Pega Foundation for Healthcare 8.7 common objects API technical specification guide
About Pega Healthcare API services
The Pega Healthcare API enables you to leverage built-in REST/JSON services to integrate your Pega applications with external systems to request, receive, and send data. You can call any of the Pega Healthcare API services by using standard HTTP methods (for example: GET, POST, or PUT). The supported APIs provides a standard set of services and requests that include access to data pages for commonly referenced objects in healthcare applications e.g., Member, Provider, Claim and so on. These APIs enable rapid deployment of your Pega’s healthcare applications.
Accessing Pega Healthcare APIs
Pega offers online help documentation on the healthcare APIs. You can access the Pega Healthcare API help documentation from the Dev Studio menu.
The API information is organized as Business Request API methods to GET (request) data from third party applications based on parameters passed in the request.
Using the above links, you can:
- View the JSON data model for each published resource
- List the parameters used for each resource
- Directly test the API by clicking the Tryit out! and viewing the actual request URL, response body, response code, and response headers.
Published Healthcare APIs
Business service APIs
Authorizations
Get Authorization by ID
Get Authorizations by Member Policy ID
Benefits
Get Benefit Coverage (in the context of member’s claim line)
Business Entities (Provider)
Get Provider Business Entity
Business Affiliations (Provider)
Get Provider Business Affiliation
Provider Contracts
Get Provider Contract
Claims
Get Claims History (for member)
Employer Group Contracts
Get Employer Group Contract
Members
Get Member
Get Member Policies
Get Member Networks
Networks
Get Network
Payers
Get Payer
Plan Networks
Get Plan Network
Policies
Get Policy
Providers
Get Provider
Get Provider Networks
Rate Sheets
Get Rate Sheets
API integration classes
The Healthcare API infrastructure provides an integration class for each published API resource. This class defines the data model used in mapping the response data returned via API call. The classes are configured as PegaHC-Int-xxxxx as shown below.
Business request APIs
Connector rule for API
The Healthcare API infrastructure contains pre-configured specified endpoint URL and populates the returned result in data pages. The following diagram illustrates the flow of execution:
Key rules in business request API execution
Rule Name | Rule Type | Usage |
D_Connect<Resource> e.g., D_ConnectPayer | Data Page | Calls the connector and identifies the request and response mapping rules |
Get<Resource> | Connect REST | Calls the REST Service using endpoint URL |
MapRequestData | Data Transform | Maps the request data |
MapResponseData | Data Transform | Maps the results data to data page |
MapToEntity | Data Transform | Maps the results to the Payer object |
Connector data page
The Connector data page for each Resource provides the configuration for the data page definition and the data source(s) that are used to fetch the data. It also identifies the request and response data mapping rules. The following Connect Data pages are configured for the APIs.
As shown below, the Source for the data is configured as a Connector which invokes the external system REST service using the endpoint URL. The Endpoint URLs for all configured services in Healthcare API are fetched through a dynamic settings data page called D_HCSettings as explained later in this document.
Connect REST rule
The Connect REST rule supports the interaction between Pega and other systems over the Hypertext Transfer Protocol (HTTPS). It identifies the resource path endpoint URL of the source system to which this rule connects, and the parameters used to pass in the request. Refer to Pega online Help for additional information on configuring Authentication, Security Settings, and Error Handling.
Above connector rule is configured with a OOTB Basic Authentication profile ‘CommonObjectAuthProfile’ to configure the appropriate user credentials to be able to invoke the services that are configured to test the corresponding Business Request APIs with the sample data provided in Pega Foundation for Healthcare.
Dynamic settings end point URL management data page
You cannot modify the End Point URL resource path configured on a Connect REST rule once you finalize and lock the rule. To be able to maintain different end point system URLs and reference them dynamically, the Healthcare API configuration provide a pre-configured node level dynamic settings data page called D_HCSettings. As shown above, this page is referenced as a parameter to retrieve the Endpoint URL for the given resource.
The data source configured to fetch the end point URL is a Data Transform rule called LoadHCSettings. The rule is configured with URLs for a test reference system used internally for testing the Healthcare APIs. The rule is marked for Extension and is expected to be updated in your application with URLs for your own source systems for the different resources.
Map request data
The MapRequestData data transform rule provides the parameter(s) passed in the request API.
