In Pega Product Composer for Healthcare, a product template, similar to a container,
sets the structure and guidelines for healthcare products in a line of business or
jurisdiction. You want to configure a product template to include your definitions for various
components of a healthcare insurance product, such as configuration for benefit sets,
networks, range of cost shares, coverage rules, and sales guardrails.
During product template configuration, you select one or more networks and assign benefits to
each network. This way, you create a structure of provider networks and their benefits where
you define coverage levels, eligibility rules, guardrail rules, and the range of values for
cost shares. The use of the product template facilitates the efficient building of products
because the products inherit the values that are defined in the product template for networks,
benefits, and groupers.
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Pega Product Composer for Healthcare
Before you begin:
View the and determine if you need to create additional
benefit coverage levels.
Use a Pega Product Composer for Healthcare product template to define multiple
products. Complete the basic information in the product template such as effective date and line
of business.
Before you begin: Configure the required networks and selected benefit sets because you need to select one
or more networks in step 2 and one or more benefit sets in step 3 of the wizard.
In the header of Dev Studio, click Launch portalProduct Development.
In the left navigation pane of your workspace, click NewProduct template.
Click New to configure a new product template or Copy
from template to copy information from an existing product template. If you
select Copy from template, select a product template from the
Copy from existing template list to reuse the information.
Enter a name for the product template.
For a new version of a product template, you can keep the same name as the old version
but you must change the effective dates. For a new product template, even if you have
different effective dates, you cannot have the same name as another product template.
Complete the fields according to your business needs.
To populate the Market segment field, click the Add a
row icon to make the field available, and then select an option from the
list.
If you select Medicare in the Market
segment field, you must select your rating in the Medicare star
rating field.
The following figure shows the first step of the product template wizard where you
enter the details or metadata:
Product template - Enter details
Click Save to complete your product template at a later time or
Continue.
Selecting a benefit set for a product template
You can select a benefit set that becomes the foundation for the product template for
your networks. A benefit set contains the list of benefits and groupers that will be included
for each network that you specified in the previous steps, except for carve-out networks.
Before you begin: Configure your networks and guardrails.
Carve-out networks cover the providers, including doctor and hospitals, for
specialized treatments.
If you are configuring a new product template, in the Benefit
set field, select a benefit set.
Optional: If you are copying a product template and you want to select a different benefit set,
in the Select benefit set section, click the Edit
selection icon and select another benefit from the list.
Optional: If you added a carve-out network, select the category and benefit from the lists and
click Add benefit.
In the Product template structure section, based on your
configuration, follow the steps in this table:
Option
Steps
When you create a new product template (not a copy)
Click Generate tree to view the list of all the benefits
and groupers within the specified benefit set.
When you create a product template from an existing product template (copy) or
create a new version of an existing product template and you select another benefit
set by clicking the Edit icon
Click Re-generate tree to view the list of all the
benefits and groupers within the specified benefit set.
When you create a product template from an existing product template (copy) or
create a new version of an existing product template and you select another benefit
set by clicking the Edit icon
Click Re-generate tree and select the Update only check
box to retain the values of the previous stand-alone benefits.
When you create a product template or create a new version of an existing
product template and you select another version of the benefit set by clicking the
Change benefit set button
There is no further action. Do not click the button or select the check box. The
values of the benefits in the previous benefit sets and stand- alone benefits are
retained.
To view the networks, click Network tree structure to expand the
section.
The following figure shows benefit set selection for a product template:
Product template - Select a benefit
Click Save to complete your product template at a later time or
Continue.
Configuring cost shares and accumulators for a product template
You can define individual cost share ranges for your product template. These values are
inherited at the product, plan, benefit, and network levels, which saves you time during
configuration. Based on the increment that you select, the cost share ranges are displayed in a
list when you select specific cost share values in your product. You can also define the order
of which cost shares are applied during claim adjudication.
If you need to customize your cost shares based on your organization's needs, see
Extending union data for cost shares in the Extending union data section.
Before you begin: Select a benefit set.
