Pega Foundation for Healthcare · A Business Entity functions in the capacity of a contracting entity, facilitating the relation of Practitioners and Providers to health plan contracts

Pega Foundation for Healthcare

SAMPLE DATA MANAGEMENT SPECIFICATIONS 7.4

© 2018 Pegasystems Inc., Cambridge, MA

All rights reserved.

Trademarks

For Pegasystems Inc. trademarks and registered trademarks, all rights reserved. All other trademarks or service marks are property of their respective holders.

For information about the third-party software that is delivered with the product, refer to the third-party license file on your installation media that is specific to your release.

Notices

This publication describes and/or represents products and services of Pegasystems Inc. It may contain trade secrets and proprietary information that are protected by various federal, state, and international laws, and distributed under licenses restricting their use, copying, modification, distribution, or transmittal in any form without prior written authorization of Pegasystems Inc.

This publication is current as of the date of publication only. Changes to the publication may be made from time to time at the discretion of Pegasystems Inc. This publication remains the property of Pegasystems Inc. and must be returned to it upon request. This publication does not imply any commitment to offer or deliver the products or services described herein.

This publication may include references to Pegasystems Inc. product features that have not been licensed by you or your company. If you have questions about whether a particular capability is included in your installation, please consult your Pegasystems Inc. services consultant.

Although Pegasystems Inc. strives for accuracy in its publications, any publication may contain inaccuracies or typographical errors, as well as technical inaccuracies. Pegasystems Inc. shall not be liable for technical or editorial errors or omissions contained herein. Pegasystems Inc. may make improvements and/or changes to the publication at any time without notice.

Any references in this publication to non-Pegasystems websites are provided for convenience only and do not serve as an endorsement of these websites. The materials at these websites are not part of the material for Pegasystems products, and use of those websites is at your own risk.

Information concerning non-Pegasystems products was obtained from the suppliers of those products, their publications, or other publicly available sources. Address questions about non-Pegasystems products to the suppliers of those products.

This publication may contain examples used in daily business operations that include the names of people, companies, products, and other third-party publications. Such examples are fictitious and any similarity to the names or other data used by an actual business enterprise or individual is coincidental.

This information is the property of:

Pegasystems Inc. One Rogers Street Cambridge, MA 02142-1209 USA Phone: (617) 374-9600 Fax: (617) 374-9620 www.pega.com

Pega Foundation for Healthcare

Document: Sample Data Management Specifications

Software Version: 7.4

Updated: April 2018

CONTENTS

Provider data management ............................................................................ 5

Overview ............................................................................................................. 5

Business entity ................................................................................................... 5

Practitioner ......................................................................................................... 6

Provider ............................................................................................................... 6

Provider Network ............................................................................................... 6

Provider Contract ............................................................................................... 7

Provider objects - Membership relationship and specifications ............... 8

Create Business Entity ....................................................................................... 9

Review Business Entity .................................................................................... 12

Update Business Entity - Metadata ................................................................ 15

Add/Update Business Entity - Contacts ......................................................... 17

Add/Update Business Entity - Locations ....................................................... 19

Create Provider ................................................................................................ 21

Review Provider ................................................................................................ 25

Update Provider - Metadata ........................................................................... 28

Add/Update Provider - Credentials ................................................................ 30

Add/Update Provider - Affiliations ................................................................. 31

Create Practitioner ........................................................................................... 33

Review Practitioner .......................................................................................... 38

Update Practitioner - Metadata ...................................................................... 42

Add/Update Practitioner - Credentials .......................................................... 44

Add/Update Practitioner - Affiliations ............................................................ 46

Create Provider Network ................................................................................. 49

Review Provider Network ................................................................................ 52

Update Provider Network ............................................................................... 55

Create Contract (Provider) .............................................................................. 58

Review Provider Contract ................................................................................ 62

Update Provider Contract ............................................................................... 65

Membership relationship and specifications ............................................. 70

Overview ........................................................................................................... 70

Create Member ................................................................................................ 73

Review Member ................................................................................................ 78

Update Member ............................................................................................... 83

Member policy relationships and specifications ....................................... 88

Create Policy ..................................................................................................... 89

Review Policy .................................................................................................... 92

Update Policy .................................................................................................... 96

Member contracts relationships and specifications ................................. 99

Create Membership Contract ....................................................................... 100

Review Membership Contract ...................................................................... 103

Update Membership Contract ...................................................................... 106

Company and payer specifications ............................................................ 109

Overview ......................................................................................................... 109

Create Company ............................................................................................. 110

Review Company ............................................................................................ 112

Update Company ........................................................................................... 114

Create Payer ................................................................................................... 116

Review Payer ................................................................................................... 118

Update Payer .................................................................................................. 120

Claim and authorization specifications .................................................... 122

Overview ......................................................................................................... 122

Create Claim ................................................................................................... 123

Review Claim ................................................................................................... 131

Update Claim .................................................................................................. 138

Create Authorization ...................................................................................... 145

Review Authorization ..................................................................................... 150

Update Authorization .................................................................................... 153

Pega Product Overview 5

Overview This document defines the business use case specifications for all the processes available in Pega Foundation for Healthcare to create and maintain Provider data objects.

Provider PractitionerGroup / Facility

Business Entity

Provider Contract

Business Affiliation

Provider NetworksContracted Products

Payer

Certifications

Malpractice Ins

Medical School

Post Grad Training

Credentialing Information

Provider types

Specialties

Geographic Locations

The following provider objects can be maintained in Pega Foundation for Healthcare:

Business entity A provider business entity is a legal structures recognized by the IRS and include such types as:

• Corporation

• Non-profit organization

• Partnership

• S-Corporation

• Sole Proprietor

Provider data management

Pega Foundation for Healthcare Sample Data Management Specifications 6

TITLE of INTERNAL DOCUMENT – Arial Bold 12

• Trust

A Business Entity functions in the capacity of a contracting entity, facilitating the relation of Practitioners and Providers to health plan contracts. A common example of a Business (Contracting) Entity is an IPA or PHO.

Business Entities unite Practitioners and Providers in business specific relationships, receive health plan remittance advices and annual IRS 1099 statements. Business entities manage locations (addresses), contain contact information and are linked to a provider contract. As Practitioners and Providers are related to a business entity, they inherit key attributes of the Business Entity such as TIN, locations, contracts and products.

Business Entities in themselves do not provide healthcare services. These are provided by the providers and practitioners associated with the Business Entity.

Practitioner A person who provides health care services. For example, a physician, registered nurse, chiropractor, etc. Practitioners are associated to a Type 1 NPI. Practitioner records contain metadata and credentials about the individual.

Practitioner records must relate to at least one Business Entity in order to inherit servicing locations or a contract. However, Practitioners may relate to more than one Business Entity to accurately describe multiple relationships.

Provider A provider is any non-person healthcare-servicing organization. They can include hospitals, DME Providers, freestanding radiology centers, etc. Providers are normally associated to Type 2 NPIs. Provider records contain metadata and credentials about an organization that provides health care services.

Provider records must relate to at least one Business Entity in order to inherit servicing locations and a contract. However, Providers may relate to more than one Business Entity to accurately describe multiple relationships.

Provider Network A provider network defines a grouping of practitioners and providers along with geographic parameters. They define the provider specialties and types of practitioners (moonlighting physicians / covering physicians / primary care physicians, specialists etc.) in the grouping as well as geographic boundaries for serve locations which can be high level including States or narrower to States and Counties or specific zip codes. Provider Networks are referenced in Provider Contracts.



