Pega Product Composer for Healthcare

Transcription

1 Pega Product Composer for Healthcare IMPLEMENTATION GUIDE 7.31

2 2017 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 document is the property of: Pegasystems Inc. One Rogers Street Cambridge, MA USA Phone: Fax: (617) DOCUMENT: Pega Product Composer for Healthcare Implementation Guide SOFTWARE VERSION: 7.31 PUBLISHED: Monday, August 07, 2017 Feedback If you have suggestions or comments for how we can improve our materials, send an to AppDocBug@pega.com.

3 CONTENTS Overview 8 Application overview 8 Industry overview 8 Implementation delivery methodology 9 Initiation stage 9 Delivery stage 10 Prerequisites 11 Initiation stage 12 Creating your application 12 Loading your sample data 13 Viewing and analyzing the structure of your application 13 Generating an application profile 14 Generating an application document 14 Generating a specification document 14 Delivery stage 16 Defining requirements 17 Mapping your application data 18 Defining integration 18 Integration points 19 Defining the case type modifications and attributes 19 Updating case types 20 Adding case types 21 Mapping case type classes to a database table 21 Application data model 22 Defining data types 23 Pega Product Composer for Healthcare Implementation Guide 3

4 Updating existing data types 23 Adding a new data type 24 Sample database model 24 Defining the security model and organization structure 24 Authentication schemes 25 Defining your authentication scheme 26 Defining your authorization scheme 26 Defining your access groups 27 Defining access roles and privileges 27 Defining the organization structure 27 Defining the operator attributes 28 Defining the operator work group 28 Defining the operator skills 29 Defining the operator calendar 29 Operators and access groups 30 Defining the work groups 30 Defining the workbaskets 30 Defining work parties 30 Customizing the user experience 31 Designing application skin and styles 31 Designing for screen performance 32 Defining your enhanced search 32 Defining reporting requirements 33 Building features 34 Configuring application settings 34 Creating Pega Product Composer for Healthcare components 35 Pega Product Composer for Healthcare Implementation Guide 4

5 Importing Pega Product Composer for Healthcare entities 36 Modifying the template 37 Extending data validation activity rules 38 Configuring a benefit 40 Creating a grouper 41 Creating a benefit set 43 Configuring a network 44 Creating a product template 45 Entering details for a product template 45 Optional: Providing additional client product information 47 Optional: Specifying the per member per month base rate with restrictions 47 Optional: Specifying other indicators 48 Defining networks and guardrails for a product template 49 Selecting a benefit set for a product template 50 Defining cost shares and accumulators for a product template 50 Defining network cost shares for a product template 53 Configuring benefits for a product template 54 Adding variations 55 Creating a product 57 Entering details for a new product 57 Defining cost shares and accumulators for a new product 59 Defining network cost shares for a new product 61 Configuring benefits for a new product 62 Generating the Summary of Benefits for a new product 63 Creating a plan 66 Entering details for a plan 66 Pega Product Composer for Healthcare Implementation Guide 5

6 Determining cost shares for a plan 67 Determining the network cost shares for a plan 69 Configuring benefits for a plan 70 Creating a plan bundle 73 Configuring settings for the plan bundle automatic update 74 Configuring enhanced search parameters 75 Renewing multiple entity types at the same time 76 Modifying the class structure 78 Implementing the security model 78 Modifying the user interface 78 Determining which part of the user interface to modify 79 Locating the user interface element to change 79 Adding a new property to a section 79 Adding a new section 80 Updating the skin 81 Extending the application 81 Extending a line of business 82 Changing the key of an entity 82 Extending a network 83 Extending benefit mapping 83 ImpIementing custom validation in the bulk renewal feature 84 Creating reports 85 Testing a new application 85 Testing your application in the Build environment 85 Testing in the Test or Production environments 86 Testing in the UAT environment 87 Pega Product Composer for Healthcare Implementation Guide 6

7 Packaging a new application 88 Merging application changes 88 Packaging an application for migration 89 Importing the packaged application 89 Pega Product Composer for Healthcare Implementation Guide 7

