Inheritance pattern 1
Values that you configure in the Cost shares and Accumulators step of the product or plan wizard, such as Copayment, Coinsurance, and Authorizations, are inherited by the networks, groupers, and benefits, as long as you have not overridden the values. These entities follow this inheritance pattern.
Copay and coinsurance example
To determine where a copay or coinsurance value originates and how its inheritance is handled, Pega Product Composer for Healthcare reviews the entity configuration by following the numerical order in the inheritance tree, as shown in the following figure:
For example, a copay value of $20 is shown for a plan benefit. PCS needs to know the origin of the $20 copay value, or where the value for the copay was entered. PCS reviews the configuration for each entity by following the numerical order up the tree until it finds the location where a value was entered (an override), in the configuration. If no override exists in the plan benefit (1), it looks for the override in the product benefit (2) configuration. If there is no override in the product benefit configuration, it reviews the plan grouper (3) configuration, if the grouper contains benefits. If there is no override, it reviews the product grouper (4) configuration, and then reviews the plan network (5) configuration, and so on. When it finds the override in the entity configuration, it stops the search because that entity has the source for the copay value.
As a user of Pega Product Composer for Healthcare, you can see the source of the cost share by reviewing the entity configuration in PCS.
The following figure shows the benefit coverage configuration within a plan. In the Inheritance column, the dash (-) next to Copay indicates that there is an override at the plan level and that inheritance has been broken for copay. Coinsurance values are inherited from the product, as indicated by PRD in the Inheritance column.
To find the origin for a copay for a product benefit, PCS reviews the entity configuration and follows the numbers straight up the product side of the tree, as shown in the following figure:
Authorization
To determine where an authorization requirement for a plan benefit originates, PCS uses Inheritance pattern 1 and follows the same steps for plan benefit or product benefit as described in the Copay and coinsurance section.
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