Provider Contract The documents mutually executed between business entities (on behalf of covered Practitioners and Providers) and health insurance plans. They define the terms of participation for the covered entities, member products for which Practitioners and Providers are considered in-network, reimbursement methodologies and pricing arrangements, policies and procedures, and rights and responsibilities of both parties. Provider contracts are directly related to one or more business entities. Practitioners and Providers related to a Business Entity will normally inherit the terms and conditions of the business entity’s contract. Provider Contracts hold the association of provider networks and products that are covered by the contract.



Provider PractitionerGroup / Facility

Business Entity

Provider Contract

Business Affiliation

Provider NetworksContracted Products

Payer

Certifications

Malpractice Ins

Medical School

Post Grad Training

Credentialing Information

Provider types

Specialties

Geographic Locations

2 Provider objects - Membership relationship and specifications



Create Business Entity Specification – Create Business Entity

Short Description: Create Business Entity

Type: Human Based Step

Status: New

Actors: Any

Triggers: Web Browser

Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new provider Business Entity data instance

Business impact:

Description

User selects New Business Entity button from the the business entity tab of Provider groper portal.

System launches a new New Business Entity flow as a three step process:

• Enter Business Entity Details

• Add Contacts

• Add Locations

Step 1: Enter Business Entity Details

User enters the following information to capture the business entity metadata:



• Tax Identification Number – Required - this is used as the key for the business entity instance

• Business Entity Name – Required

• Business Type – Required – select desired value from the available options (Corporation / Non-Profit Organization / S-Corporation / Sole Proprietor / Partnership / Trust)

• Business Entity Effective Date – Required

• End Date

User clicks Continue to proceed to the next step to add contacts

Step 2: Add Contacts

User clicks on Add Contacts to open profile section and enters information about the contact

• Name - Required • Title • Role • Email • Phone Number • Phone Number Extension • Fax • Address Line 1 • Address Line 2 • Zip – Required

o system validates for valid zip codes based on zip code table and displays appropriate message if invalid zip code is entered

• City – Read-only - auto populates based on Zip Code • State - Read-only - auto populates based on Zip Code • Country - Read-only – defaulted to “United States”

User clicks on Submit to add the entered contacts

User can add additional contacts by clicking the Add Contact button to open another section for a new contact.

User clicks Continue to proceed to the next step to add Locations (Addresses) for the Business Entity

Locations

User clicks Add Location to open section to add the address information.



Business Rules:

• At least one address needs to be added

• At least one address location should be flagged as Financial, Servicing, Remittance (see address type below)

• Only one address can be flagged as Financial

• Only one address can be flagged as Remittance

• Business Entity can have more than one Servicing addresses

Address Information

• Type – User checks one or more of the following three location type options

− Financial

− Servicing

− Remittance

• Address Line 1 – Required

• Address Line 2

• Zip – Required

− system validates for valid zip codes based on zip code table and displays appropriate message if invalid zip code is entered

• City – Read-only - auto populates based on Zip Code

• State - Read-only - auto populates based on Zip Code

• Country - Read-only – auto populates based on Zip Code

Servicing Addendum Information

If user checks the address type as ‘Servicing’, system displays a subsection to capture additional servicing information for the location

• Phone Number – Required

• Fax Number

• Email

• Website

Remittance Addendum Information



If user checks the address type as ‘Remittance’, system displays a subsection to capture additional remittance information for the location

• DBA Name – Read-only – Defaulted to Business Entity name entered earlier

• Bank Routing Number

• Bank Account Number

• Bank Account Type – user selects from available options (DA / SG)

User can add more than one address by clicking the Add location button.

Click Finish when the desired location information is entered.

System validate the entered Location information based on the business rules mentioned above and displays appropriate message if validation fails. If the locations are validated, system creates a new Business Entity profile and displays the Review screen.

Review Business Entity Specification – Review Business Entity

Short Description: Review Business Entity


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:



Primary business objective: To review a provider Business Entity data instance

Business impact:

Description

User clicks on the Business Entities tab on the provider header panel of the portal.

System retrieves and displays a list of Business Entity data instances with the following columns:

• Tax ID Number

• Name

• Business Type

The list is paginated with 20 records per page. User can navigate to subsequent pages as desired.

User can sort and filter the list by any of the columns mentioned above.

User clicks on desired Business Entity from the list to review details.

System retrieves the details of the selected Business Entity and presents a review screen organized as follows:

Header

Name (<< Tax ID >>)Business Entity Overview

• Business Type

• Effective Date

• End Date

• Default NPI

Contacts tab

Each Contact is displayed with following information along with a gear icon to display details:

• Name

• Title

• Role



• Email

• Phone Number

• Phone Number Extension

• Fax

• Address Line 1

• Address Line 2 (if available)

• City

• State

• Zip

• Country

Locations tab

Each Location is displayed with following information along with a gear icon to display details:

• Name

• Is financial

• Is Servicing

• Is remittance

• Location Type

Address

• Address Line 1

• Address Line 2 – if available

• City

• State

• Zip

• Country

Servicing Addendum Information – if available


• Fax Number

• Email

• Website



Remittance Addendum Information – if available





Provider Contracts tab

The provider contracts associated with the business entity are displayed as a list with the following columns:

• Contact ID

• Contract Type

• Payment Method

• Effective Date

• End Date

• Status

User can click on the gear icon to view additional details of any contract in the list. In addition to the above, the system displays the following information:

• Primary payment method

• Filing Limit – Plan default

• Prompt Pay requirement

• Version

User clicks on the ‘x’ icon on the top right of the data instance to close the review.

Update Business Entity - Metadata Specification – Update Business Entity - Metadata

Short Description: Update Business Entity - Metadata




Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective:

To update the metadata of an existing provider Business Entity data instance

Business impact:

Description

Pre-condition: Business Entity instance is created and available in the system. Search and open the desired Business Entity review screen.

User clicks on the Edit > Metadata link on the Business Entity header.

System displays the Update Metadata screen with the following fields in edit mode (except Read-only as shown below):

• Tax ID

• Business Entity Name

• Business Type

• Business Entity Effective Date – Read-only

• End Date

• Default provider NPI

NOTE: Updating the Tax ID will create a new Business Entity instance as the Tax ID is used as a key.

User updates desired fields and clicks Update to save the changes.



System displays the Business Entity review screen with the updated information.

Click the ‘X’ icon on the top right corner of the review screen to close the data instance.

Add/Update Business Entity - Contacts Specification – Update Business Entity - Contacts

Short Description: Add / Update Business Entity - Contacts


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:


To add or update the contacts associated with the an existing provider Business Entity data instance

Business impact:

Description


User clicks on the Edit > Contacts link on the Business Entity header.



System displays the Update Contacts screen with existing contacts information.

User clicks on the expand icon of the desired contact to view following contact information in edit mode (except Read-only fields as mentioned):

• Name

• Title

• Role

• Email

• Phone Number

• Phone Number Extension

• Fax

• Address Line 1

• Address Line 2 (if available)

• City – Read-only (auto refreshes if zip code is updated)

• State – Read-only (auto refreshes if zip code is updated)

• Zip

• Country - Read-only

User repeats the process for each contact that needs to be updated.

Alternatively, user clicks on Add Contact link to open a new contact section and enters the above information for the new contact. (See

Create Business Entity specification.).

Alternatively, user clicks on Remove Contact associated with any contact to delete the contact information.

User clicks Update to save the changes.





