configure on the product tree,

2. On the Detail screen, select the In Vitro Fertilization benefit under the appropriate Network.

3. Create master variation. Select 2 condition types: Provider Type: for Facility Provider and Place of Service: Inpatient.


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4. Select Copay, Coinsurance and Deductible.

Product level configuration

1. From product tree, product view, select Configure.

2. Select the Copay tab and select Edit.

3. Set copay to $ 0 for Benefit and variation.

4. Select the Coinsurance tab. Set coinsurance to 100%.

5. Configure Maximums. Set the Single and Family maximum coverage to $ 100,000. Select Lifetime Coverage as the maximum type. See screen example below:

6. Select Review and complete to return to the Summary view.

7. Select the Policy View.

8. Select Benefit and Configure.

9. Select the Limit tab and select Edit.

10. Select limit type of unit limit floating period.

11. Enter 3 units every 1 week.

12. Select calculation type of per episode.



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14. See screen example below:

Configure authorization.

1. Select the Authorization tab.

2. Select Authorization required prior to service.

3. See screen example below:


5. Click Finish.


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12. Preventive Routine Care – Benefit Age Tiers Use Case:

Ability to vary the coinsurance based on age.

In Network

• Benefit: Preventive Routine Care - Children

• Provider Type: Professional Provider

• Place of Service: Office Visit

• Apply Deductible? Y



• Term Date: 12/31/9999

• Age between 0 and 2 years: Coinsurance is 100%




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Network: XOUT (out of network)

• Benefit: Preventive Routine Care - Children


• Place of Service: Office Visit




• Term Date: 12/31/9999

• Age between 0 and 2 years: Either Coinsurance is 100% with a Copay of $20 per visit OR Coinsurance is 70% with no Copay, whichever has a Greater Member Liability

• Age between 3 and 13 years: Either Coinsurance is 100% with a Copay of $30 per visit OR Coinsurance is 70% with $10 Copay per visit, whichever has a Greater Member Liability

• Age between 14 and 18 years: Either Coinsurance is 100% with a Copay of $40 per visit OR Coinsurance is 70% with $10 Copay per visit, whichever has a Greater Member Liability

In Network Configuration approach

The configuration will be in the following steps:

• Product Template: Configure the master list of variation rules on the Product view and the Policy view. Go to Product to configure the variation rules.

• Product: For the In Network Benefit, configure the Product view, cost shares, “Age Tiers” tab to match the age ranges and coinsurance levels specified.

Out Network Configuration approach

• Product: For the Out Network example, configure the Product view, cost shares “Age Tiers” tab to match the age ranges and combination cost shares specified.

In Network Use Case

Create master variations on Product Template:

1. From the Product View select Configure on the product tree screen.

2. On the Detail screen, select the Preventive Routine Care benefit under the In Network.

3. Create master variation. Select 2 condition types: Provider Type: for Professional Provider and Place of Service: Office Visit.

4. Select all applicable cost share selection boxes.


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Product level configuration for In-Network example

1. From product tree, select Configure.

2. Select Benefit under In-Network.

3. Select the Coinsurance tab. Set default Benefit Coinsurance to 100%.

4. Select the Age Tier tab.

5. Configure age ranges and coinsurance percentages per the screen illustration below.

Product level configuration for Out-Network example

1. From product tree, select Configure.

2. Select Benefit under Out-Network.

3. Select the Coinsurance tab. Set default Benefit Coinsurance to 100%.


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4. Select Age Tier tab.

5. Configure Age Tier per the screen example below:

6. Click Save.


8. Finish configuring the benefits in the Product and click Set Values to indicate the Product Tree has been reviewed and is complete, then advance the flow to completion.

9. Complete the Product by going through Approval and save it.


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13. Partial Hospitalization Professional – Visit Tiers

Use Case: Ability to vary the coinsurance based on visit limit ranges.

Network: PPO (in network)

• Benefit: Partial Hospitalization Professional


• Place of Service: Hospital





• Term Date: 12/31/9999

• Tier limit between 1 and 5 Visits per Plan Year: Coinsurance is 80%



Configuration approach


Product Template: Configure the master list of variation rules on the Product view and the Policy view. Go to Product to configure the variation rules.

Product: Configure the product view, coinsurance tab to set the default coinsurance to 80%.

Product: Configure the policy view, benefit tiers tab to match the limit ranges and coinsurance levels specified.

Product: Set the authorization required tab to “authorization required prior to service”


1. Select Configure on the product tree screen, product view.

2. On the Detail screen, select the Partial Hospital Professional benefit under the In Network.

3. Create master variation. Select 2 condition types: Provider Type: for Professional Provider and Place of Service: Hospital.

Policy View


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1. Select Policy view and select Configure.


3. Select the Limits tab and select Edit.

4. Set default limit of 5 visits.


6. Select the Benefit Tier tab

7. Configure as specified in screen example below:

8. Click Save.

.


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9. Select the Authorization required tab and configure as shown below:

14. Skilled Nursing Facility – Compare Cost Shares Use Case:

Ability to compare a copay / coinsurance combination to copay / coinsurance combination and take the result that results in the greater member liability.

Network: PPO (in network)

• Benefit: Skilled Nursing Facility Admission

• Provider Type: Institutional Provider

• Place of Service: Inpatient



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• Term Date: 12/31/9999

• Coinsurance is 100% with a Copay of $40 per provider per visit OR Coinsurance is 80% with no Copay, whichever has a Greater Member Liability

• Subject to a Maximum of 100 Days per plan year

Configuration approach


Product Template: Configure the master list of variation rules on the Product view and the Policy view. Go to Product to configure the variation rules.

Product: Configure the policy view, benefit tiers tab to match the limit of 100 days and the comparison of copay / coinsurance.

Product: Set the authorization required tab to “authorization required prior to service’


1. Select Configure on the product tree screen, product view.

2. On the Detail screen, select the Skilled Nursing Facility Admission benefit under the In Network.

3. Create master variation. Select 2 condition types: Provider Type: Institutional and Place of Service: Inpatient.

Product Level Configuration

1. On the product tree select Product View and select Configure.

2. Select the Coinsurance tab and set to 100% for benefit default.

3. Select Copay tab. Set copay to $ 40 for Benefit default.

Policy View

1. Select the Policy view and select Configure.


3. Select Limits tab and select Edit.

4. Set default limit of 100 days.



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6. Select the Benefit Tier tab.

7. Configure per the screen example below:

8. Click Save.


10. Click Finish.

Product Composer System Business Use Case Guide - Pega ...

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