Map response data
The MapResponseData data transform maps the response received from the source system. The data received as JSON format is stored in Param.Response which is then mapped to appropriate object class in your application. In this example, the returned payer information is mapped to payer class using the MapToEntityWrapper data transform rule.
Wrapper map rule
A wrapper rule envelops each mapping rule for every resource API published in the Healthcare APIs. The wrapper rule contains the Pre and Post extension points to extend the mapping in your implementation. These rules are marked for Extension and you should extend as per your need. The expectation is that you maintain the main mapping rule included in the wrapper rule as is to allow Pega to maintain backward compatibility with the Pega-provided mapping rules. See the “Extending your APIs” section defined later.
Resource map rule
The configured mapping of the expected response for each Resource is configured in this data transform rule.
Business service API
Healthcare API - service package rule
The key service package rule is called Healthcare API. It lists all the REST services published in this release.
REST service method
The Healthcare API provides a mechanism for an external system to call the Pega Healthcare API REST services. The schematic shown below illustrates the flow of the REST service execution using ‘Payer’ as an example.
Key rules in service execution
Rule Name | Rule Type | Usage |
<Resource> | Service REST | REST service rule that identifies the path, parameters, and methods |
Get<Resource>API | Activity | Method in REST service to get Payer details |
MapFrom<Resource> | Data Transform | Map results from PFHC Payer to API Integration object |
Service REST rule
Each Resource published in the Healthcare API has a pre-configured REST Service rule that identifies the key properties including the path and parameters as well as all the methods configured for the Resource. Let’s look at an example below for the Payers API.
Resource and query parameters
The Resource and Query parameters configured on the REST Service rule are used to form and call the appropriate endpoint system URL. In the following example, the payer ID is passed as resource parameter, which will convert endpoint URL.
http://vfwiapppgr063:8080/prweb/PRRestService/healthcareapi/v1/payers/%7BID%7D
The Methods tab of the rule defines any of the methods - GET, PUT, POST defined for the Resource along with the parameters for each method.
Service activity rule
Each method defined on the Resource REST Service rule has an activity rule that kicks-off the process when the Service Method is executed. The requested data is retrieved using the endpoint URL of the source system using the parameters that were passed in the Method.
The data that is returned from the source system is mapped to the Integration class for the Resource as shown earlier. Results of this request will be stored in Param. Response and passed to data page.
Mapping data transform rule
The Activity defined in the Service Method calls a mapping Data Transform rule to map the returned data to the appropriate data page.
Extending Pega Healthcare APIs
The Healthcare APIs provide a mechanism for your application to extend the wrapper rule of every resource. A wrapper rule envelops each mapping rule for every resource API published in the Healthcare APIs. The wrapper rule is provided as a placeholder for extending the mapping in your implementation.
These rules are marked for Extension and you should extend them as per your need. It is expected that the main mapping rule included in the wrapper rule is maintained as is to allow Pega to maintain backward compatibility with the Pega-provided mapping rules.
MapToEntity extension pattern
This method describes the new API mapping paradigm. In this method, the pattern is described using the Authorization API as an example.
Inbound mapping
The mapping begins at the connect Data page i.e., D_ConnectAuthorization. The Connector data page for each Resource provides the configuration for the data page definition and the data source(s) that are used to fetch the data. It calls the connector and identifies the request and response data mapping rules.
MapRequestData: The MapRequestData data transform rule provides the parameter(s) passed in the request API.
MapResponseData: The MapResponseData data transform maps the response received from the source system. The data received as JSON format is stored in Param. Response which is then mapped to appropriate object class in your application. In this example, the returned authorization information is mapped to Authorization data class using the MapToEntityWrapper data transform rule.
MapToEntityWrapper: MapToEntityWrapper accepts a single Page Name parameter called Integration Page. In this case the parameter will be the ‘Authorization’ page of type ‘PegaHC- Data-Authorization.
The data transform serves as a control point for making calls out to a series of three additional Data Transform rules that provide the core mapping functionality as well as the appropriate extensibility needed by customers:
MapToEntity: a single MapToEntity rule exists in @baseclass and this rule is overridden in each of the classes that need to supply their own definitions. In the new implementation ‘MapToEntity’ would exist in the ‘Int’ classes and have the corresponding mappings. In the current example, we have the ‘MapToEntity’ data transform in the ‘PegaHC-Int-Authorization’ class. It contains the mappings related the authorization object.