Add/Update Business Entity - Locations Specification – Add / Update Business Entity - Locations

Short Description: Add / Update Business Entity - Locations


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:


To add or update the Locations associated with the an existing provider Business Entity data instance

Business impact:

Description


User clicks on the Edit > Locations link on the Business Entity header.

System displays the Update Location screen with existing locations information.

User clicks on the expand icon of the desired Location to view following information in edit mode (except Read-only fields as mentioned):

• Location Type

Address



• Address Line 1 - Required


• City - Read-only (auto refreshes if zip code is updated)

• State - Read-only (auto refreshes if zip code is updated)

• Zip

• Country

Servicing Addendum Information – if available


• Fax Number

• Email

• Website

Remittance Addendum Information – if available





User updates the desired information and repeats the process for each location that needs to be updated.

Alternatively, user clicks on Add Location link to open a new Location section and enters the above information for the new location.

Alternatively, user clicks on Remove Location associated with any location to delete the location information.






Create Provider Specification – Create Provider

Short Description: Create Provider


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new Provider data instance

Business impact:

Description

Pre-condition: Active Business Entities are required for adding Business Affiliations during Provider profile generation. Alternatively, provider profile can be created and then updated to add business affiliations.

User selects New Provider button from the provider tab of the provider grouper portal header.

System launches a new Create Provider flow as a three step process:

• Enter Provider Details

• Add Credentials

• Add Business Affiliations

Step 1: Enter Provider Details



Provider Details

User enters the following information to capture the provider’s metadata:

• Name – Required

• NPI (National Provider Identifier) – Required – this is used as the key for the provider instance

− Data entered is validated for NPI format and appropriate message displayed if incorrect format is entered

− Data entered is validated for duplicity – appropriate message displayed if another provider record with same NPI already exists

• Effective Date – Required

• End Date

• FWA alert

User clicks Continue to proceed to the next step to add credentials

Step 2: Add Credentials

User enters the following credentialing information for the provider

• Licenses

• Credentialed Specialties

Licenses

• DEA Number – Required

− system validates the DEA Number for the format as per DEA format requirements and displays appropriate error message

− system provides tool tip for expected DEA format

• Medicare Number

• Medicaid Number & State

− User can add more than one Medicaid number and State combinations

• License Number & State - Required


Credentialed Specialties

User can add one or more specialties for the provider



• Specialty Type – select from the available options (typically ‘Hospitals’)

• Specialty – select from the available options

The list of available specialties is filtered based on the specialty type selected

User clicks Continue to proceed to the next step to add business affiliations.

Step 2: Add Business Affiliations

This step allows the user to associate the provider with one or more business entities and sets up the parameters of that association.

Pre-condition – Business Entity records are created and available in the system.

Business Rule: Only the business entities effective for the Provider’s effective period are displayed.

User selects desired business entity from the list. Upon selection, the system displays affiliation parameters below that the user uses to define the association

• Provider Capacity

• Specialties

• Locations

Provider Capacity

• Market In Directory – Required - select from available options

− Yes, No

Specialties

• Primary Specialty - select from available options

− List of specialties populated based on the selections made during Add Credentials step

• Secondary Specialties - select from available options


− User can select more than one specialty depending on availability in the list

− Business Rule: Only one specialty can be selected as Primary and the selected primary specialty is not available for Secondary specialty selection

Business Affiliation Effective Period



• Business Affiliation Effective Date – Required – Provider’s Effective Date is defaulted here)

• Business Affiliation End Date

Locations

System displays the locations (addresses) associated with the selected Business Entity.

• User selects the desired Location (check option).

• System displays the Purpose options (Service / Correspondence) for the selected Location

• User selects the desired Purpose for the selected location (whether the practitioner would like to use the selected address as the Service and / or the Correspondence address

Business Rule: At least one Service Location and one Correspondence Location needs to be selected for the Business Affiliation.

After the user has completed entering the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity if desired.

Click Finish to submit the Provider record. System saves the instance and displays the Provider Review screen.



Review Provider Specification – Review Provider

Short Description: Review Provider


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a Provider data instance

Business impact:

Description

User clicks on the Providers tab on the provider header panel of the portal.

System retrieves and displays a list of Provider data instances with the following columns:

• NPI

• Organization Name

• Profession Type





User clicks on desired Provider from the list to review details.

System retrieves the details of the selected Provider profile and presents a review screen organized as follows:

• Header

• Provider name (<<NPI>>)

• Provider overview

• Provider Name

• NPI

• Provider Type

• Effective Date

• End Date

• Credentials tab

• Licenses

• DEA Number

• Medicare Number

• Medicaid Number(s) & State

• License Number(s) & State


• Specialty

Business Affiliations tab

Each associated Business Affiliation is displayed along with a gear icon to display details .. User clicks on gear icon to view additional details as follows:

• Business Affiliation Metadata


• Business Entity Type

• Business Entity Tax ID

• Market In Directory Flag

• Primary Specialty

• Effective Date



• End Date

• Locations

• Address Line 1


• City

• State

• Zip

• Country

Select Purpose (Servicing/Correspondence)

In addition, use can click on the ‘View location specifics’ hyperlink to view additional details about the location:

• Remittance Addendum

• DBA Name

• Bank Account Type



• Servicing Addendum

• Phone Number

• Fax Number

• Email

• Website

• Contacts

The following information is displayed for each contact:

• Contact Name

• Contact Address

• Email

• Phone

• Phone Extension

• Fax



• Associated Contracts

• The list has following columns:

• Contract Name

• Contract ID

• Payment Method

• Effective Date

• End Date

• Status

• Participating networks tab

• Network Name

• Type of network

• Associated business entity


Update Provider - Metadata Specification – Update Provider - Metadata

Short Description: Update Provider - Metadata


Status: New

Actors: Any


Complexity: Medium

Release:



Iteration:


To update the metadata of an existing provider data instance

Business impact:

Description

Pre-condition: Provider instance is created and available in the system. Search and open the desired Provider review screen.

User clicks on the Edit > Metadata link on the Provider header.

System displays the Update Metadata screen with the following fields in edit mode.

• Name - Required

• NPI - Required

• Effective Date - Required

• End Date

NOTE: Updating the NPI will create a NEW provider instance as the NPI is used as a key.


System displays the Provider review screen with the updated information.




Add/Update Provider - Credentials Specification – Add/Update Provider - Credentials

Short Description: Add/Update Provider - Credentials


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:


To add or update the credentials of an existing provider data instance

Business impact:



Add/Update Provider - Affiliations Specification – Add/Update Provider - Affiliations

Short Description: Add/Update Provider - Affiliations


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:


To add or update the business affiliations of an existing provider data instance

Business impact:

Description

Pre-condition: Provider instance is created and available in the system. Search and open the desired Provider review screen.

User clicks on the Edit > Affiliations link on the Provider header.

System displays the Update Affiliations screen with the following fields in edit mode.

Business Rule: Only the business entities effective for the Provider’s effective period are displayed.

User selects desired business entity from the list. Upon clicking the gear icon , the system displays affiliation parameters below that the user uses to update on the association




− Yes, No








• Business Affiliation Effective Date – Required – (Provider’s Effective Date is defaulted here)


Affiliated locations






After the user has completed updating the Affiliation parameters for the selected Business Entity, user can add another Business Affiliation for another Business Entity by clicking on the Add Business Affiliation link if desired.

User clicks Submit and then Update to save the changes.

System displays the Provider review screen with the updated information.




