Extending eligibility processing
Copy the following rules in your ruleset to extend the eligibility lookup and processing:
Pega Foundation for Healthcare
Name | Type | Description |
ProcessBenefitRequest | Activity | Main activity rule that processes the eligibility information. |
OpenPolicyByIDNoDisplay | Activity | Searches for member’s policy by Policy Number submitted on the message. |
CheckPolicyOnServiceDate | Data Transform | Checks to see if the Policy is active on the requested service date in the message. |
ProcessPlan | Activity | Fetches Plan/Product based on Plan ID associated with Policy. |
ProcessBenefit | Activity | Fetches Plan Benefits. |
ProcessBenefitGroup | Activity | Searches 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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