Pega Foundation for Healthcare · configured access privilege rules that can be used in your UI design to obfuscate desired data fields on the screen. The Foundation also provides

Pega Foundation for Healthcare

PRODUCT OVERVIEW 7.4

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Pega Foundation for Healthcare

Document: Product Overview

Software Version: 7.4

Updated: April 2018

CONTENTS

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

High level functionality ................................................................................... 2

Healthcare object model ................................................................................... 2

Healthcare enterprise organization structure ................................................ 2

Healthcare portals ............................................................................................. 2

Healthcare sample data .................................................................................... 3

Healthcare object search and retrieval ........................................................... 3

Healthcare object layouts ................................................................................. 3

Member data masking ...................................................................................... 4

Healthcare code set management ................................................................... 4

Healthcare code group management .............................................................. 4

Healthcare code lookups .................................................................................. 4

ICD code mapping .............................................................................................. 5

Healthcare Appeals and Grievances management ........................................ 5

HIPAA X12 EDI message support ...................................................................... 5

Common integration REST APIs ....................................................................... 5

Common integration FHIR®© REST APIs ........................................................... 6

Integration Data Pages ...................................................................................... 6

EDI Eligibility Request management ................................................................ 6

EDI Claim Status Request management .......................................................... 6

EDI NCPDP message support ........................................................................... 7

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

Healthcare Common Objects ........................................................................... 8

Membership Model............................................................................................ 9

Provider Model ................................................................................................. 10

Healthcare Common Codes ............................................................................ 11

X12 5010 Object Model ................................................................................... 12

HL7 FHIR Object Model.................................................................................... 13

Applications, roles, portals, and dashboards ............................................. 14

Applications ...................................................................................................... 14

Roles .................................................................................................................. 14

Operators and access groups ......................................................................... 16

Portals and dashboards .................................................................................. 17

Healthcare Codes Manager portal ................................................................. 18

Healthcare Sample Data Admin portal .......................................................... 19

Healthcare Appeals and Grievances Manager portal .................................. 20

Further reading .............................................................................................. 21

Visit the Pega Discovery Network (PDN) ........................................................ 21

Pega Product Overview 1

This Pega Foundation for Healthcare Product Overview describes default features and benefits, cases, data model, and the various preconfigured roles and portals.

Built for healthcare organizations, the Pega Foundation for Healthcare provides a set of enterprise healthcare assets including pre-configured data models for commonly referenced healthcare objects and code sets, APIs for rapid integration with external systems of records, and support for industry-standard electronic data interchange (EDI) and other message and transaction standards including HIPAA X12 5010. These assets provide you a platform for rapid configuration and deployment of SmartBPM™ solutions that deliver productivity, spur growth, and ensure compliance.

Healthcare organizations can use Pega Foundation for Healthcare to

• Address new market opportunities in a fraction of the time required by more traditional development environments and accelerate the development of personalized solutions targeting your organization’s biggest challenges across your key domains of marketing, sales and onboarding, customer service, and operations.

• Develop applications that dramatically extend the capabilities of existing systems such as claims, billing, enrollment, membership, and provider networks.

• Revitalize legacy applications.

• Create and maintain your healthcare enterprise foundation layer of shared assets across your Pega application portfolio.

Pega Foundation for Healthcare forms the enterprise foundation for all Pega healthcare solutions.

Product overview


Healthcare object model The Foundation provides a pre-configured library of more than 75 data classes and more than 3,000 property attributes for commonly referenced healthcare objects like member, provider, practitioner, claim, authorization, etc. Many of the property attributes are also compliant with HIPAA and HL7 FHIR standards. The data model forms the enterprise backbone for all Pega healthcare applications and supports most business functions in healthcare organizations. It is augmented by pre-configured data pages and APIs for rapid integration with external systems.

Healthcare enterprise organization structure A fictitious organization structure called MyHealthPlan with departments and business units serves as the backbone for a model healthcare organization and includes sample operators, access groups and access privileges. This provides a reference model for your own organization setup and security/access model. The sample operator records are leveraged in demos of the various functional capabilities included in the Foundation.

Healthcare portals The Foundation provides the following pre-configured portals based on roles and applications. The portals include personalized dashboards and preconfigured charts, known as “widgets”. The application provides a variety of widgets for users and managers.

High level functionality


TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt

Dashboard personalization allows users to customize their dashboard view. New widgets can also be created to display key metrics unique to your business and persona.