Create Practitioner Specification – Create Practitioner

Short Description: Create Practitioner


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new Practitioner data instance

Business impact:

Description

Pre-condition: Active Business Entities are required for adding Business Affiliations during Practitioner profile generation. Alternatively, practitioner profile can be created and then updated to add business affiliations.

User selects New Practitioner from the provider grouper portal header.

System launches a new Create Practitioner flow as a three step process:

• Practitioner Details



• Credentials

• Business Affiliations

Step 1: Enter Practitioner Details

Practitioner Details

User enters the following information to capture practitioner’s metadata:

• First Name – Required

• Middle Name

• Last Name – Required

• NPI (National Provider Identifier) – Required – this is used as the key for the practitioner instance


− Data entered is validated for duplicity – appropriate message displayed if another practitioner record with same NPI already exists

• Suffix – select from available options

• Gender – Required - select from available options

• Date of Birth – Required

• Practitioner Title - Required - select from available options


• End Date

• FWA alert

Contact information

User enters the Phone, Email, and Social Media contact information for the practitioner. User can add multiple records for each contact type.

• Phone Information

− Phone Number

− Type – select from available options

• Email Information

− Email ID




• Social Media Information

− Social Media ID


User clicks Continue to proceed to the next step to add credentials

Step 2: Add Credentials

User enters the following credentialing information for the practitioner


• Licenses

• Hospital Admitting Privileges

• Languages


User can add one or more specialties for the practitioner

• Specialty Type – select from the available options


− The list of available specialties is filtered based on the specialty type selected

Licenses




• Medicare Number





Hospital Admitting Privileges

Pre-condition – Provider records categorized as Hospitals is created and available in the system.

User can add one or more hospitals where the practitioner has admitting privileges



• Hospital – Select desired hospital from the available options

− System displays a list of Provider records in the system categorized as Hospitals along with their respective NPI number

Languages

User can add one or more Languages to be associated with the practitioner

• Language – Select desired language from the available options

User clicks Continue to proceed to the next step to add business affiliations.

Step 2: Add Business Affiliations

This step allows the user to associate the practitioner with one or more business entities and sets up the parameters of that association.

Pre-condition – Business Entity records are created and available in the system. (see Create Business Entity specification)

Business Rule: Only the business entities effective for the Practitioner’s effective period are displayed.

User selects desired business entity from the list. Upon selection, the system displays affiliation parameters below that user uses to define the association

• Practitioner Capacity

• Specialties

• Admitting Hospitals

• Locations

Practitioner Capacity

• Practitioner Capacity - Required – select from available options

− Covering practitioner, Moonlighting practitioner, Primary Care Physician, Primary Care with Subspecialty, Specialist Only

• Accepting New Patients - - Required – select from available options

− Yes, No


− Yes, No

• Age Restrictions



Specialties







Admitting Hospitals

• Primary Admitting Hospital - select from available options

− List of hospitals populated based on the selections made during Add Credentials step


• Business Affiliation Effective Date – Required - Practitioner’s Effective Date is defaulted here)


Locations









Click Finish to submit the Practitioner record. System saves the instance and displays the Practitioner Review screen.

Review Practitioner Specification – Review Practitioner

Short Description: Review Practitioner


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a Practitioner data instance

Business impact:

Description

User clicks on the Practitioners tab provider panel of the portal.

System retrieves and displays a list of Practitioner data instances with the following columns:

• NPI

• Last Name



• First Name



User clicks on desired Practitioner from the list to review details.

System retrieves the details of the selected Practitioner profile and presents a review screen organized as follows:

Header

• Practitioner name (<<NPI>>)

Practitioner details

• Gender

• Date of Birth

• Practitioner Title

• Effective Date

• End Date

• National ancillary provider

Languages

Contact Information

• Phone Number & Type

• Email ID & Type

Social Media ID & TypeCredentials tab

Licenses

• DEA Number

• Medicare Number

• Medicaid Number(s) & State

• License Number(s) & State




• Specialty


• Hospital Name

Business Affiliations tab

Each associated Business Affiliation is along with gear icon. User clicks on gear icon to view additional details as follows:

Business Affiliation Metadata


• Business Entity Type

• Business Entity Tax ID

• Practitioner Capacity Information

− Practitioner Capacity

− Accepting New Patients flag

− Market In Directory flag

− Age Restrictions

• Specialty Information

− Primary Specialty

− Secondary Specialties (if any)

• Admitting Hospital Privileges

− Hospital Name

• Effective Date

• End Date

Locations

• Address Line 1


• City

• State

• Zip

• Country



• Select Purpose (Servicing / Correspondence)

In addition, use can click on the ‘View location specifics’ hyperlink to view additional details about the location:

Remittance Addendum

• DBA Name

• Bank Account Type



Servicing Addendum

• Phone Number

• Fax Number

• Email

• Website

Contacts

Following information is displayed for each contact:

• Contact Name

• Contact Address

• Email

• Phone

• Phone Extension

• Fax

Associated Contracts

The list has following columns:

• Contract Name

• Contract ID

• Payment Method

• Effective Date

• End Date



Participating Networks

The list has following columns:

• Network Name

• Type of Network

• Associated Business Entity


Update Practitioner - Metadata Specification – Update Practitioner - Metadata

Short Description: Update Practitioner - Metadata


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:


To update the metadata of an existing practitioner data instance

Business impact:



Pre-condition: Practitioner instance is created and available in the system. Search and open the desired Practitioner review screen.

User clicks on the Edit > Basic Details link on the Practitioner header.

System displays the Update Basic Details screen with the following fields in edit mode.

Practitioner Details

User updates the desired information:


• Middle Name


• NPI (National Provider Identifier) – Required – this is used as the key for the practitioner instance


− Data entered is validated for duplicity – appropriate message displayed if another practitioner record with same NPI already exists

• Suffix – select from available options

• Gender – Required - select from available options


• Practitioner Title - Required - select from available options


• End Date

• FWA alert

NOTE: Updating the NPI will create a NEW provider instance as the NPI is used as a key.

Languages

User can edit or add one or more Languages to be associated with the practitioner

• Language – Select desired language from the available options

Contact information



User adds / edits the Phone, Email, and Social Media contact information for the practitioner. User can add multiple records for each contact type.

• Phone Information

− Phone Number


• Email Information

− Email ID


• Social Media Information

− Social Media ID



System displays the Practitioner review screen with the updated information.


Add/Update Practitioner - Credentials Specification – Add / Update Practitioner - Credentials

Short Description: Add / Update Practitioner - Credentials


Status: New

Actors: Any


Complexity: Medium



Release:

Iteration:


To add or update the credentials of an existing practitioner data instance

Business impact:

Description


User clicks on the Edit > Credentials link on the Practitioner header.

System displays the Update Credentials screen with the following fields in edit mode.

User updates the following credentialing information for the practitioner as desired


User can edit or add one or more specialties for the practitioner

• Specialty Type – select from the available options


− The list of available specialties is filtered based on the specialty type selected

Licenses




• Medicare Number


− User can edit or add more than one Medicaid number and State combinations




− User can edit or add more than one Medicaid number and State combinations


Pre-condition – Provider records categorized as Hospitals is created and available in the system.

User can edit or add one or more hospitals where the practitioner has admitting privileges

• Hospital – Select desired hospital from the available options

− System displays a list of Provider records in the system categorized as Hospitals along with their respective NPI number




Add/Update Practitioner - Affiliations Specification – Add / Update Practitioner - Affiliations

Short Description: Add / Update Practitioner - Affiliations


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:




To add or update the business affiliations of an existing practitioner data instance

Business impact:

Description


User clicks on the Edit > Affiliations link on the Practitioner header.

