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Configuring a benefit

Updated on April 12, 2021

You can configure a new benefit, the basic building block of Pega Product Composer for Healthcare, or copy the information from an existing benefit to save time. A benefit includes sets of code groups that define the benefit, and other parameters such as its name, effective date and end date, insurance line, and line of business.

Pega Product Composer for Healthcare

A benefit has mappings that describe the conditions of a benefit. For example, an Infertility Treatment Outpatient benefit has conditions that indicate place of service, diagnosis code, and service code. The definition of a benefit is fundamental in benefit determination during the claim adjudication process.

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. You can also configure additional benefit definition options and configure the code groups that are needed for the benefit mapping definition. For information, see Configuring benefit mapping 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 workspace, click NewBenefit.
  3. Click New or Copy existing.
    When you copy an existing benefit, the application pre-fills the subsequent screens with the data from the selected benefit and then you can make changes.
  4. Enter text in the fields, select options from lists, and enter dates to describe your benefit.

    Ensure that you complete all required fields as you perform the steps in the wizard.

    You can customize the Enter details page by configuring additional properties. For additional information, see Adding new properties to entities in the Extending the Pega Product Composer for Healthcare application section.

  5. Complete the Purpose and Alias Name fields so that business areas, such as Customer Service or Sales, understand the purpose of the benefit.

    The following figure shows benefit configuration.

    Shows details for a benefit
  6. Click Save to continue benefit configuration at a later time or Continue.
  7. Define your benefit by assigning mappings such as service groups and places of service.
    You can also exclude a code or code group.
  8. Optional: In the Override section, select the Override other claim lines? check box when you are integrated with a downstream processing claim system that requires an indicator to advise when one benefit precedes or overrides another.
    Result: The system uses this benefit on all claim lines so that the member pays only for the cost shares associated with this benefit.
  9. Click Generate Description to list the overrides to the benefit.

    The following figure shows where you map service codes and place of service codes in the benefit configuration.

    Mapping benefits
  10. Click Save to complete your benefit at a later time or Continue.
  11. Enter notes in each of the tabs that are available for use in the Summary Plan Description document or any external system that requires a description of the benefit. Then click Continue.
  12. Review the benefit and click Finish.

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