8 Overview Overview Application overview Pega Product Composer for Healthcare streamlines the creation and maintenance of health insurance products through guided assembly and reuse of atomic-level benefit components. These components can be fine-tuned for complex logic and conditions that include tools such as life-cycle management and versioning. By simplifying product design, management, and delivery, Pega Product Composer for Healthcare unlocks product innovation, accelerates compliance, and speeds time to market. The application provides a centralized product repository that exchanges accurate, detailed plan and benefit information among all your users, systems, channels, and devices. This operational support results in accurate claim determinations and benefit quoting, and delivery of exceptional customer experiences. Health plans, integrated delivery networks (IDNs), and accountable care organizations (ACOs) can transform their product approach with Pega Product Composer for Healthcare. Deployed on the cloud or on the premises, Pega Product Composer for Healthcare reduces time, cost, and risk for product development and execution. For additional information, see the Product Overview on the Pega Product Composer for Healthcare product page and the medical insurance glossary. Industry overview Health insurers need new competencies to perform in today s disruptive market. Rapid product development and efficient execution are essential for achieving regulatory compliance and winning members. Enhanced customer engagement across all sales and service transactions is critical to fulfill product promises, differentiate the brand, and grow the customer base. Organizations need the ability to service what they sell. Consumers demand access to accurate benefit information in the format of choice at their convenience, accurate claims adjudication in a timely manner, and experiences consistent with the product that they purchased. Pega Product Composer for Healthcare Implementation Guide 8

9 Overview Implementation delivery methodology Use an Agile delivery model, more specifically a Scrum-based standard for a Pega application implementation. In the rare cases where a waterfall-based implementation methodology is better suited, use Pega s Iterative Waterfall approach. These two implementation methodologies help break down the work into manageable components that you can deliver to production faster. The Pega delivery approach has the following primary stages: Initiation stage Delivery stage Initiation stage In the Initiation stage, the implementation teams build the foundation or baseline of the application and prepare for the work that is necessary to configure the first production release and subsequent extended production releases. Keep in mind that the first production release is the minimal required scope to go live into production. Additional capabilities will be added as part of the extended production releases. Building a strong foundation to support expansion and reuse is key to the success of an implementation. The Initiation stage is further organized into the following sub-stages: Plan Align the vision and roadmap to establish the foundation for the implementation. The Plan sub-stage includes the following tasks: Defining the production release milestone Refining scope alignment Set up Validate and review the Pega-provided features and capabilities to see if they meet your requirements and expectations. This sub-stage includes the following tasks: Pega Product Composer for Healthcare Implementation Guide 9

10 Overview Establishing environments and processes Creating the baseline application Loading sample data Demonstrating the baseline application Reviewing artifacts from the solution assessment Reviewing business needs and outcomes Prepare Prepare for the delivery of Pega Product Composer for Healthcare by completing the following tasks: Confirming resources Enabling team members Establishing governance At the conclusion of the Initiation stage, the scope of the work for the first production release is clearly defined. For Scrum, the scope of the work is represented in an initial backlog. For Iterative Waterfall, a specification list and schedule are prepared and finalized. Delivery stage The Delivery stage is dependent on the methodology selected (Scrum or Iterative Waterfall). During this stage, the delivery team designs, builds, configures, and tests the application by using the selected implementation methodology. The goal is to accomplish the tasks described in this document by organizing the Application Feature backlog so that the delivery team can configure the application incrementally with the result being a fully tested and performance-tuned application in production. The Delivery stage is organized into the following release types. Pega Product Composer for Healthcare Implementation Guide 10

11 Overview First production release This release includes only the essential features that are defined during the solution proposal stage and are required for the first release into production. The first production release is implemented in days, depending on the scope of the essential features. This release type includes the following features: Core Pega-provided features Extended features considered essential for your business Key day-one integrations with your systems to get data that you require Extended production release This release includes the non-essential features that are defined during the solution proposal stage. The following features are implemented incrementally after the first production release: Non-essential Pega-provided features Extended features that you have identified as required for your business This guide provides information to support both Scrum and Iterative Waterfall implementation methodologies during the first production release and the extended production release. Prerequisites Before you start your Pega Product Composer for Healthcare deployment, be sure that you understand the support for various browser versions. See the Platform Support Guide. Pega Product Composer for Healthcare Implementation Guide 11

12 Initiation stage Initiation stage The Initiation stage includes the following tasks: 1. Creating your application 2. Loading your sample data 3. Viewing and analyzing the structure of your application Creating your application The first step in implementing Pega Product Composer for Healthcare to best meet your organization's needs is to create the application on which your extended application will be built. Use the New Application wizard to create your new application. The wizard creates the application structure for you. 1. Log in to Pega Product Composer for Healthcare by entering these credentials: User Name: Password: install 2. Create the application by following the steps in Creating an application with the New Application wizard. Keep in mind your application-specific requirements. 3. Log in to your new application by entering your newly-created credentials. Note: All procedures in this guide require that you log in to your new application by entering credentials for that application, unless otherwise noted. The New Application wizard creates the application class structure for you. You can reuse the classes and rulesets that are created by the wizard in future applications that you create. As you implement this application and future applications, you can apply class hierarchy and inheritance principles Pega Product Composer for Healthcare Implementation Guide 12