System displays the Update Affiliations screen with the following fields in edit mode.

User selects desired business entity from the list and clicks on gear icon. Upon clicking on gear icon , the system displays affiliation parameters below that user uses to update in the association

Practitioner Capacity

• Practitioner Capacity - Required – select from available options

− Covering practitioner, Moonlighting practitioner, Primary Care Physician, Primary Care with Subspecialty, Specialist Only

• Accepting New Patients - - Required – select from available options

− Yes, No


− Yes, No

• Age Restrictions

Specialties









Admitting Hospitals

• Primary Admitting Hospital - select from available options

− List of hospitals populated based on the selections made during Add Credentials step


• Business Affiliation Effective Date – Required - Practitioner’s Effective Date is defaulted here)


Locations







Alternatively, user clicks on the Remove Affiliation link under the business affiliation to remove the association.






Create Provider Network Specification – Create Provider Network

Short Description: Create Provider Network


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new provider network data instance

Business impact:

Description

User selects New Provider Network from the provider grouper portal header.

System launches a new Create Provider Network flow as a three step process:

• Network Details

• Define Geography

• Define Provider Qualifiers

Step 1: Enter Network Details

User enters the following information to capture the Network metadata:




• Network ID - Read-only – auto-generated by the system

• Network Type – Required – select desired value from the available options (Accountable Care Organization (ACO) / Full / Limited / Medical Home / Super Network / Tiered)

• Customer-specific? – Yes / No option (defaulted to ‘No’)

• If user selects ‘Yes’, the system displays a list of available Companies (data instances of Company object). The list displays for following information about the available companies

− Company Name

− Type (Large Group / Small Group

− Company Industry Type (based on Standard Industry Code) (High Tech / Retail / Financial / Healthcare etc.)

− Company Industry Sub Type (based on Standard Industry Code) (Computers / Motor Vehicle Dealers etc.)


• End Date

− Status - Required – select from available options (Available / Under Development / Terminated)

• Status

User clicks Continue to proceed to the next step to define geographic details for the provider network

Step 2: Define Geography

Geographic Details

User enters the following data to capture the geographic details of the provider network

• Country –Read-only (defaulted to USA)

• State – User can select one or more States from the available options

• State & County – User can select one or more State & County from the available options

− the list of Counties is filtered based on the selected State

• Zip Code – User can select one or more Zip Codes from the available options

− The system displays the County, City, & State for the selected zip code



User clicks Continue to proceed to the next step to define the following provider qualifiers for the provider network

Step 3: Define Provider Qualifiers

User enters the following information about providers to be associated with the network.

Provider Specialties

User clicks on Add Taxonomy to add the specialties. System displays a modal window to search and select provider specialties based on the provider taxonomy Classification.

• Select desired provider taxonomy classification from the available options and click Search

• System displays list of specialties for selected classification

• User selects desired specialties from the list

− Alternatively user can use the Select All option to select all specialties displayed

− Alternatively user can use the Deselect All option to clear the selections

• User clicks Submit to add the selected specialties and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any specialties

System displays list of any added specialties with three columns:

• Classification

• Specialty

• Taxonomy Code

Practitioner Types

User clicks on ‘+ Add practitioner type’ icon to add Practitioner Types to be associated with the Provider Network.

User selects desired practitioner type from available options (Covering Practitioner / Moonlighting Practitioner / Primary Care Physician / Primary Care Physician with Sub-Specialty / Specialist Only)

• This is the same list used in the Practitioner Capacity when adding Business Affiliations to the Practitioner

User can add additional Practitioner Types to be associated with the Provider Network.



Click Finish when the desired provider qualifier information is entered.

System creates a new Provider Network profile and displays the Review screen.

Review Provider Network Specification – Review Provider Network

Short Description: Review Provider Network


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a provider network data instance

Business impact:

Description

User clicks on the Provider Networks tab on the provider panel of the portal.

System retrieves and displays a list of Provider Network data instances with the following columns:



• Network ID

• Network Name

• Network Type

• Effective Date

• End Date



User clicks on desired Provider Network from the list to review details.

System retrieves the details of the selected Provider Network and presents a review screen organized as follows:

Header

• Provider Network Name (<<Provider Network ID>>)

Provider Network Overview

• Type of Network

• Status

• Effective Date

• End Date

The Provider Network details are presented in two tabs:

• Provider Details

• Geographic Details

Provider Details Tab

This tab displays the associated provider contracts, provider specialties, and practitioner types that make up the network.

Provider contracts

List showing the following columns:

• Contract Name

• Effective Date



• Contract Status

• Contract Type

Provider specialties

Paginated list showing 10 records per page and with the following columns:

• Classification

• Specialty

• Taxonomy Code

Practitioner Types

List showing the associated Practitioner Types

• Practitioner Type

Geographic Details Tab

This tab displays the geographic details associated with the provider network.

• Country

• State list

• State & County list

• Zip Code – County – City – State list




Update Provider Network Specification – Update Provider Network

Short Description: Update Provider Network


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To add or update an existing provider network data instance

Business impact:

Description

Pre-condition: Provider Network instance is created and available in the system. Search and open the desired Provider Network review screen.

User clicks on the Edit link on the Provider Network header.

System displays the Update Provider Network screen in edit mode.

User navigates the three step process to update the information as desired.

Step 1: Network Details

User edits the desired Network metadata:




• Network ID - Read-only – auto-generated by the system

• Network Type – Required – select desired value from the available options (Accountable Care Organization (ACO) / Full / Limited / Medical Home / Super Network / Tiered)

• Customer-specific? – Yes / No option (defaulted to ‘No’)

− If user selects ‘Yes’, the system displays a list of available Companies (data instances of Company object). The list displays for following information about the available companies

- Company Name

- Type (Large Group / Small Group

- Company Industry Type (based on Standard Industry Code) (High Tech / Retail / Financial / Healthcare etc.)

- Company Industry Sub Type (based on Standard Industry Code) (Computers / Motor Vehicle Dealers etc.)


• End Date

− Status - Required – select from available options (Available / Under Development / Terminated)

• Status

• User clicks Continue to proceed to the next step to update the geographic details for the provider network

Step 2: Define Geography

Geographic Details

User updates the desired geographic details of the provider network

• Country –Read-only (defaulted to USA)

• State – User can select one or more States from the available options

• State & County – User can select one or more State & County from the available options

− the list of Counties is filtered based on the selected State

• Zip Code – User can select one or more Zip Codes from the available options

− The system displays the County, City, & State for the selected zip code



User clicks Continue to proceed to the next step to update the provider qualifiers for the provider network

Step 3: Define Provider Qualifiers

User updates the desired provider qualifier information about providers associated with the network.

Provider Specialties

To remove an existing specialty, user clicks on the ‘X’ icon next to the specialty listing to delete it from the list.

To add new specialties, user clicks on Add Taxonomy link. System displays a modal window to search and select provider specialties based on the provider taxonomy Classification.

• Select desired provider taxonomy classification from the available options and click Search

• System displays list of specialties for selected classification

• User selects desired specialties from the list

− Alternatively user can use the Select All option to select all specialties displayed


• User clicks Submit to add the selected specialties and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any specialties

System displays list of any added specialties with three columns:

• Classification

• Specialty

• Taxonomy Code

Practitioner Types

To remove an existing practitioner type, user clicks on the ‘X’ icon next to the specialty listing to delete it from the list.