The ’MapToEntityWrapper’ paradigm will be extended to all the embedded pages/objects as well. In the example, the authorization JSON response has a ‘requester’ page with page definition ‘PegaHC-Int-AuthorizationRequester’. We intend to map this page to the ‘Requester’ page on the PFHC Authorization object. The ‘Requester’ page is set as the parameter to the ‘MapToEntityWrapper’, which in turn invokes the ‘MapToEntity’ in the ‘PegaHC-Int-AuthorizationRequester’ class.
HTTP status codes
Success codes
HTTP Status Code | Description |
200 | Success(OK) |
201 | Created |
204 | No content |
Error codes
HTTP Status Code | Description |
400 | Bad request |
401 | Unauthorized |
403 | Forbidden |
404 | Not found |
412 | Precondition failed |
500 | Internal Error |
Healthcare API - key
Business request APIs
Authorizations - GET authorization details
This connector rule takes Authorization ID (certification number) as input parameter and returns the authorization details in data page.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/authorizations/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Authorization | ||
authorizations | Connect REST | |
GetAuthorizations | Activity | Method in REST service to get authorization |
MapFromAuthorization | Data Transform | Map results from PFHC Authorization to API Integration object |
D_ConnectAuthorization | Data Page | To call connector and map request and |
GetAuthorization | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | To map the results to PFHC Authorization object |
Authorizations - GET authorizations by member policy ID
This connector rule takes Authorization ID (certification number) as input parameter and returns the authorization details in data page.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/memberAuthorizations/{MemberPolicyID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Authorization | ||
memberAuthorizations | Connect REST | |
GetMemberAuthorizations | Activity | Method in REST service to get authorization |
MapFromAuthorization | Data Transform | Map results from PFHC Authorization to API Integration object |
D_ConnectMemberAuthorizations | Data Page | To call connector and map request and |
GetMemberAuthorizations | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapMemberAuthorizationsResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | To map the results to PFHC Authorization |
Benefit request - POST benefit details
URL format
POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Benefits
Parameters
This connector rule takes PlanBenefitRequest as a parameter which is claim Line details for a claim to fetch the coverage for particular line item.
PlanBenefitRequest {
claimLineNumber (string, optional), planID (string, optional), serviceFromDate (date, optional), serviceToDate (date, optional),
revenueCode (string, optional), procedureCode (A00.1, optional),
placeOfService (string, optional), diagnosis (string, optional),
age (string, optional), gender (string, optional), DateOfBirth (date, optional), billType (string, optional),
networkRelationship (string, optional), AdmissionType (string, optional),
IRC (string, optional), Modifier (string, optional), Providerype (string, optional)
}
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Benefit | ||
D_ConnectPlanBenefitCoverage | Data Page | To call connector and map request and |
PlanBenefitCoverage | Connect REST | Call REST Service using endpoint URL |
MapBenefitCoverageFilters | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToPlanBenefitCoverageWrapper | Data Transform | Wrapper DT which calls ‘MapToPlanBenefitCoverage’ and can be |
MapToPlanBenefitCoverage | Data Transform | Map results to PFHC Plan Benefit object |
Business entities - GET business entity
Business Entity API takes TIN or Tax ID as required field to fetch details and effective, end dates are optional parameters. Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/businessentities/{TIN}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-BusinessEntity | ||
businessEntities | Connect REST | |
GetBusinessEntities | Activity | Method in REST service to get Business Entity |
MapFromBusinessEntity | Data Transform | Map results from PFHC Business Entity to API Integration object |
D_ConnectBusinessEntities | Data Page | To call connector and map request and |
BusinessEntities | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Business Entity object |
Business affiliations - GET business entity
Business Affiliations API takes ID which is a comma delimited string of Provider ID, BusinessEntity ID and Effective Date (in the same order) as parameters to fetch business affiliation details.
Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/businessaffiliations/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-BusinessAffiliation | ||
businessaffiliations | Connect REST | |
GetBusinessAffliations | Activity | Method in REST service to get business |
MapFromBusinessAffiliation | Data Transform | Map results from PFHC Business Affiliation to API Integration object |
D_ConnectBusinessAffiliation | Data Page | To call connector and map request and |
GetBusinessAffiliation | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Business Affiliation object |
Policy - GET policy details
Policy API takes ID which is Policy ID as the parameter to fetch policy details.
Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/policies/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Policy | ||
policies | Connect REST | |
GetPolicyAPI | Activity | Method in REST service to get policy details |
MapFromPolicyObject | Data Transform | Map results from PFHC Policy to API Integration |
D_ConnectPolicy | Data Page | To call connector and map request and |
GetPolicy | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Policy object |
Member policies - GET member policies details
Member Policies API takes Member ID as required, PolicyID. Effective and End date as optional parameters to fetch policy details. Based on parameters passed to request – it will return results.
- If MemberID and PolicyID both are passed, then request will return details of requested policy.
- If only MemberID is passed, then it will get details of all policies Member has.
Pega Foundation for Healthcare provides connector data pages which invoke the external system REST service using endpoint URL. Below are key rules:
URL format
https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{memberID}/memberPolicies/{PolicyID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Policy | ||
memberPolicies | Connect REST | |
GetMemberPolicies | Activity | Method in REST service to get policy details |
MapFromPolicy | Data Transform | Map results from PFHC Policy to API Integration |
D_ConnectMemberPolicies D_ConnectMemberPoliciesByID | Data Page | To call connector and map request and response |
MemberPolicies MemberPoliciesByID | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Policy object |
Provider Contracts - GET contract details
This connector rule takes Provider Contract ID as required and Effective, End date as optional parameters. Based on Provider Contract ID match – it will return the contract details including Network and rate sheet IDs.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/providercontracts /{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
providercontracts | Connect REST | REST service rule that identifies the path, parameters, and |
GetProviderContracts | Activity | Method in REST service to get Provider Contract details |
MapFromProviderContract | Data Transform | Map results from PFHC Provider Contract to API Integration object |
D_ConnectProviderContract | Data Page | To call connector and map request and response |
ProviderContracts | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Provider Contract object |
Claims - GET claim
Get Claim service takes Claim ID as input path parameter and returns the claim object in JSON format.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/GetClaims
Parameters
This request takes ‘QueryString’ as parameter in format as
[patient.firstName='BOB' AND provider.name='Ian' AND claim.diagnosisType=55 OR (policy.type = 'EMP')]
Key rules
Rule Name | Rule Type | Usage |
GetClaims | Connect REST | REST service rule that identifies the path, parameters, and methods |
GetClaims | Activity | Method in REST service to get array of claims for the matched criteria |
MapRequestClaimHistoryData | Data Transform | Map results from PFHC Provider Contract to API |
GetClaimsHistoryBasedOnQuery | Connect REST | Call REST Service using endpoint URL |
MapResponseClaimHistoryData | Data Transform | To map service request data |
Claims - POST claim
This connector rule takes claim JSON data as a required parameter and returns a claim ID in JSON. HCIF provides a Pega-provided connect rule, which invokes the external system REST service using an endpoint URL. Below are key rules:
URL format
POST https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims
Output
{
"claimID": "CML-123"
}
Key rules
Rule Name | Rule Type | Usage |
PostClaim | Connect | Call REST Service using endpoint URL |
MapFromClaimWorkWrapper | Data | Map results from HCIF claims object to API Integration |
Employer group contract - GET employer group contract details
Employer Group Contract API takes ID as required field to fetch details. Foundation provides OOTB connector data page which invokes the external system REST service using endpoint URL. Below are key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Contracts/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Contract | ||
Contracts | Connect REST | |
GetContracts | Activity | Method in REST service to get Employer Group Contracts details |
MapContractData | Data Transform | Map results from PFHC Contract to API |
D_ConnectContract | Data Page | To call connector and map request and |
GetContract | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Contract object |
Member APIs
There are two resources for Member API:
- Get Member Details
- Get Member Networks
Both services take Member ID as parameter and returns relative details in data page. Foundation provides OOTB connector data pages which invokes the external system REST service using endpoint URL. Below are key rules:
Members - GET member details
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Member | ||
members | Connect REST | |
GetMember | Activity | Method in REST service to get Member details |
MapFromMember | Data Transform | Map results from PFHC Member to API |
D_ConnectMember | Data Page | To call connector and map request and |
GetMember | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Member object |