• Healthcare Codes Manager Portal - The code manager portal provides the ability to manage the enterprise use of commonly used, industry-standard, healthcare code sets. It also provides an excellent example of personalizing the portal dashboard layout by the end user using the published widgets.

• Healthcare Sample Data Admin Portal - The sample data admin portal provides easy access to sample data instances and object layouts for commonly leveraged healthcare objects like member, provider, authorization, claim, policy, contracts, etc.

• Healthcare Appeals & Grievances Manager Portal - The Appeals and Grievances management application provides a pre-configured portal for an end user to manage the healthcare complaints submitted for members.

Healthcare sample data The Foundation provides pre-packaged sample data instances that can be leveraged to visualize business workflows and capabilities. The sample data are instances of the data classes of the common object data model mentioned earlier. It includes instances of members, practitioners, providers, policies, benefit plans, authorizations, claims etc. The data instances are fictitious and do not violate any HIPAA privacy and security rules. The sample data instances are used by all the consuming Pega healthcare applications including the sales, customer service, care management, and claims applications provided by Pega. The sample data and the data pages can be leveraged in your applications to test and visualize the business functions and workflows that are being configured in your application before actual integrations to your own sources of truth are configured.

Healthcare object search and retrieval Elastic search capabilities are provided to enhance the code set lookups. This capability serves as a reference model for high performance object searches that can be leveraged across your application especially when the search is for high volume data repositories like certain code sets.

Healthcare object layouts The sample data infrastructure mentioned above can be visualized using pre-configured review screens that provide auto-generated UI layouts. These layouts for commonly referenced objects like member, practitioner, claim, authorization etc. can be used as references and sample templates for use in your application as needed.



Member data masking The Foundation provides pre-configured access rules and capability to mask a given member’s personally identifiable information (PII) on a screen when accessed by unauthorized users. Employee and/or VIP flags available on the member’s profile are leveraged to mask the sensitive information on the screen. The Foundation provides pre-configured access privilege rules that can be used in your UI design to obfuscate desired data fields on the screen. The Foundation also provides a sample implementation of Attribute-based Access Control (ABAC) Security Policy to restrict access to Member PII & PHI information.

Healthcare code set management The Foundation provides the infrastructure to maintain commonly referenced, industry-standard, healthcare code sets to be used by your healthcare enterprise applications. It provides you the ability upload and maintain your licensed code sets in Pega. It contains pre-configured data tables for many code sets. You can add more code sets based on your business need. These code sets are leveraged in Pega Healthcare applications, including Pega Customer Service for Healthcare, Claims Automation Suite, Pega Product Composer for Healthcare, and Pega Care Management. See the Pega Foundation for Healthcare 7.4 Common Codes Business Use Case Guide on the application product page for additional details.

Healthcare code group management The Common Codes management capability in the Foundation includes the ability to create and maintain custom groupings of codes to be leveraged in business processing in your applications. For example, the code group instances created in this application are used in Pega Product Composer System to define benefits and also leveraged in Pega Smart Claims Engine for benefit determination during claim adjudication. The Pega Care Management application also leverages code groups to identify gaps in care from historical claims for a member or a population. See the Pega Foundation for Healthcare 7.4 Common Codes Business Use Case Guide on the application product page for additional details on code group management.

Healthcare code lookups Highly performant Elastic search capabilities are provided to enhance the code set lookups. This capability serves as a reference model for high performance object searches that can be leveraged across your application especially when the search is for high volume data repositories like certain code sets.

https://pdn.pega.com/products/pega-foundation-healthcare




ICD code mapping The Foundation provides mapping of International Classification of Diseases (ICD) v9 and v10 diagnosis and procedure codes. The forward (ICD9-10) and backward (ICD10-9) mapping is based on mapping tables published by CMS (Center for Medicare and Medicaid Services).

Healthcare Appeals and Grievances management The Appeals and Grievances solution leverages stage-based case management capabilities of Pega Platform. The solution manages complaints received from members and other interested parties (authorized representatives, providers, and third parties such as independent review entities). It provides the capability to create and manage two different types of complaints (appeals and grievances), and processes them through to resolution.

HIPAA X12 EDI message support The Foundation provides the ability to intake HIPAA (Health Insurance Portability and Accountability) EDI message transactions for X12 version 5010. The capability includes the intake and parsing of the EDI files based on the Implementation Guides for each message standard. Pega Healthcare applications such as Pega Claims Repair for Healthcare, Smart Claims Engine, and Pega Care Management applications leverage the EDI transaction capability for some transactions (X12 837 and X12 278) to create and manage claim and authorization request cases respectively. You can leverage the message handling capability to manage the EDI transactions and leverage them in your workflows as needed. Pega Foundation for Healthcare is capable of generating 834 outbound messages from enrollment records, thereby supporting both inbound and outbound 834 EDI related processes.

