The Pega Foundation for Healthcare application also provides the infrastructure to efficiently configure and maintain membership/patient data, groups, individuals, and their family structures (spouses, dependents, and so on.). Pega Foundation for Healthcare also provides the tools to efficiently manage member/patient relationships for multiple entities such as the payers, benefit plans and employers. Member-centric in nature, the application supports a wide range of the standard membership healthcare transactions.

The member data model in PFHC consist of various member attributes. These attributes can be logically grouped into basic information (ID, name, and so on.), address information, primary care physician (PCP) information, communication options, COB information and policy information.

A member record in PFHC can also be associated with multiple policies. The group / company contract associates a member to a company / group using the policy structure. The company / group contracts also drive the enrollment rules for individuals / small groups and large groups.

Policies also help define a subscriber’s relationship to the following entities for a given period of time (policy period):

1. Subscriber’s group / company.
2. Subscriber’s effective plan or plans.
3. Subscriber’s family structure.
4. Each dependent’s effective plan or plans.