User clicks on ‘+ Add practitioner type’ icon to add Practitioner Types to be associated with the Provider Network.



User selects desired practitioner type from available options (Covering Practitioner / Moonlighting Practitioner / Primary Care Physician / Primary Care Physician with Sub-Specialty / Specialist Only)

• This is the same list used in the Practitioner Capacity when adding Business Affiliations to the Practitioner

User clicks Finish to save the changes.

System displays the Provider Network review screen with the updated information.


Create Contract (Provider) Specification – Create Contract (Provider)

Short Description: Create Provider Contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new provider contract data instance

Business impact:



Description

Pre-condition: Active Business Entity needs to be available before a Provider Contract can be created.

Pre-condition: Active Provider Networks need to be available for associating with the provider contract. Alternatively a Provider Contract can be generated and updated later to associate with provider networks.

Pre-condition: Active Products need to be loaded into the system for associating with the provider contract. See GET Plan API section in the PFHC(HCIF) API Technical Specification document on Pega Developer Network (PDN) for details on the REST API. Alternatively a Provider Contract can be generated and updated later to associate with products once they are loaded into the system.

User selects New Contract from the Contract (Provider) tab Plan & Contract grouper on the portal header.

System launches a new Create Provider Contract flow as a four step process:

• Metadata

• Contract Details

• Associate Networks

• Associate Products

Step 1: Enter Metadata

User enters the following information to capture the Provider Contract metadata:

• Contract ID – Required – Read-only - auto-generated by the system

• Type – Required - select from the available options (Ancillary / Direct Group / Direct Individual / Hospital / Independent Physician Association / Integrated Delivery Network / Management Services Organization / Physician Hospital Organization)

• Status - Required - select from the available options (Active / Open / Terminated)



• End Date

• Description



User selects the desired Business Entity from the available list. The list is filtered to only active Business Entities for the Contract Effective Date entered above. The following information is displayed for available business entities:

• Name

• Tax ID

• Type

• Effective Date

After selection the system displays the Name, Tax ID, and Type of the selected business entity

User clicks Continue to proceed to the next step to enter contract details.

Step 2: Enter Contract Details

User enters the following data to capture the provider contract details:

• Primary Payment Method – Required – select from the available options (Capitation / Fee-For-Service / Pay For Performance)

• Filing Limit – Plan Default? – Yes / No – Default selection is ‘Yes’

− If ‘No’ option is selected, system displays field to enter Claim Filing Limit.

• Prompt Pay Requirement? – Yes / No – Default selection is ‘No’

− If ‘Yes’ option is selected, system displays field to enter Number of Days.

• By-Pass Auth requirements? – Yes / No – Default selection is ‘No’

− If ‘Yes’ option is selected, system displays field to enter code groups.

• Late Payment Interest? – Yes / No – Default selection is ‘No’

− If ‘Yes’ option is selected, system displays field to enter Percentage (%).

• Contract States – Required – At least one State needs to be selected. User can select more than one

• Version

User clicks Continue to proceed to the next step to associate available Provider Networks to the contract. Active Provider Network(s) need to be available for this selection.

Step 3: Associate Provider Networks

User clicks Add Network(s) button to search and select provider networks to be associated with the contract.



System displays a modal window for provider network search and selection.

• Search the desired provider network from the dynamic search list which auto-populates with available active provider networks

• System displays the list of networks for selected search criteria

• User selects desired network from the list

− Alternatively user can use the Select All option to select all networks displayed


• User clicks Submit to add the selected networks and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any networks

System displays list of any added provider networks with three columns:

• Name

• ID

• Type

User can click on the Clear all Networks link to remove any selected networks.

User clicks Continue to proceed to the next step to associate available Products to the contract.

Step 4: Associate Plans

User clicks Add Plan(s)(s) button to search and select products to be associated with the contract.

System displays a modal window for product search and selection.

• Search the desired product ID from the dynamic search list which auto-populates with available active products for the contract effective date entered earlier

• System displays the list of products for selected search criteria

• User selects desired product(s) from the list

− Alternatively user can use the Select All option to select all products displayed


• User clicks Submit to add the selected products and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any products

System displays the following information for selected products:



• Product Number

• Category

• Plan Type

• Product Name

• Start Date

• End Date

User can click on the Clear all Products link to remove any selected products.

Click Finish when the desired Product(s) are associated.

System creates a new Provider Contract profile and displays the Review screen.

Review Provider Contract Specification – Review Provider Contract

Short Description: Review Provider Contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a provider contract data instance



Business impact:

Description

User clicks on the Provider Contracts tab Plan & Contract panel of the portal.

System retrieves and displays a list of Provider Contract data instances with the following columns:

• Contract ID

• Contract Name

• Type

• Product category

• Effective Date

• End Date



User clicks on desired Provider Contract from the list to review details.

System retrieves the details of the selected Provider Contract and presents a review screen organized as follows:

Header

• Provider Contract Name (<<Provider Contract ID>>)

Contract Summary

• Type


• Status Effective DateEnd DatePrimary Payment Method

• Filing Limit-Plan Default?

• Prompt Pay Requirement?

• By- Pass Auth requirements?

• Contract State(s)



• Version

Associated Business Entity


• Tax ID

• Business Type

Networks in Contract

List of provider networks associated with the contract with following columns:

• Network Name

• ID

• Type

• Effective Date

• End Date

Plan benefits (PCS) in Contract

Paginated list of products associated with the contract with 10 products per page and with the following columns:

• ID

• Category

• Plan type

• Name

• Effective Date

• End Date

Plan benefits in Contract

Paginated list of products associated with the contract with 10 products per page and with the following columns:

• Product Number

• Category

• Plan type

• Product Name



• Start Date

• End Date


Update Provider Contract Specification – Update Provider Contract

Short Description: Update Provider Contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To add or update an existing provider contract data instance

Business impact:

Description

Pre-condition: Provider Contract instance is created and available in the system. Search and open the desired Provider Contract review screen.

User clicks on the Edit link on the Provider Contract header.



System displays the Update Provider Contract screen in edit mode.

User navigates through the four step process to updated the contract information:

Step 1: Enter Metadata

User updates the following information on the Provider Contract metadata as desired:

• Contract ID – Required – Read-only - auto-generated by the system

• Type – Required - select from the available options (Ancillary / Direct Group / Direct Individual / Hospital / Independent Physician Association / Integrated Delivery Network / Management Services Organization / Physician Hospital Organization)

• Status - Required - select from the available options (Active / Open / Terminated)



• End Date

• Description

User selects the desired Business Entity from the available list. The list is filtered to only active Business Entities for the Contract Effective Date entered above. The following information is displayed for available business entities:

• Name

• Tax ID

• Type

• Effective Date

After selection the system displays the Name, Tax ID, and Type of the selected business entity

User clicks Continue to proceed to the next step to update the contract details.

Step 2: Enter Contract Details

User updates the desired provider contract details:

• Primary Payment Method – Required – select from the available options (Capitation / Fee-For-Service / Pay For Performance)

• Filing Limit – Plan Default? – Yes / No – Default selection is ‘Yes’

− If ‘No’ option is selected, system displays field to enter Claim Filing Limit.

• Prompt Pay Requirement? – Yes / No – Default selection is ‘No’



− If ‘Yes’ option is selected, system displays field to enter Number of Days.

• By-Pass Auth requirements? – Yes / No – Default selection is ‘No’

− If ‘Yes’ option is selected, system displays field to enter code groups.