13 Initiation stage to help you decide where in the class structure to create your rules to improve the maintainability and overall efficiency of your application. For more information, see Class layers. Note: You must update all workbaskets with the work group of the new application. See Defining the work groups. Also, update the class name with the implementation layer class group for the WorkGroupBasketWorkList and pyuserworklist report definitions. For additional information, see the Class joins section in Report Definition Data Access tab. Loading your sample data Pega Product Composer for Healthcare includes sample data to support the Pega-provided demonstration application. Pega recommends that you load customer-supplied sample data so that implementation efforts are more meaningful. For more information on importing the Pega Product Composer for Healthcare sample data, see Importing sample data in the Pega Product Composer for Healthcare Installation Guide on the Pega Product Composer for Healthcare product page. Viewing and analyzing the structure of your application To avoid duplicating existing features, review the following documents to familiarize yourself with the default rules and rulesets of your application. During the solution assessment, a number of requirements, specifications, and other artifacts are captured to represent the scope of the work. If captured in the Pega Platform, these artifacts can be reused to streamline the first production release scope identification. You can export application specification and requirements artifacts from the Pega Platform, and then import them into your new baseline application so that you can build on the content that has already been created. For more information, see Exporting specifications and requirements and Importing specifications and requirements. The following documents define what is contained within your application. Pega Product Composer for Healthcare Implementation Guide 13

14 Initiation stage Generating an application profile This document is created during the Sales stage and includes the process stages and steps, case types, reports, requirements, specifications, participants, collaborators, and actors that are associated with the implementation of your application. When you generate this document, you can include process flow diagrams. To generate the document, log into your application by entering your newly created credentials and follow the procedure in Generating an application profile document. Generating an application document This document and its associated controls provide the ability to customize the presentation of the application information based on the document's intended audience. When you run the Application Document tool, you can include or exclude content by selecting and clearing various options. During an implementation, this document reflects the current state of your application. The Application Document tool automatically updates the content of your document as you modify and extend your application to reflect additional requirements. If you have not yet built anything, the content of this document is the same as the application profile. To generate the document, log into your application by entering your newly-created credentials and follow the procedure in Generating an application document. Generating a specification document This document shows all of the specifications and linked requirements associated with your application at the time that you generate the document. You can generate this document at any point during the implementation life cycle to include any updates to the application's specifications and requirements. Review this document before and after each sprint, using the available filters to tailor the content to meet the business requirements of your implementation. Pega Product Composer for Healthcare Implementation Guide 14

15 Initiation stage To generate the document, log into your application by entering your newly-created credentials and follow the procedure: Generating a specification document. Pega Product Composer for Healthcare Implementation Guide 15

16 Delivery stage Delivery stage The Delivery stage includes the following tasks: Defining requirements Building features Testing a new application Packaging a new application Pega Product Composer for Healthcare Implementation Guide 16

17 Defining requirements To ensure that you stay on target for a successful deployment, use a structured approach for your implementation methodology. You will need to prepare for your implementation and determine key aspects of the design that will affect the behavior of your application. Defining requirements for an implementation includes the following tasks: Reviewing extension requirements Refining customizations and determining the availability of required data and integrations Prioritizing, for example, revising the solution backlog, re-estimating the effort for extensions and customizations, and confirming the project scope Defining your requirements also involves DCO sessions and incorporating those requirements into the application design. During these sessions, you review each of the case types and process flows that the application already provides. Update the Application Specifications with planned changes as described in About Application Specifications. The Implementation Planning Workbook helps you capture decisions as you define your requirements. You can download the Implementation Planning Workbook from the Pega Product Composer for Healthcare product page. To define requirements, review the topics in the following sections: Mapping your application data Defining integration Defining the case type modifications and attributes Application data model Defining the security model and organization structure Customizing the user experience Pega Product Composer for Healthcare Implementation Guide 17