Optional: In the Product template cost shares and accumulators section,
select the N/A check box if a particular cost share does not
apply.
At least one cost share is required and cannot be set to N/A.
Click Set default cost share ranges to set values in the low and
high ranges (in US dollars) and set incremental values for the cost shares.
The value in the Increment field defines how much the value of
the cost share increases within the range of low to high.
Optional: Modify the values in the cost share fields, if necessary.
To specify the accumulators to which the copay and coinsurance values contribute,
perform these steps:
For each cost share, click the Configure the contributions
of icon in the Contributes to column.
In the dialog box, select the check boxes that apply and click
Submit.
In the Deductible and out-of-pocket calculation methods list,
select an option for your calculation method for deductible and out-of-pocket values.
Option
Description
Policy type
You enter out-of-pocket maximum amounts (in US dollars) based on the policy-type
tiers that are defined by the product template, product, or plan structures.
Number of family members
You enter the individual out-of-pocket maximum dollar amount (in US dollars) and
the number of family members who are required to meet the individual out-of-pocket
maximum amount. The family out-of-pocket maximum amount is automatically calculated
when you enter the number of family members.
Embedded
You enter the individual out-of-pocket maximum amount and family out-of-pocket
maximum amount (in US dollars).
Subscriber salary
You enter out-of-pocket maximum amounts (in US dollars) based on the
subscriber's salary. You can define multiple out-of-pocket maximum amounts based on a
salary range. You can also define the salary ranges as needed for product template,
product, or plan structures.
If you select this option, . click the
Configure subscriber salary ranges link, complete the
fields, and click Submit before you perform the next step.
Based on the calculation method that you select:
Optional: In the Deductible and Out-of-pocket
sections, select the N/A check box if a line item
does not apply.
Enter values in the Low, High, and
Increment fields in the Deductible
section.
Click the Configure the contributions of individual
deductible icon, select the check boxes for deductible contributions,
and click Submit.
Enter values in the Low, High, and
Increment fields in the Out-of-pocket
section as needed.
In the Accumulators section, select options from the available
lists to show how deductibles, out-of-pocket, annual maximum, and lifetime maximum
expenses accumulate: within the product or across all products.
In the Default order of cost shares section, select a cost share from
each list to represent the order in which the cost shares are applied to the benefits
during claim adjudication.
An individual benefit can have its own custom order of cost shares configured within
the benefit at the network level in a product template, product, or plan. If an order of
cost shares is not specified for an individual benefit, the default order of cost shares
that is defined in this step applies.
A penalty might be calculated for the provider or
member if the claim does not meet mandated or contractual authorization
requirements.
Click Coordination of benefits (COB) to expand the section.
Select the COB savings eligible check box if the member is
eligible to use cost savings from the coordination of benefits toward out-of-pocket
expenses.
In the Secondary payment type list, select an option to
determine whether the secondary payment is the lesser value of the COB calculation or
the remaining patient liability.
In the Cost share exclusions section, select the check boxes
to indicate if the cost share is not included in the COB calculation.
Click Authorization to expand the section.
Select the Authorization not applicable? check box if
authorizations do not apply.
If authorizations do apply, clear the check box and complete the fields.
Result: When you enter an authorization, it is inherited by all the benefits for all the
networks in the product template. It is also inherited in the product and plan from the
product template.
Click Save to complete your product template at a later time or
Continue.
The following figure shows the step for configuring cost shares and accumulators in the
product template:
Product template - Cost shares and accumulators
Configuring networks and guardrails for a product template
In the product template, you define networks and guardrails that can be inherited from
this product template when you configure products and plans later. You reuse existing
information and save time during configuration.
Network guardrails are applied when products are configured by using a product template. For
example, you can apply a rule that requires that the co-payment for in-network expenses is
less than or equal to the co-payment for out-of-network expenses. When you build a product or
plan by using the product template, this rule is enforced during the cost share selection
process.
Before you begin: Enter the details for a product template.
To add a network to your product template, in the Network field,
select a network from the list of predefined networks and click Add
Network.
