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Pega Foundation for Healthcare company / group contract record

Updated on February 10, 2022

Pega Foundation for Healthcare

Group contract definition: A group contract can be defined as an entity created to configure rules and capture details about a healthcare company / group. A group contract is used to:

  1. Capture additional details about the group. (billing information, broker information, and so on.)
  2. Help manage the rules around enrolling members in a group. The contract houses configurations which validate:
    1. Member’s enrollment period.
    2. Member’s PCP.
    3. Member’s plan within the group.
Note:

  1. The word “company” and “group” are used interchangeably.
  2. A company / group is expected to be associated with at least one group contract record.
  3. A group contract can be associated to only one payer.
  4. If a group is associated to multiple payers, then the group would need to be associated with multiple contracts. For example, if a Group had different payers / plans covering the medical and dental plans, then separate contracts would need to be created for each.
  5. Each contract configured belongs to one, and only one group / company.
  6. Members cannot be enrolled in a group without a group contract.

Tags

Pega Foundation for Healthcare 8.7

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