You can edit the cost-sharing information and limitation details on this tab so that it
adheres to your product or plan.
Members use this section of the SBC document to understand cost-sharing information for certain
common medical events such as copayments and coinsurance amounts and significant
limitations or exclusions. Services that are described might include a visit to a
provider’s office, a laboratory appointment for an MRI or CAT scan, a hospital stay, or
prescription drug information.
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Information about how values are calculated for the
Common medical events tab includes the
following:Note: Mapping applies only to the first network, In-network.
Action
Result
Add benefits that represent the medical event for each row.
Values for copayments and coinsurance for the selected benefit
and the network for the specified product or plan are displayed in
the SBC document.
If the values for the copayment and coinsurance for the selected
service cost shares are both configured in the product or plan as
N/A
The SBC document for the product or plan displays No
charge.
If the selected service is configured as Not
covered in the product or plan
The SBC document for the product or plan displays Not
covered.
For authorizations that are configured in the product or
plan
The SBC document for the product or plan displays information as
follows:
Only when the authorization is specified as
Always required
Only if the method is Flat amount or
% of
If the selection for Limit type on
the SBC template is Auth required,
but the selected benefit does not have authorizations
configured in the benefit for the product or plan, then the
SBC document for the product or plan displays
None.
If the selection for Limit type on
the SBC template is Auth required and
Limits, but the selected benefit
does not have authorizations configured in the benefit for
the product or plan, but does have a limit configured, then
the SBC document for that product or plan displays only the
limit data.
If the selection for Limit type on
the SBC template is Auth required
with custom text, but the selected benefit does not have
authorizations configured in the benefit for the product or
plan, then the SBC document for that product or plan
displays None.
If the selection for the Limit type
on the SBC template is Auth required
and Limits, but the
selected benefit does not have both configured for the
product or plan, then the SBC document for the product or
plan displays None.
The following figure shows the Common medical events tab in the SBC
template.
Common medical events tab
In the Configure template step of your SBC template,
click the Common medical events tab.
To edit the disclaimer section, click in the cell, and in the text box in the
right pane, modify the text, and then click Apply.
To change the text that describes medical events, do the following:
You cannot add or delete a common medical event. You can add or delete
multiple services for each common medical event. At least one service is
required for each common medical event.
In the Common medical event column, click a
cell.
In the right pane, edit the text to meet your business needs, and
click Apply to apply your changes.
To add or modify the description of the service for a common medical event,
what you will pay, and the limitations and exceptions, click a cell in the
Services you may need column, and then perform the
following steps:
The second, third, and fourth columns are interrelated. To edit, use the
common section in the right pane. You must provide data for the cells in the
third and fourth columns.
In the right pane, next to the service that you want to modify, click
the Edit icon.
In the Service name field, modify the text as
needed.
To add a benefit, in the Benefit list, select a
benefit and add text in the Benefit details
field, if needed.
You can map or remove multiple benefits for each service.
The name of the benefit and the text display in the What
you will pay column after you apply your changes.
You must map a benefit to each service.
To add a limitation in the Limitation type list,
select a limitation and add text in the Custom text
field, if needed.
You can provide the two limitation types for one benefit:
Authorization required and
Limits.
The authorization and the text displays in the Limitations,
exceptions, and other important information column after
you apply the changes.
To include additional benefits or limitations, click the Add
limitation link or the Add benefit
link and complete the fields. For example: You might add another service if a service such as Diagnostic test
has two benefits, one for lab and one for x-ray tests.
The limitation data is copied from the prior service in the
Limit column. In the final PDF file of the
SBC document that is specific to a product or plan, the cells are
merged.
Click Apply before you proceed to another
service for the specified common medical event.
Mapping for Limits and Authorization
required display in the fourth column after you click
Apply.
Click Save.
Repeat steps a through h for each service for the specified common
medical event.
Repeat steps 3 and 4 for each service for other common medical events.
Optional: Extending the rules of the Common medical events tab
As an administrator, you can extend rules that are related to the Common
medical events tab by using the data transforms to modify text that meets
your business needs.
To modify the rules that are listed in the following table, in Dev Studio,
enter the rule name from the following table in the search box.
Click the rule name.
On the Data Transform page, click Save
as and save the rule to your implementation layer.
Make your changes and click Save.
For more information about data transforms, see Data transforms.
Repeat these steps for each rule that you want to modify.
Action
Rule name
Override the text in the Common medical
event column for on the Common
medical events tab.
InitializeCommonMedicalEventsEXT
Override the default text in the Services you
may need column on the Common
medical events tab.