Optional: Click the network link to configure a new version or update an existing version of the
network. On the Network page, tabs describe the network, provider
networks, and notes.
To configure a new version of the product template, click Save as new
version, complete the fields, and click
Save.
To resume or update the current version, click Resume/update
version, complete the fields, and click
Save.
Optional: To compare the cost shares of two networks, in the Network
guardrails section:
Click the Add a row icon to add a row.
Select your options from the lists.
Repeat these steps for each cost share that you are comparing.
The following figure shows where you configure the network and guardrails in a product
template:
Product template - Network and guardrails
Click Save to complete your product template at a later time or
Continue.
Configuring cost shares at the network level
View the summary of all the network cost shares and guardrails that you defined in
the product template and modify coverage at the network level. For example, you might want to
increase the high range of the cost shares to accommodate out-of-network services because the
copayment for an out-of-network service might be higher than the cost of the same service
within a network.
Additionally, you can add or modify variations and network details that are specific to the
selected network. And you can control accumulation across the networks.
The Guardrail summary in the bottom section of the page displays the
cost share boundary rules that you previously defined.
Before you begin: Configure your cost shares and accumulators.
In the Network cost shares step of the product template wizard, in
the Networks section on the Configure
networks page, click a network name link to update coverage at the network
level.
To modify covered and required services:
In the expanded Configure network details window, click
Edit.
In the Configure or modify coverage dialog box, in the
To edit, select one or more check boxes for corresponding
fields section, select the Covered and required
check box and click OK.
Based on the specified benefit or grouper, click Covered
or Not covered.
The shaded button shows the current setting.
Click Close.
If you are not making any other changes to the networks, click
Continue.
To modify the requirement for services, follow these steps:
For example: Some services are required as part of the plan.
In the expanded Configure network details window, click
Edit.
In the Configure or modify coverage dialog box, in the
To edit, select one or more check boxes for corresponding
fields section, select the Covered and required
check box and click OK.
Based on the specified benefit or grouper, click Required
or Not required.
The shaded button shows the current setting.
Click Mark complete, and then click
Close.
To modify the coverage values that you set in the product template:
On the Configure network details page, on the Cost
shares and accumulators tab, click Edit.
In the Configure or modify coverage dialog box, select the
check boxes for the values that you want to modify, and then click
OK.
On the Configure network details page, modify the values as
needed in the selected sections, click Save, and then click
Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
Optional: To restore the original values, click Restore. In the
Clear the check boxes to restore values dialog box, clear the
check boxes that you previously selected, and click OK.
On the Configured network page, click
Save and Mark complete when you are
finished editing the coverage values for networks.
For each network whose coverage you are modifying, on the Configure
networks page, click the network name link and repeat these steps.
Click Continue if you are not making any other changes to
the networks.
To add variations:
On the Configured network details page, click the
Variations tab and click Edit.
Click Add variation.
Name the variation, provide the effective and end dates, select the check box for
the type of variation, and select a condition type.
Complete the corresponding fields that appear, based on your selections, and click
OK. Always add a unique combination of the variation name and
effective date. An error message is displayed if you choose a combination that is
already been used.
Repeat steps b through d for each variation that you are adding.
When you finish adding or editing the variations for the specified network, click
Save, then click Mark complete.
Click Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
For each network to which you are adding variations, on the Configure
networks page, click the network name link and repeat these steps.
To view more details about the variations, click the variation count link.
Variation count shows the presence of variation(s) configured on the
network.
Click Continue if you are not making any other
changes.
To edit network details:
On the Configure network details page, click
Edit.
Click the Additional network details tab, and then click
Edit.
Complete the fields, click Save to save the changes, click
Mark complete, and then click Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
For each network to which you are adding details, on the Configure
networks page, click the network name link and repeat these steps.
When you finish making changes, on the Configure networks page,
click Mark all as complete, and then click
Continue.
