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Configuring a benefit set

Updated on January 26, 2021

When you configure a product or a plan in Pega Product Composer for Healthcare, you can associate it with a benefit set, which is a package that contains multiple benefits that are managed as a single unit. A benefit set maps to potential claims that are submitted to the health plan for payment.

Pega Product Composer for Healthcare
Before you begin: Ensure that you have configured benefits and groupers as needed. For additional information, see Configuring a benefit and Setting up a grouper.
Note: Based on your organization's needs, you can extend the metadata. For additional information, see Extending entity metadata in the Extending the Pega Product Composer for Healthcare application section.
  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the left navigation panel of your work area, click NewBenefit Sets.
  3. Enter the information to describe your benefit set.
    1. If you select Copy existing, select the benefit set from the Copy from benefit set list.
      You can also review the benefit set details, update the benefit set, or save the benefit set as a new version.
    2. Optional: Click the Edit icon to select another benefit set from the list.
  4. Click Save to complete the benefit set at a later time or Continue to continue the benefit set configuration.
  5. In the Add benefits section of the Select groupers and benefits step:
    1. Select the category and the benefit, and click Add.
      The benefit appears in the Benefit set section on the right side of the page.
    2. In the Add groupers section, select the insurance line and grouper, and then click Add.
  6. Repeat step 5 for each benefit or grouper that you want to add to the benefit set.
  7. Click Save or Continue to complete the benefit set configuration.
  8. Click Finish.
  9. Optional: In the Review and submit step of the wizard, for each item, click the Open this item for review icon to review, update, or configure a new version of the benefit or grouper.
Result: The case is submitted to the manager.

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