Skip to main content

         This documentation site is for previous versions. Visit our new documentation site for current releases.      

Introduction to Pega Care Management Application

Updated on February 14, 2019

Care management industry overview

Healthcare organizations face challenges in providing care and managing disease at a lower cost because of legacy systems that are fragmented and not connected. The principles of care management are to provide the best healthcare outcomes for patients by ensuring that they receive the appropriate level of quality services in a timely manner.

The practice of care management consists of the following program categories:

Health and wellness programs

Health and wellness programs are typically population-focused and preventive with the purpose of helping healthy people stay healthy. Specialized campaigns, such as flu shot clinics, weight-loss challenges, and vaccinations, are delivered with the goal that targeted people avoid future health problems.

Disease management

Disease management programs are used for a subset population with one or more chronic diseases. They address nationally defined chronic disease categories to provide long-term management of particular disease states such as asthma, diabetes, and arthritis.

Utilization management

Utilization management refers to the authorization of services across the spectrum of care. It comprises the management, approval, or denial of benefits allowed by a patient's healthcare plan. For example, a physician might need approval for a hospital stay to be covered. Other examples include inpatient, rehabilitation, and outpatient services such as physical therapy, durable medical equipment, and home healthcare.

Case management

Case management programs address a patient’s engagement with providers during pre- or post-acute care or when involved in a complex medical scenario. Some examples of case management programs include gestational diabetes, transitional care for level-of-care changes, high-risk pregnancy, and surgical care for pre- and post-surgery.

Business value

Care management programs face disconnected processes and fragmented medical management initiatives among patients, providers, and care plans. This situation places tremendous pressure on healthcare organizations to improve the quality of patient care while simultaneously lowering costs.

Care Management Application solves the problem of disconnection and fragmentation by delivering a patient-centric view across the continuum of care. The product is intended for care management providers such as health plans, physician groups, and government agencies who bear the risk for a patient’s care. It supports the workflow from identification to assessment, risk assessment or stratification, and care plan development. It provides a unified model that gives the care team access to complete clinical and general health information to deliver consistent results while lowering costs.

The patient profile captures detailed information, including demographics, program enrollments, open requests, clinical data, recent claims, and authorized contacts. Case managers can track in a care manager portal all the work that is associated with patients. Using Pega 7 Platform integration capabilities, the fully integrated, patient-centric platform can access systems of record in a manner that suits a healthcare organization's requirements.


Care Management Application in the field

The purpose of Care Management Application is to coordinate, manage, track, and improve the overall health outcome of a patient and population by facilitating continuous changes through automation and collaboration.

For example, Glendale Health Plans provides government-sponsored managed care services, primarily through Medicaid and Medicare, to patients with complex medical needs. In an effort to improve the quality of care and services provided to members, Glendale recently purchased a Pegasystems Care Management Application license.Pegasystems Care Management Application license.

In this scenario, Tom Brown, a patient enrolled with Glendale Health Plans, is injured while hiking, and visits his primary care physician, who decides to admit Tom for evaluation. The doctor contacts Glendale to ensure that his healthcare benefits cover his medical costs. The doctor also requests prior authorization before Tom is admitted. An MRI reveals that Tom needs a total hip replacement. Tom works with his doctor to select an orthopedic specialist who can perform the surgery.

When all the information is collected, the request is sent to a clinical nurse for review. The nurse evaluates the request to make sure that the treatment is medically necessary according to standard clinical guidelines. The nurse approves the authorization request and Tom enters the hospital.

Application extensions

Sample business rules included in the application allow an organization to automate the review and approval process. An authorization request, for example, can be automatically resolved without a clinical review when prior authorization is not required by customized business rules.

The application extends business rules in several key areas. You can configure these settings to automate decisions about requests for authorization and referrals. You can also extend these rules to identify other conditions and service requests that can be automatically approved. You maintain the key application configuration settings in Designer Studio.

Customizing a care plan

A care plan can be customized to better meet the patient’s ongoing healthcare needs by extending additional ad-hoc components, or rule instances, such as problems, tasks, goals, barriers, and alerts.

In Tom’s case, he is unable to arrange transportation for his followup care after the surgery. His care manager enters this issue as a problem so that the care manager can arrange for transportation services as well as a home care nurse visit after Tom is discharged from the hospital. The application also sets an alert to ensure that the correct primary diagnostic code for the authorization claim is included. Meanwhile, the hip replacement care plan template has been configured with a task to mail Tom information about long-term care after a hip joint replacement.

