Pega Sales Automation for Healthcare supports account renewals as described in the following sections.

• Renewals features
• Renewals case types
• Renewals workflow
• Mapping old healthcare plans to new plans
• Creating Renewal Batch cases automatically
• Creating a Renewal Batch case from the Renewals portal
• Fixing mapping errors
• Processing the Quote Request cases
• Technical details for developers extending the account renewal features

Renewals features

For individual and small group accounts that use Pega Sales Automation for Healthcare as the system of record, you can renew the account plans when the enrollment end date approaches. Healthcare plan details and rates often change each year. To keep the same logical plan, you need to map last year's plans to current year’s plans before starting the renewals process.

For automatic renewals, configure the renewals job scheduler and dynamic system settings to your needs. For manual renewals, use the Renewals portal to find active accounts and explicitly renew their expiring plans.

For automatic renewals, configure the renewals job scheduler and dynamic system settings. For manual renewals, use the Renewals portal.

In addition to the application-provided renewals features, you can extend the application to include the following renewals features:

• Renewals for large group and Medicare accounts
• Renewals for healthcare accounts from an external system of record

For information about how to extend the Pega Sales Automation for Healthcare renewals features, see Technical details for developers extending the account renewal features.

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Renewals case types

An expiring account with a status of Open-Enrolled is eligible for renewal. Eligible accounts are added to a Renewal Batch case by an automatic or manual renewal process. A Renewal Batch case ID has a prefix of RB, and it includes a Quote Request child case for each account in the batch. A Quote Request case ID has a prefix of either QRIND (for individual accounts) or QRSG (for small group accounts).

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Renewals workflow

Initiating and processing renewals includes the following tasks:

1. Mapping expiring healthcare plans to new plans
2. Creating Renewal Batch cases automatically
3. Creating a Renewal Batch case from the Renewals portal
4. Fixing mapping errors, if applicable
5. Processing the Quote Request cases

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Mapping old healthcare plans to new plans

The available healthcare plans change each year. Before you create a Renewal Batch case, use the Plan Mapping utility to map last year's healthcare plans to new plans. The renewals process generates an error if a Quote Request case is associated with an old plan.

1. Log in to the Underwriting portal with Underwriter credentials.
2. In the left pane, click Manage Data.
3. In the Application configuration window, to the right of the Plan Mapping option, click Edit.
4. To add a new mapping, at the bottom of the grid, click Add record.
5. Enter the information required to map the old plan to a new plan, such as the old and new plan names, and new plan effective dates.
6. Save the mapping.
7. To map multiple old plans to new plan, use a CSV file to import the mappings:
   1. To create the CSV file, click Export.
   2. Enter the new mappings in the template file, and then save the file.
   3. Click Import.
   4. When prompted, select whether to add new mappings only or to add new mappings and also overwrite existing mappings.

The next step after mapping old plans is to create the Renewal Batch case.

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Creating Renewal Batch cases automatically

To automatically renew accounts, configure the job scheduler and settings as described in the Pega Sales Automation for Healthcare Implementation Guide, on the Pega Sales Automation for Healthcare product page.

Creating a Renewal Batch from the Renewals portal

To manually renew accounts, use search filters to find the accounts that you want to renew (for example, all plans that expire during a selected month), and then add those accounts to a batch. The batch creation process generates a Renewal Batch case that contains a child Quote Request case for each account in the batch.

1. Log in to the Renewals portal as an operator who is part of the SPMHC:RenewalRep access group.
2. In the left panel, click the Renewals link.
   By default, the page shows small group accounts. To create a batch for individual accounts, click Individual.
3. Click New batch renewals.
4. To view a list of accounts whose healthcare plans are eligible for renewal, enter values in the following fields, and then click Filter:
   1. In the Month field, select the plan expiration months. You can select more than one value.
   2. In the Year field, select the year when the healthcare plan expires.
   3. In the Territory ID field, select the ID of the sales territory for the accounts that you want to renew.
   4. In the Market segment field, select the name of the market segment whose healthcare plans you want to renew: Individual, Small Group, or another segment that is configured in your application.
   5. Click Advanced to use the Plan Types and Partners filter fields to further refine your search results. You can select more than one value in both of those fields.
   6. In the search results, select the check box to the left of each account that you want to include in the batch.
      To select or clear all check boxes, click the check box to the left of the Account column.
5. Click Create.

The application creates the Renewal Batch case and the Quote Request child cases.

If a Quote Request case has a mapping error, you must fix the error before the case can proceed. If a Quote Request case has no mapping errors, the application either processes the renewal automatically or it routes the Quote Request case to the account's opportunity owner so that the owner can manually process the renewal.

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Fixing mapping errors

A mapping error occurs when an account renewal includes a healthcare plan that is not available for the new plan period. A Quote Request case with a mapping error has a status of Pending-Investigation. Before the renewal can proceed, you must fix the error by selecting an available plan.

1. Log in to the Renewals portal as an operator who is part of the SPMHC:RenewalRep access group.
2. In the left panel, click the Renewals link.
   The Batch Renewals tab shows existing Renewal Batch cases for small group accounts. To view Renewal Batch cases for individual accounts, click Individual.
   A Renewal Batch case with mapping errors has a status of Pending-Investigation.
3. In the ID column, click the ID of the renewal batch that contains the error.
   The screen displays a list of Quote Request cases in that batch.
4. In the Quote request ID column, click the ID of the Quote Request case that contains the error.
   The Renewal details section shows the Quote Request case details.
5. Click Review.
   The Fix plan mapping errors section lists the available healthcare plans.
6. To change a plan, click Select new plan.
7. To save the plan changes, click Submit.

After the mapping error is fixed, the application either processes the renewal automatically or routes the Quote Request case to the account's opportunity owner (a sales rep or a partner sales rep) to manually process the renewal.

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Processing the Quote Request cases

If a Quote Request case has only one plan to renew and one plan type available for the renewal, then Pega Sales Automation for Healthcare automatically processes the renewal. For more complex renewals, the application routes the child Quote Request cases to each account's opportunity owner to manually process the renewal. The owner updates the plan and census information.

1. Log in to the Partner Sales Rep Admin portal as the opportunity owner for the account that is being renewed.
2. In the left panel, click Renewals.
3. Locate the Renewal quotes section.
4. To view the case details, click the Assignment link.
   To stop the renewal process for an account, open the assignment, click the Actions menu, and select Close.
5. In the Review rates section, review the old and new plan rates. Click a plan name to view the employer contribution information or make changes to that information.
6. In the Capture Census section, review the existing census information and make changes, if needed. You can upload new census information, use the existing census information, or make changes manually by clicking the census ID.
7. In the Select plans section, change the default plan selections as needed by selecting and clearing the check boxes.
8. Click Submit.

When the quote request process is complete, the Quote Request case is resolved. When all Quote Request cases in a Renewal Batch case have been processed or closed, the Renewal Batch case status changes to Resolved-Completed. A nightly job scheduler checks the status of the child Quote Request cases, and then updates the status of the parent Renewal Batch case if all child cases are resolved.

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