Routing appeals to other applications
You can create and route appeals to other applications by using Pega Customer Service for Healthcare, which automates the work and reduces manual tasks.
Pega Customer Service
Implementation Guide
The out-of-the-box Claims Inquiry and Appeal a Prior Authorization Microjourneys
can use the scenarios that are described in the following table:
- Follow the steps that apply to your implementation option.
Options Actions Create the Complaint/Appeal case directly in the Pega Appeals and Grievances Manager application when it is in the same environment as Pega Customer Service for Healthcare - Ensure that the value for the Create complaint in ext app setting in Pega Customer Service for Healthcare is false. For more information see the "Modifying the Create complaint in ext app setting" section below.
- Save the SetComplaintDetailsExtn data transform to your implementation layer and add properties, for example, you might want additional contact properties that providers use. For more information, see Data transforms.
Create the Complaint/Appeal case in Pega Appeals and Grievances Manager application in an environment that is separate from Pega Customer Service for Healthcare - Ensure that the value for the Create complaint in ext app setting in Pega Customer Service for Healthcare is true. For more information see the "Modifying the Create complaint in ext app setting" section below.
- Override the CreateAppealExtension
flow and write logic to call an API that the client creates. The API creates a case in their Appeals and Grievances Manager application (present on a different instance) to call the case in Pega Customer Service for Healthcare.For additional information, see Pega API services.
Create the Complaint/Appeal case in Pega Appeals and Grievances Manager application in a non-Pega application - Ensure that the value for the Create complaint in ext app setting in Pega Customer Service for Healthcare is false. For more information see the "Modifying the Create complaint in ext app setting" section below.
- Save the CreateAppealExtension flow rule in the implementation layer and use it to call the application’s API for routing the work to the external application.
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