The following figure shows where you configure the network cost shares in the product
template:
Product template: Network cost shares
Configuring benefits for a product template
Modify the coverage, for example copayment or coinsurance, for a benefit or grouper that
was previously included as part of a benefit set for a specific network. During this step, you
add the values for the benefit-specific coverage, for example deductible or out-of-pocket
amount. You can also add another benefit or grouper that was not included in the benefit set
that you previously added. In addition, you can configure the order of cost shares that is
used in claim adjudication.
You can assign cost shares for specific conditions or assign limits to a benefit. For
example, you can limit physical therapy sessions to 60 visits per year or require an
authorization for certain conditions.
Additionally, you can set services that are covered and set services that are required.
Before you begin: Configure the cost shares at the network level.
To add a benefit or grouper, follow these steps:
Click Add benefit/grouper.
In the Add Benefit/Grouper to benefit tree window add the
grouper or benefit by completing all the fields, and then click
Close.
Result: The Grouper/Benefit section shows the benefits,
groupers, and their cost share values per network.
To modify the coverage of a single benefit, a grouper that contains multiple benefits,
or one benefit within a grouper, follow these steps:
On the Configure groupers and benefits page, click the
Configure item icon to the right of the benefit or grouper
name.
In the Configure details for product template window, click
the network for which you are modifying the benefit coverage.
In the expanded Configure details for product template window,
click Edit.
In the Configure or modify benefit-specific coverage dialog
box, in the To edit, select one or more check boxes for corresponding
fields section, select the Covered and required
check box and click OK.
Based on the specified benefit or grouper, click Covered
or Not covered.
The shaded button shows the current setting.
Click Mark complete, and then click
Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
To modify the requirement for services of a single benefit, a grouper that contains
multiple benefits, or one benefit within a grouper, follow these steps:
For example: Some services are required as part of the plan.
On the Configure groupers and benefits page, click the
Configure item icon to the right of the benefit or grouper
name.
In the Configure details for product template window, click
the network for which you are modifying the benefit requirement.
In the expanded Configure details for product template
window, click Edit.
In the Configure or modify benefit-specific coverage dialog
box, in the To edit, select one or more check boxes for corresponding
fields section, select the Covered and required
check box and click OK.
Based on the specified benefit or grouper, click Required
or Not required.
The shaded button shows the current setting.
Click Mark complete and then click
Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
To configure the coverage of a new or an existing item, follow these steps:
On the Configure groupers and benefits page, click the
Configure item icon at the right of the benefit or grouper
name in the list.
In the Configure details for product template window, on the
Coverage tab, click the network name.
In the Configure details for product template expanded window,
to update coverage information, click Edit.
In the Configure or modify benefit-specific coverage dialog
box, to update the network coverage values, select the check boxes in the
Select the check box to edit the corresponding fields section
or the Select the check box to configure the corresponding
coverage section that you want to modify and click
OK.
For example: You might want to increase the values of copayment or coinsurance or change the
accumulators. Additionally, you can modify coordination of benefits and
authorizations. You also might want to change the values of your deductible or
out-of-pocket expenses for the benefit.
In the corresponding sections in the Configure details for product
template window, modify the values, and then click
Save or Save across networks. If you
select Save across networks, select the network name check
boxes that appear in the dialog box, and click Close.
If you click Close without saving the changes, an error message
is displayed. You can discard the unsaved changes by closing the dialog box.
To remove one or all changes that you made in steps c through e and restore the
original values, click Restore, clear the check boxes in the
dialog box, and click OK.
Repeat step 4 to configure or modify each benefit or grouper.
To configure the values and network contributions of annual maximum and lifetime
maximum, follow these steps:
On the Configure groupers and benefits page, click the
Configure item icon at the right of the benefit or grouper
name in the list.
In the Configure details for product template window, on the
Coverage tab, click the network name.
In the Configure details for product template expanded window,
to update coverage information, click Edit.
In the Configure or modify benefit-specific coverage dialog
box, select the Accumulators check box. Then based on your
business needs, select either the Annual maximum or
Lifetime maximum check box, or both, and click
OK.
In the Configure details for product template window, in the
Annual maximum and Lifetime maximum
fields, select the values.
In each field, click the Cross network for icon, select one
or more network name check boxes in the dialog box, and click
Close.
