Pega Foundation for Healthcare

Transcription

1 Pega Foundation for Healthcare PRODUCT OVERVIEW 7.4

2 2018 Pegasystems Inc., Cambridge, MA All rights reserved. Trademarks For Pegasystems Inc. trademarks and registered trademarks, all rights reserved. All other trademarks or service marks are property of their respective holders. For information about the third-party software that is delivered with the product, refer to the third-party license file on your installation media that is specific to your release. Notices This publication describes and/or represents products and services of Pegasystems Inc. It may contain trade secrets and proprietary information that are protected by various federal, state, and international laws, and distributed under licenses restricting their use, copying, modification, distribution, or transmittal in any form without prior written authorization of Pegasystems Inc. This publication is current as of the date of publication only. Changes to the publication may be made from time to time at the discretion of Pegasystems Inc. This publication remains the property of Pegasystems Inc. and must be returned to it upon request. This publication does not imply any commitment to offer or deliver the products or services described herein. This publication may include references to Pegasystems Inc. product features that have not been licensed by you or your company. If you have questions about whether a particular capability is included in your installation, please consult your Pegasystems Inc. services consultant. Although Pegasystems Inc. strives for accuracy in its publications, any publication may contain inaccuracies or typographical errors, as well as technical inaccuracies. Pegasystems Inc. shall not be liable for technical or editorial errors or omissions contained herein. Pegasystems Inc. may make improvements and/or changes to the publication at any time without notice. Any references in this publication to non-pegasystems websites are provided for convenience only and do not serve as an endorsement of these websites. The materials at these websites are not part of the material for Pegasystems products, and use of those websites is at your own risk. Information concerning non-pegasystems products was obtained from the suppliers of those products, their publications, or other publicly available sources. Address questions about non-pegasystems products to the suppliers of those products. This publication may contain examples used in daily business operations that include the names of people, companies, products, and other third-party publications. Such examples are fictitious and any similarity to the names or other data used by an actual business enterprise or individual is coincidental. This information is the property of: Pegasystems Inc. One Rogers Street Cambridge, MA USA Phone: (617) Fax: (617) Pega Foundation for Healthcare Document: Product Overview Software Version: 7.4 Updated: April 2018

3 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 Healthcare Common Codes X Object Model HL7 FHIR Object Model Applications, roles, portals, and dashboards Applications Roles Operators and access groups... 16

4 Portals and dashboards Healthcare Codes Manager portal Healthcare Sample Data Admin portal Healthcare Appeals and Grievances Manager portal Further reading Visit the Pega Discovery Network (PDN)... 21

5 Product overview 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 X 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. Pega Product Overview 1

6 High level functionality 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. Pega Product Overview 2

7 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. Pega Product Overview 3

8 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 preconfigured 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, industrystandard, 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. Pega Product Overview 4

9 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 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 (X 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 Pega Product Overview 5

10 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 X EDI straightthrough processing for X and 271 message transaction Healthcare Eligibility Request & Response. This capability includes the ability to intake the EDI X 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 X 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 X EDI straightthrough processing for X and 277 message transaction Healthcare Claim Status Request & Response. This capability includes the ability to intake the EDI X 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 X claim status response message. The functionality can be extended based on your business rules and with appropriate integration with your claims system. Pega Product Overview 6

11 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. Pega Product Overview 7

12 Data model Healthcare Common Objects Accumulators - Header Claim Line Issues Provider Business Entity Accumulators - Detail Clinical Condition Lab Results (Clinical) Provider Certifications Accumulators - Family Clinical Procedure Languages Provider Malpractice Ins Accumulators - Ind Communication Measurements (Clinical) Prov Post Grad Training Address Company Medical History (Clinical) Provider Medical School Allergies Contact Member (Patient) Provider Group / Facility Appointment Device Notes Provider Network Appointment Schedule Diagnostic Report Observation (Clinical) Provider - Practitioner Attachements Disability Observation Component Provider Referral Circle Authorization (Service) DRG Grouper Patient Medications Provider Service Address Bank Account Drug Payer Prov Pricing Rate Sheet Benefit Eligibility Request Payment Rating Area (Sales) Benefit - Coverage Emp Group Contract Plan Sponsor Risk (Clinical) Benefit - Definition Employment Policy (Membership) School Benefit Plan Enrollment Population Service Area Broker Episode of Care Postal (Zip) Codes Svc Definition - Benefits Broker Agency Goal (Clinical) Prescription (Clinical) Service (Healthcare) Campaign Guardian Product (Benefits) SIC - Division Census Imaging Study Provider SIC - Factor Claim Immunization Provider Affiliation SIC - Group Subscriber Pega Product Overview 8

