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Configuring benefits

Updated on September 10, 2021

A benefit is the basic building block of Pega Product Composer for Healthcare. Benefits include sets of code groups that define the benefit, as well as general parameters that describe the benefit such as its name, effective date, and end date.

A benefit has mappings that describe the conditions of a benefit. For example, the 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.

For this tutorial, you configure six benefits for the Preferred Provider Organization (PPO) plan:

Before you begin

Before you configure your benefits:

  1. Ensure that you have configured code sets and code groups in Pega Foundation for Healthcare.
    To map the benefit during benefit configuration, you need to have configured your code sets and code groups, such as
    International Classification of Diseases (ICD)-10 and Current Procedural Terminology (CPT) sets. For information, see the Pega Foundation for Healthcare product page.
  2. Configure the benefit categories that are needed during benefit configuration.
    See Configuring benefit categories.

What to do next

After you complete the prerequisites, configure the first benefit, FAC-IP Hospital benefit. See Configuring the FAC-IP Hospital benefit.

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