Because Pega Care Management is built on top of Pega Customer Service for Healthcare and the healthcare foundation, the application can leverage features. Through this architecture, the team escalate development and re-use great features for healthcare clients.
For more information about the healthcare foundation, see the documentation here.
HIPAA X12 EDI message support
Pega Foundation for Healthcare provides the ability to intake Health Insurance Portability and Accountability (HIPAA) EDI message transactions for X12 version 5010. The capability includes the intake and parsing of the EDI files based on the implementation guides for each message standard.
Pega healthcare applications such as Pega Claims Repair for Healthcare, Smart Claims Engine, and Pega Care Management leverage the EDI transaction capability for some transactions (X12 837 and X12 278) to create and manage claim and authorization request cases respectively. You can leverage the message handling capability to manage the EDI transactions and leverage them in your workflows as needed. Pega Foundation for Healthcare and Pega Care Management support the straight through processing of inbound and outbound responses for 278 requests.
Common integration REST APIs
Pega Foundation for Healthcare 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. An API landing page is provided to review the schema and test the APIs. Pre-configured external data pages and easy extension patterns are provided to accelerate your integration with your systems of record.
Common integration FHIR APIs
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.