Common integration REST APIs The Foundation provides pre-configured REST JSON APIs to integrate Pega applications with external sources of truth. These include Business Request APIs for Member, Provider, Policy, Authorization, Claim, Employer Group and Provider Contracts, and Provider Networks. There is an API Landing page provided to review the schema and test the APIs. Pre-configured External Data Pages and easy extension patterns are provided to accelerate your integrations with your systems of record. See Healthcare Common Objects API Technical Specifications on the Pega Foundation for Healthcare product page for additional details on the REST APIs published in the application.

Common integration FHIR®© REST APIs FHIR®© – Fast Healthcare Interoperability Resources (hl7.org/fhir) is a next generation standards framework created by the HL7 organization. It is designed to support the

https://pdn.pega.com/products/healthcare-industry-foundation-hcif



http://hl7.org/fhir



interoperability and exchange of healthcare related information including clinical, administrative, public health, and research data between organizations The Foundation provides pre-configured REST JSON APIs to integrate to integrate your application with external electronic medical/health record (EMR/EHR) systems and other clinical data repositories and GET or fetch desired information about the patients / consumers managed in your application. These include Business Request APIs for commonly referenced clinical data including Allergy, Diagnostic Report, Imaging Study, Medication Statement, Observation etc. See Healthcare Common Objects API Technical Specifications on the Pega Foundation for Healthcare product page for additional details on the REST APIs supported in the Pega Foundation for Healthcare.

Integration Data Pages In addition to the External Data Pages supporting specific REST APIs, the Foundation provides pre-configured Data Pages for other commonly referenced data objects that can be leveraged to accelerate your integrations with your systems of record.

EDI Eligibility Request management The Foundation provides a reference implementation to manage X12 5010 EDI straight-through processing for X12 270 and 271 message transaction – Healthcare Eligibility Request & Response. This capability includes the ability to intake the EDI X12 270 eligibility request message, parse the message according to the EDI transaction implementation guide, create a work object for the case, process the eligibility request leveraging the sample plan benefit eligibility information provided in the sample data layer of the Foundation, and return an appropriate X12 271 eligibility response message. The functionality can be extended based on your business rules and with appropriate integration with your membership eligibility system.

EDI Claim Status Request management The Foundation provides a reference implementation to manage X12 5010 EDI straight-through processing for X12 276 and 277 message transaction – Healthcare Claim Status Request & Response. This capability includes the ability to intake the EDI X12 276 claims status inquiry request message, parse the message according to the EDI transaction implementation guide, create a work object for the case, process the claim status request leveraging the sample claims provided in the sample data layer of the Foundation, and return an appropriate X12 277 claim status response message. The functionality can be extended based on your business rules and with appropriate integration with your claims system.





EDI NCPDP message support Pega Foundation for Healthcare provides the ability to intake National Council for Prescription Drug Programs (NCPDP) pharmacy claims. The capability includes the intake and parsing of the NCPDP D.0 standard files for transaction B1-Claim billing, B2-Claim reversal, and B3-Claim rebilling. You can leverage the message handling capability to manage the EDI transactions and leverage them in your workflows as needed.


Healthcare Common Objects

Accumulators - Header

Accumulators - Detail

Accumulators - Family

Accumulators - Ind

Address

Appointment

Appointment Schedule

Authorization (Service)

Bank Account

Benefit

Benefit - Coverage

Benefit - Definition

Benefit Plan

Broker

Broker Agency

Campaign

Census

Claim

Claim Line

Communication

Company

Contact

Disability

DRG Grouper

Drug

Eligibility Request

Emp Group Contract

Employment

Enrollment

Guardian

Issues

Lab Results (Clinical)

Languages

Measurements (Clinical)

Medical History (Clinical)

Member (Patient)

Notes

Observation (Clinical)

Observation Component

Payer

Payment

Plan Sponsor

Policy (Membership)

Population

Postal (Zip) Codes

Prescription (Clinical)

Product (Benefits)

Provider

Provider Affiliation

Provider Business Entity

Provider Certifications

Provider Malpractice Ins

Prov Post Grad Training

Provider Medical School

Provider Group / Facility

Provider Network

Provider - Practitioner

Provider Referral Circle

Provider Service Address

Prov Pricing Rate Sheet

Rating Area (Sales)

