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Extending eligibility processing

Updated on April 23, 2021

Copy the following rules in your ruleset to extend the eligibility lookup and processing:

Pega Foundation for Healthcare
ProcessBenefitRequestActivityMain activity rule that processes the eligibility information.
OpenPolicyByIDNoDisplayActivitySearches for member’s policy by Policy Number submitted on the message.
CheckPolicyOnServiceDateData TransformChecks to see if the Policy is active on the requested service date in the message.
ProcessPlanActivityFetches Plan/Product based on Plan ID associated with Policy.
ProcessBenefitActivityFetches Plan Benefits.
ProcessBenefitGroupActivitySearches for matching benefit coverage based on submitted service type code on the message.

For additional information, refer to the Healthcare X12 EDI Message Management Technical Specifications on the Pega Foundation for Healthcare product page.

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