Products contain information, networks, benefits, and cost shares. In Pega Product Composer for Healthcare, products are built from product templates and are the
foundation of standard and non-standard plans that health insurance organizations take
to market.
You configure cost shares and variations in a product. Although cost shares are
configured as ranges in the product template, the product requires configuration of a
specific value from within the range set at the product template level.
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
Pega Product Composer for Healthcare
Ensure that you have configured your product template. For additional information,
see Product templates.
Entering details for a new product
Configure a new healthcare insurance product by copying an approved product or using a
product template that facilitates the efficient building of a product. Product templates outline
the network structure, list of benefits, cost share ranges and defaults, and accumulator design
that all support product configuration.
In the header of Dev Studio, click Launch portalProduct Development.
In the left navigation panel of your workspace, click NewProduct.
Click an option to configure a product by using a product template or copying from an
existing product and then select the name of the product template or product from the
Create or Copy list.
Enter a name.
For a new version of a product, you can keep the same name as the old version but you
must change the effective dates. For a new product, even if you have different effective
dates, you cannot have the same name as another product.
Complete the required fields.
The following figure shows where you enter the details or metadata in the first step of
the product wizard:
Product - Enter details
Click Save to complete your product at a later time or
Continue to configure cost shares and accumulators.
Configuring cost shares and accumulators for a new product
Configure custom individual cost shares for your product by selecting the appropriate
cost share types with values for your product. You want to specify the most common values so
that when you reach the Configure benefits step of the wizard, you change
only those values that need to be modified and maximize the inheritance as much as possible.
In this step of the wizard, you must configure at least one cost share.
If your product
has multiple networks, define the values for the first network, for example, In-network, in
this section. When you get to the Network step of the wizard, you can
just define values for Out-of-network.
If you are configuring your product from a product template, you inherit the values that
were configured in the product template. If you are copying a product from another product,
you receive the values from the existing product. You can also define the accumulators, the
order to apply cost shares during claim adjudication, and information to coordinate benefits.
You can override the default order of cost shares for a specific benefit.
Before you begin: Enter the details for the product.
Optional: Select the N/A check box only if a particular cost share does
not apply.
In the Product cost shares section, select an option in the
Calculation method fields and the Value
fields for the copayment and coinsurance cost shares.
To specify if these cost shares contribute to the deductible or out-of-pocket expense
accumulators, perform the following steps for copayment and coinsurance:
In the Contributes to column, click the Configure
the contributions of icon to the right of the field.
In the dialog box, select the check boxes that apply.
Click Submit to ensure that the specified cost share values
contribute to the accumulators that you selected.
In the Annual maximum, Lifetime maximum,
and Carryover fields for the individual and family, select an
option in the Value field. In the Carryover
field, you also select a time frame.
In the Deductible and out-of-pocket calculation methods list,
select an option for your calculation method. The selected method applies to both
deductibles and out-of-pocket maximums.
Option
Description
Policy type
You select values for deductible and out-of-pocket expenses that are based on
the policy-type tiers that are defined by the product template, product, or plan
structures. You also specify whether the deductible contributes to the out-of-pocket
accumulators.
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. The system automatically calculates the family out-of-pocket maximum amount.
You also specify whether the deductible contributes to the out-of-pocket
accumulators.
Embedded
You select the individual and family out-of-pocket maximum amounts (in US
dollars) and specify whether the deductible amounts contribute to the out-of-pocket
accumulators.
Subscriber salary
You enter out-of-pocket maximum amounts (in US dollars) that are based on the
subscriber's salary. You can define multiple out-of-pocket maximum amounts that are
based on a salary range. You can also define the salary ranges as needed for product
template, product, or plan structures. You also specify whether the deductible
contributes to the out-of-pocket accumulators.
Based on the calculation method that you select, complete the fields in the
Deductible and the Out-of-pocket sections
that apply. Guidelines include:
Optional: Select the N/A check box if a line item
does not apply to your product.
If you select Subscriber Salary as a calculation method,
configure the salary range.
When applicable, click the Contributes to icon to the right
of the field, select the boxes that apply, and click Submit.
In the Accumulators section:
Select options from the accumulator lists to specify whether sharing applies.
Click the buttons to specify whether the benefits will contribute to the
accumulators.
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 that is 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.
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.
Enter an amount in the Credit savings amount field.
In the Secondary payment type list, select an option to
indicate how this payment works.
In the Cost share exclusions section, select the check boxes
to specify the cost shares that are not included in the COB calculation.
Click the Authorization section to expand it.
Authorizations or penalties that you enter in this step are inherited by all the
benefits.
Check the Authorization not applicable? check box if
authorizations do not apply to services.
If authorizations do apply, clear the check box and complete the fields to describe
the authorization types and conditions.
The following figure shows the cost share configuration in the product wizard:
Product - Cost shares
Click Save to complete your product at a later time or
Continue to define network cost shares.
Modifying network cost shares for a new product
To meet the specifications for your product, modify the values for the network coverage
and guardrails that are defined in the product from either the product template or another
product.
For example, you might want to increase the amount 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.
Each network line displays the source
of the cost shares and the cost share values. If the cost shares for the network are
inherited from the product template, the abbreviation PT appears in the
Inheritance column. If the cost shares are not all inherited and
you manually entered some of them, a Click to view the inheritance
pattern icon appears in the Inheritance column. If the
cost shares have been overridden, this mark is displayed to show that the
inheritance has been broken.
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.
Network guardrails are applied when products are configured by using a product template.