Risk (Clinical)

School

Service Area

Svc Definition - Benefits

Service (Healthcare)

SIC - Division

SIC - Group

SIC - Factor

Allergies

Attachements

Clinical Condition

Clinical Procedure

Device

Diagnostic Report

Episode of Care

Goal (Clinical)

Imaging Study

Immunization

Patient Medications

Subscriber

Data model



Membership Model

Member / Patient(Consumer)

Unique member record

Subscriber(Policy holder)

Holds policy holder info and links all members

associated with a given policy

Policy(Account)

Medical / Dental insurance account for

an individual or family

Employer Group Contract

Payer(Health Plan)

Insurance provider

Company(Employer)

Contracted Plan/

Products

Selected Plan/

Product

Offered Plan/

Products



Provider Model

Provider PractitionerGroup / Facility

Business Entity

Provider Contract

Business Affiliation

Provider NetworksContracted Products

Payer

Certifications

Malpractice Ins

Medical School

Post Grad Training

Credentialing Information

Provider types

Specialties

Geographic Locations



Healthcare Common Codes

Claim Admission Type

Claim Bill Type

Common Dental Term (CDT)

Diagnosis Related Groups (DRG)

Mental Disorders (DSM)

Claim Facility

Claim Frequency

Generic Drug

HCPCS

ICD 9 – 10 Diagnosis Mapping

ICD 9 -10 Procedure Mapping

ICD 10 – 9 Diagnosis Mapping

ICD 10 – 9 Procedure Mapping

ICD 9 Diagnsis

ICD 9 Procedure

ICD 10 Diagnosis

ICD 10 Procedure

Procedure Modifier

NDC - Package

NDC Product

Claim Occurrence Date

Claim Occurrence Span

Place of Service

Claim Patient Relation

Claim Patient Status

Claim Point of Origin

Provider Specialty (Medicare)

Provider Taxonomy

Claim Revenue

Service Type

Claim Value

Provider Type

Common Proc Term (CPT®)

BETOS

Event

Claim Adjustment Reason

Claim Field Qualifier

Claim Condition

Claim Remark

Claim Status

Claim Status Category

Code Group Categories

Code Group

Code Set

CVX Vaccine

DICOM Acquisition Modality

LOINC

No Immunization

Observation Category

Observation Interpretation

Observation Method

Obs Ref Range Meaning

Observation Relationship Type

Service Review

SNOMED

UCUM

Vaccine Adm Route

Vaccine Body Site



X12 5010 Object Model X12 N 270

Eligibility Request

X12 N 271Eligibility Response

X12 N 276Claim Status Request

X12 N 277Claim Status Response

X12 N 278Service Review and Response

X12 N 271Eligibility Response

X12 N 834Benefit Enrollment

X12 N835Claim Payment

X12 N837Claim



HL7 FHIR Object Model Allergies

Appointment Schedule

Care Plan

Clinical Condition

Clinical Procedure

Device

Diagnostic Report

Document Reference

Encounter

Goal

Imaging Study

Immunization

Medical History

Medication

Medication Dispense

Medication Order

Medication Statement

Patient (Member)

Episode of Care

Family History

Patient Medications

Practitioner

Procedure

Appointment Slot

For additional details on the entity relationships for commonly referenced objects as well as a detailed listing of property attributes available on the data model, see the Healthcare Object Model – ERD and Healthcare Object Model – List on the Pega Foundation for Healthcare product page.






Applications Pega Foundation for Healthcare contains several application layers in its stack. The applications are organized by logical business and technical capability for ease of deployment and flexibility of use.

The following applications are included in Pega Foundation for Healthcare:

Application Description PegaHCCore Core foundation rulesets containing healthcare data

models, common object APIs and code management capabilities. This is the default application and pre-requisite for all following optional applications.

PegaHCAGM Optional application for managing member complaints (appeals and grievances)

PegaX125010 Optional application for X12 EDI management capabilities

PegaHCEWS Optional application with Microsoft Exchange Web Services (Outlook) integration capabilities

PegaHCFhir Optional application with REST APIs supporting the HL7 FHIR Standard for exchanging data with Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) and other clinical data repositories

PegaHL7 Optional application with support for integration with clinical systems for ADT (Admission Discharge Transfer) transactions using v2.2 & 2.3 HL7 Standard

Roles This matrix describes each of the roles provided with Pega Foundation for Healthcare, their access group, and portal.