18 Defining your enhanced search Defining reporting requirements Mapping your application data The application data types provide a default set of properties for your use. You can add or remove properties from these data types depending on your requirements. You can also add new data types. Use the "Data model" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. In the Designer Studio Explorer panel, click Data. 2. Click the data type that you want to modify. 3. On the Data model tab, determine the properties to add, remove, or leave unchanged. For more information about data types, see Viewing data type details. Repeat these steps for any other data types, as necessary. Defining integration Inventory which external applications exist at your site and plan how to connect to them. Policies Business entities Benefits Tip: Identify integration points as early in your planning as possible. If a connection to an external data source is required and either the data does not exist or the interface to that data does not exist, you must account for the time to publish these data sources and the time to configure the interface for this application. The External Data Entities landing page lists the application data types and shows the source for that data. Pega Product Composer for Healthcare Implementation Guide 18

19 To record your decisions during this procedure, use the "Integration" worksheet in the Implementation Planning Workbook. 1. Identify all integration points for your application. 2. Identify which data is needed from each system of record, if you have not already done so. 3. Determine whether an interface to that system of record already exists and how to connect to it. Integration points Based on your needs, you can integrate with the following options: Claims system Provider system Call center Sales Automation Authorization Member data Defining the case type modifications and attributes Your application includes a set of predefined case types.each case contains one or more processes that will be extended or created to meet your business requirements. If you do not see an existing case type, you can create one during your planning process. When you define a new case type, you provide stages for that case type. A stage is the first level of organizing work in your case type. Each stage has one or more steps. Note: The Pega-provided application lets you select legacy case types that were created in earlier versions of the application. However, during configuration, you will notice that the legacy case types have fewer options than the newer, stage-based case types. The following are the primary cases: Pega Product Composer for Healthcare Implementation Guide 19

20 Benefit Benefit Set Bundle Grouper Network Plan Policy Product Product Template To define case types, complete the steps in the following topics: Updating case types Adding case types Mapping case type classes to a database table Updating case types If an existing case type is close to meeting your business requirements, you can modify it and use it. 1. In the Designer Studio Explorer panel, click Cases. 2. Click the case type that you want to modify. 3. Update the settings for a case type. 4. Update the processes associated with the case type. In addition, you can add processes by using the Case Designer. Repeat these steps for any other case types, as necessary. Pega Product Composer for Healthcare Implementation Guide 20

21 Adding case types If you require a case type that is not similar to an existing case type, create a new one that meets your business requirements. 1. In the Designer Studio Explorer panel, click Cases. 2. Click Add a case type. 3. Enter the Name for the new case type. 4. Click Advanced Settings. 5. Select the Derived from (Directed) class. 6. Select the Derives from (Pattern) class. 7. Select the appropriate Ruleset and Ruleset version. 8. Click Submit. 9. Define a life cycle for the case type. 10. Click Finish. Mapping case type classes to a database table When you run the New Application wizard to create your initial case types, the system creates a default class group mapping for each case type. Mapping a class to a physical database table affects data storage and security decisions. If you expect the volume of the case types to be low, consider sharing the table with other case types. To restrict access to instances of this case type, create a separate class group for each case type. For each class corresponding to the case type, complete the following steps: 1. In the Designer Studio Explorer panel, click App. 2. Right-click the class name that you want to map and select Definition. Pega Product Composer for Healthcare Implementation Guide 21

22 3. In the Settings section, view the This Class setting to see if this class is a class group or a member of a class group. If the class belongs to a class group, note the class group to which it belongs. 4. In the Test Connection section, click Test Connection to see the name of the table that is currently mapped to this class. 5. Determine the name of your database table. 6. Record your decision in the "Case type modifications" planning worksheet. Application data model The application provides a set of data types, data pages, and sample data, which you can use to begin implementing your application. Data modeling involves creating a conceptual model of how data items relate to each other in an application. In the Pega Platform, the data model refers to a set of rules that work together to populate the data in your application. The system displays this data to help you process the information and can help you make decisions in your sales processes. The following rule types constitute your data model: Data types Data type is another name for a class in your application. It holds data that the application uses. A data type has one or more data pages and several property definitions associated with it. Properties Properties define the format and visual presentation of data in your application. Data pages Data pages define the content of a clipboard page. Data pages also control the loading of that data from a source system, as shown here. Pega Product Composer for Healthcare Implementation Guide 22