Repeat step 5 as needed for each benefit.
To specify that a benefit limit in a product template applies to multiple networks,
follow these steps:
Click the Configure item icon next to the benefit.
On the Configure benefit details page, select a network.
Click Edit.
In the Configure or modify benefit-specific coverage dialog
box, select the Accumulators and Limit
check boxes and click OK.
In the Accumulators section, clear the Limit not
applicable check box.
Enter the limit information in the fields.
Click the Configure the cross-network for limit icon, select
the networks that apply, and click Save.
Click Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
To create or modify variations of benefits or groupers, follow these steps:
Note: Use variations sparingly and only when you need to configure an item that is not
standard.
On the Configure groupers and benefits page, click the
Configure item icon next to the benefit or grouper.
In the Configure details for product template window, click
the Variations tab.
Click the network link and then click Edit.
Add or edit variations, click Save, and then click
Close. Always add a unique combination of the variation name
and effective date. An error message is displayed if you choose a combination that is
already been used. The variation count link under the network columns shows how many
variations are configured for the grouper or benefit. The total count of all inherited
variations (network + grouper + benefit) is displayed.
To review details about the variations that are configured for a grouper or
benefit, click the variation count link.
Variations
Repeat these steps for each benefit or grouper variation that you are creating or
modifying.
To configure additional details for a benefit or grouper, follow these steps:
On the Configure groupers and benefits page, click the
Configure item icon next to the added benefit or
grouper.
In the Configure details for product template window, click
Additional details.
Click the network link
In the expanded Configure details for product template window,
click Edit.
To meet your business needs, you can configure fields for compliance support,
documentation support, and claims instructions.
Click Save and then click
Close.
If you click Close without saving the changes, an error
message is displayed. You can discard the unsaved changes by closing the dialog
box.
Repeat these steps for each new benefit or grouper detail that you are creating or
modifying.
To review the mapping for a benefit, follow these steps:
On the Configure groupers and benefits page, click the
Configure item icon next to the added benefit or grouper.
In the Configure details for product template window, click
the Mapping tab.
Review the information that you previously entered. Click Mark
Complete and then click Close.
If you need to make changes based on your review of the
Mapping tab, you must modify the specific benefit. For
additional information, see Configuring a benefit.
When you are finished configuring benefits and groupers, click Mark all as
complete and then click Continue.
The following figure shows benefit configuration in a product template:
Product template - Configure benefits
Optional: Changing the default benefit
During product template creation, the system automatically assigns the first
benefit as the default benefit in the benefit category. The default benefit best
represents the cost share for the benefit category. The cost share, such as copay or
coinsurance, on the benefit category displays in a Summary of Benefits and Coverage
(SBC) document or in a sales application when using the Plan API. However, you can also
change the default benefit for the product template to meet your business needs.
When you use a product template to create a product or plan, the product inherits it from
the product template and the plan inherits it from the product. You can also change the
default benefit at both the product and plan levels.
In this wizard step, you can also change and add benefit categories. However, if you add
a benefit category, there is no default benefit.
Before you begin: Configure the benefits for the product template.
In the Configure benefit categories step of the wizard, in
the Benefit category column, click a tab to expand
it.
For the benefit that you are setting as default, click the
Gear icon and click Set as default display
benefit.
Result: The default benefit displays Yes. Other benefits
within the benefit category display No.
Click Finish.
Changing or adding a benefit category
During product template creation, you can change the benefit category assignments.
For example, you might change the benefit category for the Office visit benefit from
Inpatient services as defined during benefit creation to Outpatient services. You can also
add a benefit category. However, if you add a benefit category, there is no default
benefit.
In this wizard step, you might want to change the default
benefit.
In the Configure benefit categories step of the wizard, in
the Benefit category column, click a tab to expand
it.
Click the Gear icon to the right of the benefit that you
are modifying.
Click Change benefit categories.
In the Change benefit categories dialog box, click
Add benefit category and then enter and click a
category from the list.
Click Submit.
When you have completed your changes, click Finish.