Members - GET members policy networks
URL format
GET
https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/members/{ID}/memberPolicies/{policyID}/networks
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Network | ||
members | Connect REST | |
GetMember | Activity | Method in REST service to get Member details |
GetMemberNetworks | Activity | Method in REST service to get Member’s |
MapFromNetwork | Data Transform | Map results from PFHC Network to API |
D_ConnectMemberNetworks | Data Page | To call connector and map request and |
MemberNetworks | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapNetworkResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Network object |
Networks - GET network details
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/networks/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Network | ||
networks | Connect REST | |
GetNetworkAPI | Activity | Method in REST service to get Network details |
MapFromNetwork | Data Transform | Map results from PFHC Network to API |
D_ConnectNetwork | Data Page | To call connector and map request and |
GetNetwork | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Network object |
Payers - GET payer details
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/payers/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Payer | ||
payers | Connect REST | |
GetPayerAPI | Activity | Method in REST service to get Payer details |
MapFromPayer | Data Transform | Map results from PFHC Payer to API Integration |
D_ConnectPayer | Data Page | To call connector and map request and |
GetPayer | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Payer object |
Plan details - GET plan details
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/plans
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Plan | ||
plans | Connect REST | |
GetPlanDetailsAPI | Activity | Method in REST service to get Plan details |
MapFromPlan | Data Transform | Map results from PFHC Plan to API Integration |
MapFromBenefitDefinition | Data Transform | Map results from PFHC Benefit Definition to API Integration object |
MapFromBenefitCoverage | Data Transform | Map results from PFHC Benefit Coverage to API Integration object |
D_ConnectGetPlanDetails | Data Page | To call connector and map request and |
GetPlanDetails | Connect REST | Call REST Service using endpoint URL |
MapPlanRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Plan object |
MapToEntity (PegaHC-Int-Benefit- Definition) | Data Transform | Map results to PFHC Benefit Definition object |
MapToEntity(PegaHC-Int-Benefit- Coverage) | Data Transform | Map results to PFHC Benefit Coverage object |
Plan networks - GET plan networks
This connector rule takes Plan ID as required and Effective, End date as optional parameters. Based on plan’s network – it will return the network details.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/plans/{ID}/{ Resource}
Parameters
Key rules
Rule Name | Rule Type | Usage |
plans | Connect REST | REST service rule that identifies the path, parameters, and methods |
GetPlanAPI | Activity | Method in REST service to get Plan’s Network |
MapFromNetwork | Data Transform | Map results from PFHC Network to API |
D_ConnectPlanNetworks | Data Page | To call connector and map request and |
PlanNetworks | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapNetworkResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Network object |
Providers APIs
The following are the resources provided for Provider API:
- Get Provider Details
- Get Provider Networks
Pega Foundation for Healthcare provides connector data pages which invoke the external system REST service using endpoint URL. Below are key rules:
Providers - GET provider details
This connector rule takes NPI ID as required and TIN, Effective, End date as optional parameters to fetch provider details. For Provider – all details including Provider demographic, Provider Affiliations will be returned to data page.
If TIN is passed, then it will return only matching TIN details in Provider Affiliations.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Provider/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Provider | Connect REST | REST service rule that identifies the path, parameters, and |
GetProvider | Activity | Method in REST service to Provider details |
MapFromProvider | Data Transform | Map results from PFHC Provider to API Integration object |
D_ConnectProvider | Data Page | To call connector and map request and response |
GetProvider | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data Transform | To map service request data |
MapResponseData | Data Transform | To map result data to data page |
MapToEntity | Data Transform | Map results to PFHC Provider object |
Providers - GET provider networks
This connector rule takes NPI ID as required and TIN, Effective, End date as optional parameters to fetch provider details. For Provider – all details including Provider demographic, Provider Affiliations will be returned to data page.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/provider/{ID}/{Resource}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Provider | Connect REST | REST service rule that identifies the path, parameters, |
GetProvider | Activity | Method in REST service to get Provider details |
GetProviderNetworks | Activity | Method in REST service to get Provider’s Network |
MapFromNetwork | Data | Map results from PFHC Network to API Integration |
D_ConnectProviderNetworks | Data Page | To call connector and map request and response |
ProviderNetworks | Connect | Call REST Service using endpoint URL |
MapRequestData | Data | To map service request data |
MapNetworkResponseData | Data | To map result data to data page |
MapToEntity | Data | Map results to PFHC Network object |
Rate sheets - GET rate sheet details
This connector rule takes Rate Sheet ID as required and Effective, End date as optional parameters and returns the Rate sheet details in data page.