23 When planning your data model, work with the data modeling resource at your site to understand the attributes of the data types that need to be supported by your application. Note: Pega Product Composer for Healthcare is rarely the system of record for application data. Integrating your application data with your site's system of record is critical to the success of your deployment. Defining data types Data types categorize the data used by your application. The data types that come with your application have one or more data pages associated with them. Data pages control the sourcing of your application data. Updating existing data types 1. In the Designer Studio Explorer panel, click Data. 2. Click the data type that you want to modify. 3. On the Definition tab, scroll to the bottom. 4. Click Add property. Add as many properties as your application requires. Repeat these steps for any other data types, as necessary. Pega Product Composer for Healthcare Implementation Guide 23

24 Adding a new data type 1. In the Designer Studio Explorer panel, click Data. 2. Click the Down Arrow key to show the Data type menu. 3. Click Add data type. 4. Provide a label and description for the data type. 5. Click Submit. Repeat these steps for any other data types, as necessary. Sample database model Pega Product Composer for Healthcare comes with an industry-standard sample database. You can use this sample database model as delivered without additional configuration, or you can add or modify the data to meet your needs. For information about how to view and modify the database schema, see Viewing database schema using the Modify Schema wizard and related topics. Defining the security model and organization structure Security planning involves defining authorization and authentication strategies for your application. Authentication Proves to the application that you are who you say you are. Authorization Determines the functions that you can perform in the application. This corresponds to access group and role configuration. Security planning also involves setting up the organization structure and operator attributes. The application provides security in the form of access settings and denial rules. Many integration rules also incorporate authentication. Pega Product Composer for Healthcare Implementation Guide 24

25 For more information about the additional aspects of security, enroll in the Lead System Architect course on Pega Academy and cover the Security lessons that correspond to the following topics: Authentication schemes Defining your authentication scheme Defining your authorization scheme Defining your access groups Defining access roles and privileges Defining the organization structure Defining the operator attributes Defining the operator work group Defining the operator skills Defining the operator calendar Operators and access groups Defining the work groups Defining the workbaskets Defining work parties Authentication schemes The Pega Platform offers the following authentication types: PRBasic Based on passwords in the Operator ID data instances and the login form. This is defined by the rule, which your application can override. PRSecuredBasic Similar to PRBasic, but passes credentials using Secure Sockets Layer (SSL) using Basic HTTP authentication. The login form is defined by the Pega Product Composer for Healthcare Implementation Guide 25

26 rule, which your application can override. PRCustom Supports access to an external LDAP directory or a custom authentication scheme. PRExtAssign Supports external assignments (Directed Web Access). J2EEContext Specifies that the application server in which the Pega Platform is deployed uses JAAS to authenticate users. Defining your authentication scheme Your site can use a centralized, automated means of maintaining operator data instead of maintaining it manually in the Pega Product Composer for Healthcare application. To record your decisions during this procedure, use the "Security Model" worksheet in the Implementation Planning Workbook. 1. Discuss Authentication schemes with your site's security and application server teams. 2. Determine the appropriate authentication type. For more information on authentication scheme planning, see Authentication in the Pega Platform. Defining your authorization scheme Pega Product Composer for Healthcare comes with a predefined set of access groups, roles, and privileges. You can use the application roles as a starting point, but you should create your own application-specific access groups and roles to avoid any future problems when upgrading. Other rule types such as sections, flow actions, and activities use roles and privileges to allow access to these rules at run time. Pega Product Composer for Healthcare Implementation Guide 26

27 Tip: You can review the Pega Product Composer for Healthcare access groups and roles. Click Designer Studio > Org & Security > Groups & Roles > Access Groups or Designer Studio > Org & Security > Groups & Roles > Access Roles. Defining your access groups Use the "Security model" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. Identify additional access groups that are needed for your application. 2. Identify portals associated with these access groups. Defining access roles and privileges You can associate one or more roles with an access group. Roles are additive. The more roles that you add to an access group, the more authorization there is. Privileges can be associated with one or more roles. Use the "Security model" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. Determine which roles are needed for your application. You can use the Pega Product Composer for Healthcare roles as a starting point. 2. Determine which privileges to associate with each role. 3. Associate each role with an access group. For more configuration information, see Groups and roles. Defining the organization structure Use the organization structure for routing and reporting within the application. Typically, the application organization structure does not map operators exactly to the site's organization chart but instead, it maps the work that those operators do. Tip: For design guidance, see Organization landing page. Pega Product Composer for Healthcare Implementation Guide 27