All of these customized components can be combined to manage an entire program.

Extending a program

A program can contain multiple care plans. The hip replacement program that Tom is now enrolled in is managed with three care plans for different levels of risk management. These programs each have to be extended from the base application.

When you extend a program, you customize a top-level rule such as one that automatically identifies candidates for program enrollment based on a diagnosis or procedure. For example, Tom’s case triggers an ICD-10 diagnostic code that enrolls him in a joint replacement therapy program.

Data elements such as ICD-9 and ICD-10 codes are maintained as licensed code sets in the code management layer. These code sets are required standards adopted under HIPAA for diagnoses, procedures, and drugs. The application can be extended to also identify other conditions that need to be proactively managed, such as patient case summaries that require additional information for printing.

Case types

Care Management Application includes the following set of predefined case types. Each case type has one or more processes and provides stages for organizing work.

  • Appeal
  • Care Management
  • Utilization Management
  • Admission

Authorization process

The authorization process is a key component of a utilization management case. Detailed workflows provide direction about the steps that are required within a certain timeframe.

The Utilization Management case type supports these additional subcases in the authorization process:

  • Prior authorization – A patient or care manager gets authorization, such as for Tom’s hip surgery, which is scheduled for a future date
  • Concurrent review – A review takes place as the services are taking place; for example, a patient is in the hospital while her case is being reviewed
  • Retrospective review – A review takes place after the service has taken place; for example, a patient broke his hip while on vacation

Tom’s surgeon has added authorization details for an orthopedic screening that can integrate with national or local criteria code sets. These details support the automated workflow of assignments, directing work to specific users or work queues through conditional processing. Automatic communications can then be delivered to interested parties, such as Tom’s nurse, primary care physician, and physical therapist.

Tom’s health plan has indicated that no manual review is needed for his hip replacement claim and the approved authorization is automatically communicated to the surgeon and hospital in real time. The health plan also determines when to do concurrent reviews and when to pay the claim.

Each of the four authorization request types supports the process of determining the medical necessity for a requested inpatient or outpatient service.

  • Inpatient – For acute or subacute service provided in a healthcare organization, such as a hip replacement surgery performed in a hospital
  • Outpatient – For example, a patient might need to arrange for durable medical equipment such as a wheelchair
  • Referral – The healthcare plan provides the criteria to determine whether a patient is qualified; for example, the patient might need to be seen by an out-of-network specialist
  • Pharmacy – For example, there might be a dispensing limit or prescribed step therapy to control costs and minimize risks

Authorization approval is based on the combined review of member benefits, eligibility, health plan requirements, and the use of standard clinical guidelines.


Guidelines are the tools that are used by health plans and providers to determine the medical necessity of the requested care. They cover the different types of care that a patient or member might receive, such as acute inpatient, skilled nursing facility, home health care, or outpatient services.

When Tom is discharged from the hospital, his care manager uses the application’s Patient 360 data view to support Tom’s care in all of his programs, including clinical information, assessments, and analytics. Tom is now enrolled in a disease management program for his long-term condition of osteoporosis. He is also enrolled in a health and wellness program to help him maintain a healthy lifestyle. Tom’s eligibility for these programs is reviewed and approved in the application based on an evaluation of national guidelines licensed by Glendale Health Plans.

These guidelines are integrated with Care Management Application during implementation through external connectors or other configuration settings. For example, Glendale uses an MCG connector to establish that Tom’s care delivery is consistent with his member benefits, preventive care standards, and best practice treatment guidelines.

In addition to national standard guidelines such as MCG and McKesson (Interqual), there are also a number of internal guidelines that are specific to a certain organization or group. Healthcare organizations that have their own sets of internally managed guidelines can use them separately or in conjunction with national guidelines providers.

Additional resources


Business Architect System Architect System/Cloud Ops Administrator Healthcare and Life Sciences

Have a question? Get answers now.

Visit the Support Center to ask questions, engage in discussions, share ideas, and help others.

Did you find this content helpful?

Want to help us improve this content?

We'd prefer it if you saw us at our best. is not optimized for Internet Explorer. For the optimal experience, please use:

Close Deprecation Notice
Contact us