13 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 Selected Plan/ Product Company (Employer) Employer Group Contract Contracted Plan/ Products Payer (Health Plan) Insurance provider Offered Plan/ Products Pega Product Overview 9

14 Provider Model Credentialing Information Certifications Malpractice Ins Group / Facility Provider Practitioner Medical School Post Grad Training Business Affiliation Business Entity Provider types Contracted Products Provider Contract Provider Networks Specialties Geographic Locations Payer Pega Product Overview 10

15 Healthcare Common Codes BETOS Claim Status ICD 10 Diagnosis Obs Ref Range Meaning Claim Adjustment Reason Claim Status Category ICD 10 Procedure Observation Relationship Type Claim Admission Type Claim Value ICD 10 9 Diagnosis Mapping Place of Service Claim Bill Type Code Group Categories ICD 10 9 Procedure Mapping Procedure Modifier Claim Field Qualifier Code Group ICD 9 Diagnsis Provider Specialty (Medicare) Claim Condition Code Set ICD 9 Procedure Provider Taxonomy Claim Facility Common Dental Term (CDT) ICD 9 10 Diagnosis Mapping Provider Type Claim Frequency Common Proc Term (CPT ) ICD 9-10 Procedure Mapping Service Review Claim Occurrence Date CVX Vaccine LOINC Service Type Claim Occurrence Span Diagnosis Related Groups (DRG) NDC - Package SNOMED Claim Patient Relation Mental Disorders (DSM) NDC Product UCUM Claim Patient Status DICOM Acquisition Modality No Immunization Vaccine Adm Route Claim Point of Origin Event Observation Category Vaccine Body Site Claim Remark Generic Drug Observation Interpretation Claim Revenue HCPCS Observation Method Pega Product Overview 11

16 X Object Model X12 N 270 Eligibility Request X12 N 271 Eligibility Response X12 N 276 Claim Status Request X12 N 277 Claim Status Response X12 N 278 Service Review and Response X12 N 271 Eligibility Response X12 N 834 Benefit Enrollment X12 N835 Claim Payment X12 N837 Claim Pega Product Overview 12

17 HL7 FHIR Object Model Allergies Goal Appointment Schedule Imaging Study Appointment Slot Immunization Care Plan Medical History Clinical Condition Medication Clinical Procedure Medication Dispense Device Medication Order Diagnostic Report Medication Statement Document Reference Patient (Member) Encounter Patient Medications Episode of Care Practitioner Family History Procedure 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. Pega Product Overview 13

18 Applications, roles, portals, and dashboards 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 PegaHCCore PegaHCAGM PegaX PegaHCEWS PegaHCFhir PegaHL7 Description Core foundation rulesets containing healthcare data models, common object APIs and code management capabilities. This is the default application and prerequisite for all following optional applications. Optional application for managing member complaints (appeals and grievances) Optional application for X12 EDI management capabilities Optional application with Microsoft Exchange Web Services (Outlook) integration capabilities 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 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 View_VIP_PII End user role with access to sample data maintenance portal to review and edit instances of sample data provided with the application End user role with access to sample data portal with privileges to view VIP member data and WITHOUT Pega Product Overview 14

19 Role View_Emp_PII CodeManager Description Appeals and Grievances Management Application (AGM) AGManager AGCoordinator AGAssistant CLMCoordinator MedicalDirector MRUCoordinator PNSCoordinator QICoordinator privileges to view Employee member data. (Used to see Member Data Masking). 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). Code manager role with access to Healthcare Codes Management portal to create and maintain code sets and custom code groupings. 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. AGM Coordinator role with access to AGM user portal to perform AGM case intake. AGM Assistant role with access to AGM user portal to perform AGM case intake. 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. AGM medical director role with access to AGM manager portal with visibility into cases routed for medical director review. 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. 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. AGM Quality Improvement role with access to AGM manager portal with visibility into reporting dashboard, team members, and work baskets. Can Pega Product Overview 15

20 Role CaseManager Description perform managerial functions like transferring work from one team member/workbasket to another for complaint cases routed for quality audit. 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) Pega Product Overview 16

21 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 X 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 Pega Product Overview 17

22 Healthcare Codes Manager portal Pega Product Overview 18

23 Healthcare Sample Data Admin portal Pega Product Overview 19

24 Healthcare Appeals and Grievances Manager portal Pega Product Overview 20

25 Further reading Visit the Pega Discovery Network (PDN) For release notes, and product guides go to the Pega Foundation for Healthcare product page. Pega Product Overview 21