28 Use the "Organization structure" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. Click Designer Studio > Org & Security > Organization > Organizational Chart. 2. Review the existing structure. 3. Determine the organization, division, and unit levels of the hierarchy. Defining the operator attributes An operator's access group affects what the operator can do in the application. In addition to the access group, three fields in the operator record influence how the application handles assignment of work to the user: Work group Skills Calendar Tip: In many implementations, it is more efficient for the application to set values in the operator record during the authentication process than it is to have an administrator manually maintain these records. These rules must be configured as part of the authentication mechanism for your site. For more information, see More about Authentication Services. Defining the operator work group The work group setting in the operator record affects how the application delivers work to the operator. 1. Review the Operator record. 2. Determine the rules for assigning a work group to an operator or the role that multiple operators hold. Use the "Organization structure" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. Pega Product Composer for Healthcare Implementation Guide 28

29 1. Click Designer Studio > Org & Security > Organization > Operators. 2. Select an operator ID. 3. On the Work tab, review the work group information for the operator record. 4. Determine your policy for assigning a work group to an operator or the role that multiple operators hold. Defining the operator skills Skill settings in the operator record affect how the application routes work to the operator. Skill settings also affect how the application gets the most appropriate work when using the Get Next Work feature. You must determine the skills that are appropriate for your application and operators. Use the "Organization structure" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. Define the skills that are needed for the application. 2. Determine which operator records or roles should be associated with those skills. Defining the operator calendar The application calendar affects date calculations within the application, such as the date between business days calculation, and the SLA goal and deadline date calculation. The calendar on the operator record is relevant only if you have users who are not working in the same time zone as the rest of the organization. Otherwise, the application uses the calendar on the organization record and you can skip this step. Use the "Organization structure" worksheet in the Implementation Planning Workbook to record your decisions during this procedure. 1. Determine the calendar instances that are needed for your application. 2. Determine which operator roles need a distinct calendar. 3. Determine the operator location. Pega Product Composer for Healthcare Implementation Guide 29

30 For more information, see More about Calendar data instances. Operators and access groups Pega Product Composer for Healthcare includes the following operators and access groups: - HC-USA-PCS:Administrators - HC-USA-PCS:ProductDevelopment HC-USA-PCS:ProductManager HC-USA-PCS:SuperUsers Defining the work groups A work group determines which workbaskets you can access. 1. Click Designer Studio > Org & Security > Tools > Work Groups to display a list of associated work groups. 2. Review and modify the list if necessary. For more information, see Initial Work Groups. Defining the workbaskets A workbasket is a queue of open assignments in the application. 1. Click Designer Studio > Org & Security > Tools > Work Baskets to display a list of workbaskets. 2. Review and modify the list if necessary. For more information, see Initial Workbaskets. Defining work parties A work party represents a person, business, or organization that is involved in a case. It receives correspondence, such as , and can be an active or passive participant based on its role. Pega Pega Product Composer for Healthcare Implementation Guide 30

31 Product Composer for Healthcare comes with default work parties, but you may need to configure them for site-specific requirements. 1. In the Case Type Explorer, click the name of the case of which you want to modify the work parties. 2. Click the Settings tab and select Parties. 3. Click the work party name to open the settings for the work party. 4. Make your modifications and click OK. For more information, see Defining the stakeholders of a case. Customizing the user experience While Pega Product Composer for Healthcare is fully functional immediately after installation, you may change portions of the user experience (UX) to meet the needs of the users at your site. To design the user experience, complete the steps in the following topics: Designing application skin and styles Designing for screen performance Designing application skin and styles Your site very likely has user experience (UX) standards for the appearance of your applications. Your task is to determine which styles have to change to adhere to those standards. To record your decisions during this procedure, use the "Skinning" worksheet in the Implementation Planning Workbook. 1. Click Designer Studio > User Interface > Skins & Portals. 2. On the Skins tab, double-click PCS. Pega Product Composer for Healthcare Implementation Guide 31