• Late Payment Interest? – Yes / No – Default selection is ‘No’

− If ‘Yes’ option is selected, system displays field to enter Percentage (%).

• Contract States – Required – At least one State needs to be selected. User can select more than one

• Version

User clicks Continue to proceed to the next step to associate available Provider Networks to the contract. Active Provider Network(s) need to be available for this selection.

Step 3: Associate Provider Networks

To remove an existing network listing, user clicks ‘X’ icon next to the listing to delete its association.

To add new Network associations, user clicks Add Network(s) button to search and select provider networks.

System displays a modal window for provider network search and selection.

• Search the desired provider network from the dynamic search list which auto-populates with available active provider networks

• System displays the list of networks for selected search criteria

• User selects desired network from the list

− Alternatively user can use the Select All option to select all networks displayed


• User clicks Submit to add the selected networks and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any networks

System displays list of any added provider networks with three columns:

• Name

• ID

• Type

User can click on the Clear all Networks link to remove any selected networks.



User clicks Continue to proceed to the next step to update Product associations to the contract.

Step 4: Associate plans

To remove an existing product listing, user clicks ‘X’ icon next to the listing to delete its association.

To add new products, user clicks Add Product(s) button to search and select products.

System displays a modal window for product search and selection.

• Search the desired product ID from the dynamic search list which auto-populates with available active products for the contract effective date entered earlier

• System displays the list of products for selected search criteria

• User selects desired product(s) from the list

− Alternatively user can use the Select All option to select all products displayed


• User clicks Submit to add the selected products and close the modal window

− Alternatively user can use the Close button to close the modal window without selecting any products

System displays the following information for selected products:

• ID

• Category

• Plan type

• Name

• Effective Date

• End Date

System displays the following information for selected plan benefits (PCS):

• Product Number

• Category

• Plan type

• Product Name

• Start Date

• End Date



User can click on the Clear all Products link to remove any selected products.

User clicks Finish to save the changes.

System displays the Provider Contract review screen with the updated information.



Overview • Member -- A member is anyone covered under a health insurance plan, an enrollee or

eligible dependent.

• Policy – The employer or other group that purchases the group insurance contract is known as the policyholder.

• Contract – The document that explains the benefits, risk and assumptions that insurance company offers to an employer.

3 Membership relationship and specifications



Member / Patient(Consumer)

Unique member record

Subscriber(Policy holder)

Holds policy holder info and links all members

associated with a given policy

Policy(Account)

Medical / Dental insurance account for

an individual or family

Employer Group Contract

Payer(Health Plan)

Insurance provider

Company(Employer)

Contracted Plan/

Products

Selected Plan/

Product

Offered Plan/

Products



Member Record

PCP Information

A Member is associated with a PCP.

• Member ID and Suffix• NPI• Effective Date• End Date

Address Information

A Member is associated multiple address types

• Member ID and Suffix• Address Type• Address Line 1• Address Line 2• City, State, Zip• Country• Effective Date• Term Date

Communication Options

A Member is associated with multiple communication modes and types.• Communication mode (Email, Phone, Social

Media)• Communication Type (Home, Personal)

HCIF Member Relationships and Fields

Account Information (Account No, Routing Number, Bank Name etc)

COB Information (Needs to be Added) – If we know Member has a

Policy not captured within our System.

Pend Information (Needs to be Added)

Medicaid & Medicare InformationMedicaid and Medicare Number

A Member if eligible has the following information captured for Medicare and Medicaid:

• Eligibility Reason• Qualifying Date• Medicare ID• Medicaid ID • Part A and Part B

Effective Dates.

A Member record contains the following attributes:

• First Name• Last Name• Middle Name• Date of Birth• Gender• Prefix Martial Status

• Gender• Member ID and Suffix• Previous Name and Effective Date• Employment Status & Hire Date• Student Status

Policy



Create Member Specification – Create Member

Short Description: Create Member


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new Member data instance

Business impact:

Description

User selects Member from the member grouper portal header.

System launches a new Create Member flow as a three step process:

• Member

• Details

• Contact

Step 1: Enter Member

User enters the following information to capture the Member metadata:



• Member Member ID –Required – this is used as the key for the member instance


• Middle Name


• Prefix

• Suffix – select desired value from the available options (Jr./Sr./I/II/III/IV/V)


• Gender – Required – select desired value from the available options (Male/Female/Unknown)

• Marital Status --– select desired value from the available options (B- Registered Domestic Partner/D- Divorced/I- Single/M - Married/R - Unreported/S - Separated/U – Unmarried/W – Widowed/X – Legally Separated)

• Race/Ethnicity – select desired value from the available options (7 – Not Provided/A – Asian or Pacific Islander/B - Black/C - Caucasian/H - Hispanic/I – American Indian/ N – Black (Non-Hispanic)/O – White (Non- Hispanic))

• Social security number

• Exchange ID

• VIP – User checks the option if applicable

• Employee -- User checks the option if applicable

• Picture :- Choose picture file by clicking on button

Previous name(s)If user clicks on the add symbol, system displays a subsection to capture additional Previous Name information for the member

Users can add multiple Previous name by clicking on Add symbol

• First Name

• Middle Name

• Last Name

• Effective Date

• End Date

• Employment and education Employment status – select desired value from the available options (AO – Active Military-Overseas/AU – Active Military - USA/FT – Full-time/L1 – Leave of Absence/PT – Part time/RT - Retired/TE - Terminated)



• Student – select desired value from the available options (F- Full-Time/N – Not a Student/P – Part-Time)

Hire Date

If user checks the Employment status as ‘Part-Time’, system displays a subsection to capture additional information for the employment

• Hire Date

School Address Information

If user checks the Student type as ‘Full-Time’ or ‘Part-Time’, system displays a subsection to capture additional School address information for the student

• School Name

• Address

• Zip


• State– Read-only - auto populates based on Zip Code

User clicks NEXT to proceed to the next step to Other Details

Step 2: Details

User enters the following other detail information for member.

• Primary Care physician NPI – User search by NPI or First Name of Primary Care Physician and then selects

• Effective Date

• End Date

• Medicaid/Medicare detailsMedicaid -- User checks the option if applicable

• Medicare - User checks the option if applicable

Medicaid Details

If user checks ‘Medicaid’, system displays a subsection to capture additional Medicaid information for the member

• Medicaid Number – Required

Medicare Details



If user checks ‘Medicare, system displays a subsection to capture additional Medicare information for the member

• Eligibility reason – Required

• Qualifying Date – Required

• Medicare number (HICN) – Required

• Medicare plan type

• Account Information Account type

• Bank Name

• Account holder name

• Account Number

• Routing number

User clicks Continue to proceed to the next step to add Contact Information for member.

Step 3: Contact

Contact

• Preferred language -- select desired value from the available options

User enters the Phone, Email, and Social Media contact information for the Member. User can add multiple records for each contact type.

• Phone number

− Phone number

− Type -- select desired value from the available options (Home/Business/Pager/Mobile)

• Email

− Email

− Type -- select desired value from the available options (Personal/Work)

• Social Media

− Social Media -- select desired value from the available options (Facebook/Twitter/FaceTime/Skype/LinkedIn)

− ID



• Guardian Type -- select desired value from the available options (Power of Attorney Nominee/Spouse/Adult Child/Parent/Close Relative/Trust/Voluntary Agency/Government Agency/Other Designee)

• First Name

• Guardian address Line 1

• Guardian address line 2

• Last Name

• Phone

• Zip

• Email


• State – Read-only - auto populates based on Zip Code

Address User enters the Address for the Member by clicking on Add Address button. User can add multiple records for each contact type.