If you defined network guardrails at the product template level, they appear in the
Guardrail summary section on the Configure networks
page. When configuring network cost shares, if the values are outside the defined
guardrails, validations are generated.
For example,
you apply a rule that requires the copayment for in-network expenses to be less than or
equal to the copayment for out-of-network expenses. When you build a plan by using a
product, this rule is enforced during the cost share selection process on
the Configure networks page.
Before you begin: Configure the cost shares and accumulators for the product.
In the Network cost shares step of the product 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 Coverage section, click the Set services
required link or the Set services NOT required
link, and click OK in the confirmation dialog box.
In the Coverage section, click the Set services
covered link or the Set services NOT covered
link, and click OK in the confirmation dialog box.
Click Close.
If you are not making any other changes to the networks, click
Continue.
To modify the coverage values in the product:
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.
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, and 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.
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.
For each network to which you are adding variations, on the Configure
networks page, click the network name link, and repeat repeat steps a
through g.
To view more details about the variations, click the variation count link t.
Variation count shows the variations that are configured on the network, as shown
in the following figure:
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, and 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 details, on the Configure
networks page, click the network name link and repeat these steps.
The following figure shows the configuration of network cost shares in the product
wizard:
Product: Network cost shares
When you finish making changes, on the Configure networks page,
click Mark all as complete, and then click
Continue.
Configuring benefits for a new product
Modify the coverage, for example, copayment or coinsurance, for a benefit that was
previously included as part of a benefit set or as part of a grouper for a specific network.
You add the values for the benefit-specific coverage, for example, deductible or out-of-pocket
costs, during this step because these values were not inherited. You can also assign cost
shares for specific conditions or assign limits to a benefit. In addition, you can add other
benefits and groupers to the product.
For example, when you configure benefits for a product, you might limit physical therapy 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: Modify your network cost shares.
To add a benefit or grouper, follow these steps:
On the Configure groupers and benefits page, 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 window, click the network
for which you are modifying the benefit coverage.
In the expanded Configure details for product 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 window, click the network
for which you are modifying the benefit requirement.
In the expanded Configure details for product 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 benefit or grouper, 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 window, on the
Coverage tab, click the network name.
In the Configure details for product 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
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 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 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:
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 window, on the
Coverage tab, click the network name.
In the Configure details for product 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 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 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 specify that a benefit limit in a product 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 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.
Click Save.
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 window, click the
Variations tab.
Click the network link and then click Edit.
Add or edit variations, 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.
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 window, click
Additional details.
Click the network link.
In the expanded Configure details for product 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 window, click the
Mapping tab.
Review the information that you previously entered. Click Mark
Complete and then click Submit.
The following figure shows the benefit configuration in the product wizard:
When you are finished configuring benefits and groupers, click Mark all as
complete and then click Continue.
Optional: Changing the default benefit
During product creation, the product inherits the default benefit from the
product template or a copied product. 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.
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.
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.
The following figure shows the benefit category seletion in the product
wizard.
Product: Benefit category
Changing or adding a benefit category
When you create a product, you can change the benefit category assignments for the
product. 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.
You can also change the default benefit in this wizard step.
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.
Selecting SBC metadata
In this step, you select the template that you want to use as the base for the SBC
document in your product. Select the required networks from the product that you want to
display in the SBC document. You must select at least 1 network; the maximum number of
network selection is 3. The first network is considered In-network. You can
provide names for the networks and order them as you want them displayed in the SBC
document.
Before you begin: Create an SBC template. For more information about creating
the template, see Creating an SBC template.
In the Select SBC metadata step, in the SBC
template field, enter and click the specified template.
In the Select network order section, select the
appropriate networks.
In the Network name field, enter a descriptive name that
corresponds to the network to the left.
If you do not want to generate the SBC document in PDF format, select the
Skip SBC PDF Generation check box.
This means that no SBC document in PDF format will be attached to the product.
Click Continue to display the document.
The following figure shows the selection of SBC metadata with the product
wizard:
Product - SBC metadata
Editing the SBC document
In the last step of the product wizard, the SBC document that is part of the product
displays. You can edit the document and preview it.
To preview the document, click Preview document.
To edit the document by overriding values that were in the SBC template, follow
the steps to edit a specific tab in the SBC template section.
When you have finished editing the template, return to the product to complete
the step.
To restore all changed values to the values in the SBC document, click
Restore.
The following figure shows editing of the SBC document within the product
wizard:
Product - Edit SBC document
Click Finish.
Extension rules for SBC in products
To meet your business needs, you can extend rules for SBC data within the product.
For example, you might add more metadata fields in the Enter details step of the product.
Rule name
Description
SelectSBCMetadataPreEXT
Use this data transform in the
PegaPCS-HC-USA-Work-Commercial-Medical-Product
class to set additional metadata on the product.
SelectSBCMetadataPostEXT
Use this data transform in the
PegaPCS-HC-USA-Work-Commercial-Medical-Product
class to perform additional validations on SBC metadata in the
product.
SelectSBCMetadataPostEXT
Use this activity in the
PegaPCS-HC-USA-Work-Commercial-Medical-Product
class to perform additional validations and actions on the template
post-SBC metadata selection in the product.
EditSBCDocumentPreEXT
Use this data transform of the
PegaPCS-HC-USA-Work-Commercial-Medical-Product
class to update data that displays in the SBC document in the
product.
EditSBCDocumentPostEXT
Use this activity of the
PegaPCS-HC-USA-Work-Commercial-Medical-Product
class to perform additional validations or any more actions
on the data.
is displayed to show that the
inheritance has been broken. 