32 3. Click the Component Styles tab. 4. Review each component. Note: As you plan your application styles, consider using mixins to provide incremental style changes. For more information, see Using mixins in the skin to drive consistency and efficiency. Designing for screen performance You want your application to respond immediately as your end users interact with customers. As you design your user interface, complete the following steps: 1. Review transactional service level agreements. For example, the customer details must be available in one second or less while a representative is on the phone with the customer. 2. Review service performance, such as how long it takes back end systems to gather the data needed to display customer details. 3. Review data requirements to determine which fields contain the information that the representatives absolutely need for the task that they need to perform. 4. Determine if any network configuration could cause latency, for example, if there are representatives logged in through a corporate VPN or in a remote location. Defining your enhanced search Pega Product Composer for Healthcare provides a configurable, advanced search feature. You can configure and manage the search parameters for all entities including benefits, groupers, benefit sets, networks, product templates, products, plans, plan bundles, policies, and policy terms on the application configuration page. Because the Pega Product Composer for Healthcare data model has a deep hierarchy of nested structures, with the advanced search configuration, you can search by using any of the properties within the hierarchy. The search is no longer limited to the high-level exposed properties. For example, you can search for a list of plans that have a specific copay or coinsurance value. The following are the benefits of using this feature: Pega Product Composer for Healthcare Implementation Guide 32

33 You eliminate the need for IT to configure and manage your search parameters. You use the Pega-provided elastic search feature to search on any of the fields in the complex data model, which also serves the evolving business needs. To record your decisions during this procedure, use the "Defining search parameters" worksheet in the Implementation Planning Workbook. 1. Log in to your application by entering the following credentials: User Name: Password: install 2. Click Launch > Product Development. 3. In the left navigation panel, click an entity and review the default parameters in the search section for the entity. Record the parameters that you want to keep and the parameters that you want to remove. 4. On the entity search page, click Advanced search. Record the parameters that you want to display in your advanced search. 5. Repeat steps 3 and 4 for each entity. 6. After you finalize your decisions for the entities, configure the entities. See Configuring enhanced search parameters Defining reporting requirements Based on your login and portal, Pega Product Composer for Healthcare provides numerous preconfigured reports to monitor case and work inventory as well as monitor workforce productivity and quality. These standard reports are driven by the case and work object lifecycle infrastructure as well as the work and assignment-level service level rules for goals and deadlines used in managing the life cycle of a case. Pega Product Composer for Healthcare Implementation Guide 33

34 Building features Follow the steps in these topics to build your application features: Configuring application settings Creating Pega Product Composer for Healthcare components Configuring application settings The key application configuration settings are maintained on the Product Composer System Configuration page. Four tabs of information are available for the various settings. Based on your client's business needs, complete these settings early in the project so that the corresponding features will work properly. 1. In Designer Studio, click Designer Studio > Product Composer System > Configuration. 2. On the Applications settings tab, complete settings for your application, change the class names to match the names that were created after you ran the New Application wizard, and select the check boxes for stage actions for versioning. For additional information on versioning, see Versioning in Pega Product Composer for Healthcare. 3. On the Flow settings tab, complete the settings for the following items: Coverage Benefit mapping For additional information on benefit mapping, see Extending benefit mapping. PCS import templates For additional information on the import feature, see Importing Pega Product Composer for Healthcare. Pega Product Composer for Healthcare Implementation Guide 34

35 Benefit consumer notes Effective dates of entities Plan bundle settings For additional information, see Configuring settings for the plan bundle automatic update. Bulk renewal settings For additional information, see Renewing multiple entity types at the same time 4. On the Claims system settings tab, complete information for your claims system 5. On the Search configuration settings tab, complete the search fields for your advanced searches. For additional information, see Configuring enhanced search parameters. 6. Click Actions > Save as system configuration. You also click Save as personal configuration to save the settings as a personal configuration for testing. Creating Pega Product Composer for Healthcare components You create the components for Pega Product Composer for Healthcare in the following order. You can also import configuration information by using the PCS Imports feature. Benefit Benefit grouper Benefit set Network Product template Product Pega Product Composer for Healthcare Implementation Guide 35

36 Plan Plan bundle Tip: For more information about the terms used in these procedures, see the Medical Insurance Glossary. Importing Pega Product Composer for Healthcare entities The challenges in healthcare benefits and plans are many, including implementing insurance regulation updates, migration to new solutions in a line of business, collaboration across business lines and functions, scalability, and auditing. Pega Product Composer for Healthcare provides the capability to bulk upload benefit, grouper, benefit set, network, policy term, and policies data. With this feature, you can upload existing data, for example, one hundred medical benefits, by entering the data in a Microsoft Excel format into the Pega Product Composer for Healthcare application. Using this feature, you can bring benefit and plan configuration enterprise data into Pega Product Composer for Healthcare for complete transparency and support the delivery of accurate coverage rules, cost shares, authorization requirements, and quality customer service. 1. In Designer Studio, click Launch > Product Development. 2. In the left navigation panel, click Process Entities > Imports. 3. Click Run PCS Import. 4. On the Import PCS Entities page, enter a name for the entity that you are importing such as HMO Benefits and then select an option from the Select entity to import list. In this example, select Benefits. 5. In the Select target stage section, click an option to indicate the target stage of the entity. Pega Product Composer for Healthcare supports the Development, Implementation, and Production stages. For example, if you click Development, the uploaded entities are routed to the Dev-Approved workbasket with the Dev-Approved status. Pega Product Composer for Healthcare Implementation Guide 36

