Extending eligibility processing
Copy the following rules in your ruleset to extend the eligibility lookup and processing:
| Name | Type | Description |
| ProcessBenefitRequest | Activity | Main activity rule that processes the eligibility information. |
| OpenPolicyByIDNoDisplay | Activity | Searches for member’s policy by Policy Number submitted on the message. |
| CheckPolicyOnServiceDate | Data Transform | Checks to see if the Policy is active on the requested service date in the message. |
| ProcessPlan | Activity | Fetches Plan/Product based on Plan ID associated with Policy. |
| ProcessBenefit | Activity | Fetches Plan Benefits. |
| ProcessBenefitGroup | Activity | Searches for matching benefit coverage based on submitted service type code on the message. |
For additional information, refer to the Healthcare X12 EDI Message Management Technical Specifications on the Pega Foundation for Healthcare product page.
Previous topic Extending message validation Next topic X12 276 – 277 – Claim status request and response message