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/ratesheets/{ID}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-RateSheet | ||
D_ConnectRateSheet | Data Page | To call connector and map request and response |
RateSheet | Connect REST | Call REST Service using endpoint URL |
MapRequestData | Data | To map service request data |
MapResponseData | Data | To map result data to data page |
MapToEntity | Data | Map results to PFHC Rate Sheet object |
Accumulators - GET accumulators
Accumulators API takes accumTypeID, accumStartDate, accumTermDate and accumStatus as required parameters to fetch details and accumType, subtype, network and secondaryID as optional parameters. Below are key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/accumulators/{accumTypeID}/{accumStartDate}/{accumTermDate}/{accumStatus}
Parameters
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Accumulators-Header | ||
accumulators | Connect REST | |
GetAccumulators | Activity | Method in REST service to get Accumulator |
MapFromAccumulator | Data Transform | Map results from PFHC Accumulators to API Integration object |
Plan catalog - GET Plan search results
Plan catalog API takes JSON request as shown below, also listed are other key rules:
URL format
GET https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/PlanCatalog
Parameters
The incoming data is a JSON formatted stream that is mapped to a Page property on the clipboard.
Request Structure
Property Name | Property Type | Applies to class | Page class |
PlanCatalog_Request | Page | PegaHC-API | PegaHC-Int- PlanCatalog_Request |
RequestParameters | Page List | PegaHC-Int- PlanCatalog_Request | Embed-PegaHC-Stringlist |
RequestParameters would take Name and Value as properties to send the request.
Sample JSON request:
{"RequestParameters":[{"Name":"Category","Value":"Med"},{"Name":"Version" ,"Value":"01"}]}
Similarly, above request can be extended to PlanID, Plan Name, Effective date, End Date, Status, LOB, PlanType.
Response structure
Property Name | Property Type | Applies to class | Page class |
PlanCatalog_Response | Page | PegaHC-API | Code-Pega-List |
Key rules
Rule Name | Rule Type | Usage |
Plan Catalog Request Class: PegaHC-Int-PlanCatalog_Request Plan Catalog Response Class: Code-Pega-List | ||
PlanCatalog | Connect REST | Plan Search REST Service |
GetPlanCatalogAPI | Activity | Method in REST service to get Plan details |
GetPCSPropertyUsingRequestParam | Decision Table | Decision table to set request parameters to be |
Business service API
Claims - GET claim
Get Claim service takes Claim ID as input path parameter and returns the claim object in JSON format.
URL format
Get https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims/{ID}
Parameters
This service rule takes claims id as path parameter and then returns claim object in the form of JSON.
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Claim | ||
GetClaimAPI | Service activity | Method in REST service to find claim and return claim details as response |
Claims | Service REST | REST service rule that identifies the path, parameters, and methods |
Claims - POST (create) claim
Post Claim service rule takes claim JSON as parameter and returns the created Claim ID in JSON format
Parameters
{
"claimID": "CML-123"
}
Parameters
{
"claimID": "CML-123"
}
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Claim | ||
PostClaimAPI | Service activity | Method in REST service to create claim and return claimed created as response |
Claims | Service REST | REST service rule that identifies the path, parameters, and methods |
Claims - PUT (update) claim
PUT claim service rule takes claim json as parameter and then returns updated claim ID in the form of json.
URL format
PUT https://[hostname:port]/prweb/PRRestService/healthcareapi/v1/Claims
Output
{
"claimID": "CML-123"
}
Key rules
Rule Name | Rule Type | Usage |
Class: PegaHC-Int-Claim | ||
PutClaimAPI | Service activity | Method in REST service to create claim and return claimed created as response |
Claims | Service REST | REST service rule that identifies the path, parameters, and methods |
Previous topic FHIR API technical specification guide Next topic Pega Foundation for Healthcare X12 message processing tech note