37 6. Click the Download Template link to download an entity template in an Excel spreadsheet. You can also modify this template to suit your business needs. See Modifying the template. The Microsoft Excel template has three worksheets: Template Instructions Data Validation 7. In Microsoft Excel, open the Template worksheet and complete the fields for the entity. The Instructions worksheet provides help in completing the fields in the Template worksheet. The Data Validation worksheet lists the fields that are validated by Pega Product Composer for Healthcare. You can add other fields to suit your business. See Extending data validation activity rules. If you are importing a benefit set, be sure to enter all the benefits of the set in one cell of the template spreadsheet. 8. Save the file. 9. In Pega Product Composer for Healthcare, click Upload for the specified entity. 10. Choose the file and click Upload. All the benefits appear in the entity that you created. Its status is Pending-Approval. The manager either approves (status is Resolved-Completed) or returns the submission to the originator for further work (status is Pending-Resubmission). 11. Click Submit. The entity is routed to the specified workbasket for approval. Modifying the template You can modify the Microsoft Excel template to meet your business needs when you are importing Pega Product Composer for Healthcare entities. The modified template is then available for your use. Pega Product Composer for Healthcare Implementation Guide 37

38 If you update the settings on the Product Composer System Configuration page, you also need to modify the template. 1. In Designer Studio, click Designer Studio > Product Composer System > Configuration. 2. Click the Flow settings tab. 3. On the Product Composer System Configuration page, scroll to the PCS import templates section. 4. Click the entity for which you want to modify the template. 5. Click Download file to download the template. 6. Open the file, modify the fields, and save the file. 7. Click Upload file to upload the modified template. 8. In the Upload File dialog box, click Upload file. When you download the template again, you will see your modifications. Extending data validation activity rules You can use the extension activity rules listed in the table below to add validation fields that you need for the PCS Import flows. The main activity rule calls the extension activity rule at run time. For additional information about activities, see More about Activities. 1. In the Designer Studio header search field, enter the name of the extension activity rule that is listed in the table below. 2. Add the fields for validation. 3. Click Save as. Extension activity rule Call from this activity rule Description ValidatePrimaryExcelFieldsEXT ValidatePrimaryExcelField This activity rule validates the main properties that are required for the PCS Pega Product Composer for Healthcare Implementation Guide 38

39 import flows. ValidateDatesAndStatusEXT ValidateDatesAndStatus This activity rule validates the overlapping dates of the consumed entities, for example, a benefit being added to a benefit set. If there is not at least one day overlapping between the benefit and the benefit set, a validation error appears and the benefit is not accepted. This activity rule also checks for rejected or retired statuses of entities. ConvertingDatesForPolicy TermEXT ConvertingDatesForPolicyTerm This activity rule validates the dates that you entered for policy terms in the PCS import flows. GroupPolicyListEXT GroupPolicyList This activity rule groups all the rows that are related to one policy into a single list. BenefitDataLoadValidations WrapperEXT BenefitDataLoadValidations Wrapper This activity rule validates all the business functionality that is related to the PCS import flows for benefits and calls all post-activities from the main flows. AutoDataLoadGrpValidationEXT AutoDataLoadGrpValidation This activity rule validates all the business functionality that is related to the PCS import flows for groupers and calls all post-activities from the main flows. ADLBenefitSetValidation WrapperEXT ADLBenefitSetValidationW rapper This activity rule validates all the business functionality that is related to the PCS import flows for benefit sets and calls all post-activities from the main flows. NetworkValidationsWrapperaEXT NetworkValidationsWrapper This activity rule validates all business functionality related to the PCS import flows for networks and calls all postactivities from the main flows. PolicyTermsValidations WrapperEXT PolicyTermsValidations Wrapper This activity rule validates all the business functionality that is related to the PCS import flows for policy terms and calls all post-activities from the main flows. Pega Product Composer for Healthcare Implementation Guide 39