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Example case types

Updated on April 12, 2021
Pega Foundation for Healthcare Product Overview

The examples shown here represent some of the key features of PFHC sample applications.

Example 1: Complaint

  • Provides end-to-end workflow processes to capture and manage member complaints.
  • The complaint case can contain one or more sub-cases of type appeal and/or grievance.
  • Key stages include Intake, Research, Acknowledge, & Resolve.
  • The workflow processes include service level (SLA) management, routing, prioritization, and escalation processes. SLAs may be dynamically driven by the member’s Line of Business.
  • The workflows have pre-configured and automated correspondence generation for acknowledging the receipt of a complaint, requesting additional supporting information, as well as communicating final disposition of the complaint (approvals or denial letters). Both email and letter correspondence are available.
  • Letter templates may be configured and stored by line of business. PFHC includes 2 out-of-the box categories: GVT (for Medicare, Medicaid, and Federal Program LOBs) and Commercial (all other LOBs).

Example 2: Codes

  • It provides end-to-end workflow processes to create, search, view, and maintain industry standard code sets and custom code groups in the Foundation.
  • The workflow processes include management of code set files as well as the ability to create and maintain custom code groupings.
  • The workflows include approval processes by managers.

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