• Enhanced Organization Determination Workflow. During this release, the foundation enhanced its organization determination workflow to accommodate pre- and post-service prescription drug and formulary requests. In this workflow, the user is now able to select members with Medicare Part D plan coverage and process and resolve such cases as formulary exception requests, drug tiering exceptions, prior authorizations for prescribed drugs, and out-of-pocket reimbursement requests. The enhanced organization determination workflow supports closer compliance with CMS Part D Coverage Determination requirements. For more information, see the 8.7 Pega Foundation for Healthcare Implementation Guide and the 8.7 Appeals and Grievances Business Use Case Guide.
• Further refinement for CMS ODAG and CDAG reporting. In this release the Foundation has made additional enhancements to its ODAG and CDAG reporting capability to support closer compliance with CMS universe reporting, particularly in the areas of prescription drug and formulary Coverage Determinations. The Foundation has enabled the capture of additional required fields to improve automation of ODAG and CDAG reporting. These additional fields include but are not limited to: authorization or claim number, type of exception requested, beneficiary’s long-term care status, and drug data, such as NDC name, strength and dosage form. For more information, see the 8.7 Pega Foundation for Healthcare Implementation Guide.
• Additional workflow enhancements. Two substantial enhancements to the Appeals and Grievances workflows were completed during this release. These enhancements are focused on the pre- and post-service appeals workflows, during the Nurse and MD review stages, to support dispositions driven by logic configured against authorization line and claim line items. Specifically, these enhancements include:
  • The display of authorization line denial and rejection reasons,
  • The display of claim line denial reasons, and
  • The setting of an appeal disposition based on authorization line-item status.

For more information, see the 8.7 Pega Foundation for Healthcare Implementation Guide, and the 8.7 Appeals and Grievances Business Use Case Guide.