Complementing the 834 inbound message processing capability mentioned above, Pega Foundation for Healthcare also provides a mechanism to generate HIPAA-compliant 834 outbound messages for Member / Policy - Adds / Updates / Terminations.
Like inbound, there are two sets of files generated for outbound messaging:
- New Benefit Enrollment Full File (typically generated monthly)
- Benefit Enrollment Change File (for adds / updates / deletes of member and policy profiles)
The 834 benefit enrolment outbound messaging capability is dependent on the enrolment data being mapped to PFHC data objects around Member and Policy for e.g., inbound 834 message parsing (discussed in preceding section) maps enrolment information to PFHC’s member-policy data model and these records can be used to generate the outbound file(s).
Following are the rules used to generate the outbound file:
- ‘Generate834FromPolicy’ activity will generate a file from policy and is the starting point for the whole flow. Here, we will create few pages and then will verify if the policy type (selected from the UI) is single or multiple. After this in the same rule we will verify if we have selected the option of “full file” or “change file” (for multiple policy type).
- D_GetPoliciesUpdatedForAMonth is the data transform that will return policies updated For a Month. GetPolicyInformation activity will set policy information.
- D_GetPoliciesUpdatedForAWeek the data transform that will return policies updated for a week. This data transform is used for change files. Again, GetPolicyInformation will be called to set policy information.
- X12OutboundMapping data transform will loop over the transactions and will call ‘SetTransactionLoops’ data transforms will call other data transforms to build entire Header,Trailer and policy Structure.
- ‘Generate834’ will generate message from clipboard page.
- ‘SetMessage’ data transform then generates the outbound 834 file that could be placed in a desired location using the ‘FilePathParam’ data transform.