Admission
An admission case is part of a medical record that documents the patient’s status,
policy details, requesting and servicing provider details, facility information, admission
type, level of care, member condition, admission dates, length of stay, diagnosis and
procedure details. After the patient or member details are provided, the system checks if there are any
active admission cases. It does not allow the case to proceed if there any active
admissions. It also checks if the requested services require prior authorization and
moves the case to the medical director’s workbasket if the prior authorization does not
exist. For more information, see Admission case management in the Pega Care
Management Business Use Case Guide on the Pega Documentation home page. The following list describes items that are related to the Admission Microjourney: In App Studio, you can view the Admission data model in Case
types. Click the Data model tab. Hospitals provide a limited amount of observation care for patients that is based on
a well-defined set of specific, clinically appropriate services. These services include
ongoing short-term treatment, assessment, and reassessment that are provided while a
decision is being made about whether patients require further treatment as hospital
inpatients or if they can be discharged from the hospital. You can configure the observation
period for an admission case in Pega Care Management. To ensure that the requests for authorization are routed correctly, configure a work
group for the medical director review of an authorization. Ensure that you assign operators
who have the medical doctors skills to the work group. You can change the work group in the Medical Director flow to correspond to the work
queue that you specify on the Care Management Application configuration
page. You can also change the skill level for the work group to meet the needs of
your organization. For example, you might change the default skill level from 10 to
7. To ensure that the application can find an operator with the proper skills to route the
authorization assignment, associate the skill and the appropriate level with the operator. For
example, you might assign an operator with a specified skill to review out-patient
authorizations or pharmacy authorizations. To ensure that the requests for authorization are routed correctly, configure a work
queue for the medical director review of an authorization. Based on your organization's requirements, you can provide other sources for use in
admission case creation. Field name:
Complexity Column name: AR (for admission) Field name: ClinicalCaseType Parameter is ServiceCodeType:
pyWorkPage.Admission.ServiceTypeCodeData model for Admission
Configuring the observation days for an admission
Configuring the work group for medical directors
Modifying the skill-level settings for the medical director review
Associating work group operators with medical review skills
Configuring the work queue for medical directors
Configuring list of sources for admission case creation
Rule name Rule type Purpose NewAdmissionNotification Flow action Notifies the admission of a patient to a hospital or facility.
CreateMDReviewAdmissionCase Flow action Checks if the prior authorization is required and routes the case to
the medical director's work basket IsPriorAuthRequired Data transform Checks if the requested services (procedure codes) are in the list of
procedure codes that require prior authorization D_PegaHCDataPriorAuthCodesList Data page Fetches the configured list of procedure codes that require prior
authorization PegaHC-Data-PriorAuthCodes Data type Maintains procedure codes that require prior authorization GetFieldvalues Report definition Adds or modifies complexity types; updates the field values with the
Complexity field name . ServiceTypeCodeList Report definition Maintains the supported service types for each request type in the
PegaHC-Data-ServiceTypeCode data
table. GetFieldvalues Report definition Report for Clinical case types. DiagnosisCodeTypes Report definition Fetches code set types. AddCPContactsWrapper Activity Adds requesting or service provider details to a care provider team.
AddCPContacts Activity Saves a new contact, for example, a requesting or service provider
Key list rules for an admission case
Prompt list or local list Purpose Priority Source for the Priority list AdmissionTypeCode Source for the Admission type list AdmissionSourceCode Source for the Admission source list ConditionCodePatient Source for the Member Condition list InpatientServiceLocation Source for the Level of care list ProcedureCodeType Source for the Procedure code list
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