Role Description Core Foundation Application including Codes Management HCAdminUser End user role with access to sample data

maintenance portal to review and edit instances of sample data provided with the application

View_VIP_PII End user role with access to sample data portal with privileges to view VIP member data and WITHOUT

Applications, roles, portals, and dashboards



Role Description privileges to view Employee member data. (Used to see Member Data Masking).

View_Emp_PII End user role with access to sample data portal with privileges to view Employees member data and WITHOUT privileges to view VIP member data. (Used to see Member Data Masking).

CodeManager Code manager role with access to Healthcare Codes Management portal to create and maintain code sets and custom code groupings.

Appeals and Grievances Management Application (AGM) AGManager AGM overall manager role with access to AGM

manager portal with visibility into reporting dashboard, team members, and work baskets all AGM cases. Can perform managerial functions like transferring work from one team member / workbasket to another.

AGCoordinator AGM Coordinator role with access to AGM user portal to perform AGM case intake.

AGAssistant AGM Assistant role with access to AGM user portal to perform AGM case intake.

CLMCoordinator AGM Claims Manager role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for claims review.

MedicalDirector AGM medical director role with access to AGM manager portal with visibility into cases routed for medical director review.

MRUCoordinator AGM Member Research role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for member research.

PNSCoordinator AGM Provider Network Services role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for provider research.

QICoordinator AGM Quality Improvement role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can



Role Description perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for quality audit.

CaseManager AGM Case Management role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for utilization management review.

Operators and access groups This matrix describes each of the roles provided with Pega Foundation for Healthcare, their access group, and portal.

Operator ID Access group Portal name

Super Application (all layers of PEGAFHCPEGAFHC installed) Administrator PegaHC:Administrators Developer (Default)

Sample Data Admin AGM Manager Portal AGM User Portal Exchange WS Portal X12 Demo Portal Code Manager Portal

CoreAdministrator PegaHCCore:Administrators Developer (Default) Sample Data Admin Code Manager Portal

DemoAdministrator UHealth:Administrators Developer (Default) Sample Data Admin AGM Manager Portal AGM User Portal Exchange WS Portal X12 Demo Portal Code Manager Portal

HCAdminUser HCAdmin:Users Sample Data Admin HCUser PegaHC:HCUser Sample Data Admin HCUserEmp PegaHC:HCUserEmp Sample Data Admin HCUserVIP PegaHC:HCUserVIP Sample Data Admin HealthCodesAdmin PegaHealth:Administrators Developer (Default)

Code Group Manager CodeManager PegaHealth:CodeGroupManager Code Group Manager Appeals & Grievances Manager (AGM)



Operator ID Access group Portal name

AGMAdmin AGM:Administrators Developer (Default) AGM Manager AG User

AGManager AGM:AGManager AGM Manager CLMManager AGM:CLMManager AGM Manager MDReview AGM:MedicalDirector AGM Manager MRUManager AGM:MRUCoordinator AGM Manager PNSManager AGM:PNSManager AGM Manager QIManager AGM:QIManager AGM Manager UMManager AGM:CaseManager AGM Manager X12 5010 EDI Processing 5010Administrator PegaX125010:Administrator Developer (Default)

X12 Demo Portal 5010AdminUser PegaX125010:Users X12 Demo Portal HL7 FHIR API Integration HCFHIRAdministrator PegaHCFhir:Administrators Developer HL7 ADT Integration HL7Admin PegaHCHL7:Administrator Developer Exchange Web Services Integration EWSAdministrator PegaHCEWS:Administrators Developer EWSUser PegaHCEWS:Users Exchange WS Portal

Portals and dashboards Pega Foundation for Healthcare provides the following pre-configured portals based on roles and applications. The portals include personalized dashboards and preconfigured charts, known as “widgets”. The application provides a variety of widgets for users and managers. Dashboard personalization allows users to customize their dashboard view. New widgets can also be created to display key metrics unique to your business and persona.

• Healthcare Codes Manager portal

• Healthcare Sample Data Admin portal

• Healthcare Appeals & Grievances Manager portal



Healthcare Codes Manager portal



Healthcare Sample Data Admin portal



Healthcare Appeals and Grievances Manager portal


Visit the Pega Discovery Network (PDN) For release notes, and product guides go to the Pega Foundation for Healthcare product page.

Further reading



Documents

Pega Foundation for Healthcare · configured access privilege rules that can be used in your UI design to obfuscate desired data fields on the screen. The Foundation also provides