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Benefit category and benefit coverage levels

Updated on January 26, 2021

This section describes how to configure a benefit category, a default benefit category and how to map multiple benefits or groupers to benefit categories.

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Configuring a benefit category

In Pega Product Composer for Healthcare, a benefit category is a container that you use to associate related benefits. Benefit categories are helpful in planning when you use a minimal number of benefits. You might create an Inpatient Hospital category that contains physician and surgeon fees or a Preventive Care category that contains screening and blood tests.

With benefit categories, sales representatives or brokers can easily select a plan that matches or is closest to their needs. Then they can identify the gaps when requesting a plan. Also, the benefit category can be easily changed at the product template, product, and plan level as needed.

  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the left navigation panel of your workspace, click NewBenefit Category.
  3. Enter a name and description for your benefit category.
  4. Click Save to continue benefit creation at a later time or Continue.
  5. Click Finish after you review the benefit category.

Configuring a default benefit category

If you are upgrading your application, create a default benefit category.

Before you begin: Ensure that you created a benefit category. For additional information, see Configuring a benefit category above.

To set up a default benefit category on the Product Composer System Configuration page, click the Flow settings tab, and configure the settings in the Default benefit category field.

Viewing default benefit coverage settings

Pega Product Composer for Healthcare provides default benefit coverage levels. If the benefit coverage levels do not meet your business needs, you can add new benefit coverage levels.

  1. In the header of Dev Studio, click ConfigureProduct composer systemconfiguration.
  2. Click the Flow settings tab.
  3. In the Coverage levels section, click View legacy coverage levels.
What to do next: To configure additional benefit coverage levels, see Configuring additional benefit coverage levels.

Mapping multiple benefits or groupers to benefit categories

To assign existing benefits or groupers that were not assigned to benefit categories or reassign them to other benefit categories, use the benefit category mapping option in the PCS Import feature. You can quickly map multiple benefits or groupers to benefit categories.

For example, to assign the Ambulance benefit to another benefit category, you can select which benefits apply such as Ambulance – Air and Ambulance – Ground, and map the selected benefits to the benefit category.

Before you begin: Ensure that you have created benefits, groupers, and benefit categories.
  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the navigation panel, click Reusable EntitiesImport.
  3. Click Run PCS Import.
  4. In the Name field, enter a meaningful name that represents the data that you are going to import.
  5. In the Select entity to import list, click one of the two mapping options. Based on your selection, perform the tasks in the following table.
    Benefit to benefit categories mapping
    1. Click Select benefits.
    2. In the Select entities dialog box, complete the fields that are necessary for your search.

      For example, enter the name of the benefit that you are mapping to a benefit category such as Ambulance.

      You can also enter an asterisk (*) in the fields to perform a wild card search.

    3. Click Search.
    4. In the Benefits results section, click Add next to each item that you are mapping.

      To select a specific version of the benefit, click the Down arrow next to the name of the benefit and select the version.

    5. Click Submit.
    6. On the Import entities page, review the list of benefits to ensure that there are no duplicate items, and then click Submit.

      For example, you delete one of these two duplicate items: Ambulance 01-01 and Ambulance 01-03.

    7. Click Download benefit to benefit categories mapping to download the Microsoft Excel template and then perform the remaining steps in the procedure.
    Grouper to benefit categories mapping
    1. Click Select groupers.
    2. In the Select entities dialog box, complete that fields that are necessary for your search.

      For example, enter the name of the grouper that you are mapping to a benefit category such as Radiology-Complex.

      You can also enter an asterisk (*) in the fields to perform a wild card search.

    3. Click Search.
    4. In the Groupers results section, click Add next to the items that you are mapping.
    5. Click Submit.
    6. On the Import entities page, review the list of groupers to ensure that there are no duplicate items, and then click Submit.
    7. Click Download grouper to benefit categories mapping to download the Microsoft Excel template and then perform the remaining steps in the procedure.
  6. Open the template, and follow these steps:
    1. Modify only the Identifier and Benefit categories fields.
    2. Review the template and remove duplicate entries.
    3. Save and close the file.
  7. Click Upload benefit to benefit categories mapping or Upload grouper to benefit categories mapping.
  8. Choose your file and upload it. Result: On the Import entities page, in the Category section, you can see your modified benefit categories.
  9. Click Submit to route the mapping changes for manager approval.

Tags

Pega Product Composer for Healthcare 8.5

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