• Type -- select desired value from the available options (Billing/Home/Location1)

• Address Line1

• Address Line 2

• Zip

• City -- Read-only - auto populates based on Zip Code

• State -- Read-only - auto populates based on Zip Code

• Effective Date

• End Date



Review Member Specification – Review Member

Short Description: Review Member


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a member data instance

Business impact:

Description

User clicks on the Members tab Member panel of the portal.

System retrieves and displays a list of Member data instances with the following columns:

• Member ID

• Member last name

• Member first name

• Date of Birth

• Gender





User clicks on desired Member from the list to review details.

System retrieves the details of the selected Member and presents a review screen organized as follows:

The Member details are presented in four tabs:

• Member

• Details

• Contact

• Policy

Member tab

This tab displays the member header, previous names and employment and education details of the member

Header

• Name (<<Member ID>>)

Member Summary

• Member ID

• Gender

• Date of birth

• Marital status


• Employee?

Member

• Member ID

• First Name

• Middle name

• Last Name

• Prefix

• Suffix



• Date of Birth

• Gender

• Marital status

• Race/Ethnicity


• Exchange ID

• VIP?

• Employee?

Previous name(s)

• First Name

• Middle Name

• Last Name

• Effective Date

• End Date

Employment and education

• Employment status

• Student

Details tab

Primary Care physician

• NPI

• Name

• Specialty

• Effective Date

• End Date

• Reason for PCP Change

• Policy ID

Medicaid/Medicare details

• Medicaid



If the field is true, below details are displayed

− Medicaid Number

• Medicare

If the field is true, below details are displayed

− Eligibility reason

− Qualifying Date

− Medicare number (HICN)

− Medicare plan type

Account information

• Account type

• Bank Name


• Account Number

• Routing number

Contact tab

Contact

• Preferred language -- select desired value from the available options

• Phone number

− Phone number

− Type

• Email

− Email

− Type

• Social Media

− Social Media

− ID

Guardian Information

• Guardian Type

• First Name





• Last Name

• Phone

• Zip

• Email

• City

• State

Address information

• Type

• Address Line1

• Address Line 2

• Zip

• City

• State

• Effective Date

• End Date

Policy tab

Medical Policies

• Policy Type

• Contract ID

• Contract Type

• Plan Type

• Plan ID

• Payer Name

• Member ID

• Member effective date

• Member end date

Dental Policies



• Policy Type

• Contract ID

• Contract Type

• Plan Type

• Plan ID

• Payer Name

• Member ID

• Member effective date

• Member end date


Update Member Specification – Update Member

Short Description: Update member


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update the data of an existing member data instance



Business impact:

Description

Pre-condition: Member instance is created and available in the system. Search and open the desired member review screen.

User clicks on the Edit button on the Member header.

System displays the Member Metadata screen as a three step process with the following fields in edit mode.

• Member Details

• Other details

• Contact Info

Member Details

• Member ID

• First Name

• Middle Name

• Last Name

• Prefix

• Suffix

• Date of Birth

• Gender

• Marital Status

• Race/Ethnicity


• Exchange ID

• VIP

• Employee

• Picture :- Choose picture file by clicking on button

• Previous Name(s) First Name

• Middle Name



• Last Name

• Effective Date

• End Date

Employment and Education EMPLOYMENT AND EDUCATION

• Employment status

− Hire Date

• Student

− School Name

− Address

− Zip

− City

− State

User clicks Continue to proceed to the next step to Other Details

Other Details

• Primary Care Physician NPI

• Effective Date

• End Date

Medicaid/ Medicare Details MEDICAID/MEDICARE DETAILS

• Medicaid

− Medicaid Number

• Medicare

− Eligibility reason

− Qualifying Date

− Medicare number (HICN)

− Medicare plan type

• Account Information Account type

• Bank Name


• Account Number



• Routing number

User clicks Continue to proceed to the next step to edit Contact Information for member

Contact

• Contact Preferred language

• Phone number

− Phone number

− Type

• Email

− Email

− Type

• Social Media

− Social Media

− ID

• Guardian Guardian Type

• First Name



• Last Name

• Phone

• Zip

• Email

• City

• State

• Address Type

• Address Line1

• Address Line 2

• Zip

• City

• State



User clicks on submit to update the information




Policy

Plan

Member

Each Policy will have the following basic fields:

• Policy ID• Insurance Type (Group, Individual)• Policy Coverage Type (Individual, Individual + spouse etc)• Policy Effective Date• Policy Term Date• Policy Elected Amount• Policy used Amount• Policy remaining Amount• VIP Indicator

Policy

A Member can be associated multiple policies.

A Policy contains the Family Structure:

• Relationship Code / Policy Role• Effective Date• Term Date

Employer Group Contract.

Member Policies

A Policy can be associated to only one Contract.

Based on the Plans available in the Employer Group Contract, a policy can be associated with only 1 Plan.

4 Member policy relationships and specifications



Create Policy Specification – Create Policy

Short Description: Create Policy


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new Policy data instance

Business impact:

Description

Pre-condition: Active Contract and Plan are required during policy generation

User selects New Policy from the the Member grouper portal header.

System launches a new Create Policy flow as a five step process:

• Policy

• Contract

• Plan

• Subscriber

• Dependents



Step 1: Enter Policy Metadata


MEMBER HEADER

• Policy ID –Required – this is used as the key for the policy instance and is auto generated

• Insurance Type – Required – select desired value from the available options (GP –Group Policy/IP – Individual Policy/MC - Medicaid/MP – Medicare Primary/WC – Workers Compensation)

• Policy coverage type – Required -– select desired value from the available options (Employee Only/Employee and Spouse/Employee and Children/Employee and Family)

If user select Insurance Type as ‘Medicaid’ or ‘Medicare Primary’ or ‘Workers Compensation’ the Policy coverage type is read only as ‘Employee Only’

• Policy effective date – default date is current date

• Policy term date

• Policy elected amount

• Policy used amount

• Policy remaining amount

• VIP indicator – User checks the option if applicable

User clicks Continue to proceed to the next step to select contract

Step 2: Select contract

User enters the following contract information.

• Contract ID -- Required – User search by Contract ID or Contract Name or Group ID or Group Name and then selects

Once user has selected ‘Contract ID, system displays a subsection to capture additional Contract information

• Contract identifier – Read only

• Contract type – Read only

• Group ID – Read only

• Group Name – Read only

• Effective date – Read only



• End date – Read only

User clicks Continue to proceed to the next step to select plan

Step 3: Select plan

User enters the following plan information.

• Plan ID – Required -- User search by Plan ID or Name and then selects

Once user has selected ‘Plan ID’, system displays a subsection to capture additional Plan information

• Plan ID – Read only

• Category– Read only

• Plan type – Read only

• Plan name – Read only



• Network ID – Read only

User clicks Continue to proceed to the next step to select subscriber

Step 3: Select subscriber

User enters the following plan information.

• Subscriber – Required -- User search by Member ID or Name and then selects

Once user has selected ‘Subscriber’, system displays a subsection to capture additional Subscriber information

• Subscriber ID – Read only

• Member profile key– Read only

• Policy Role – Read only

• Effective date

• Term Date

System also displays a subsection to capture additional Primary care physician information

• Name – Read only

• NPI – Read only



• Specialty – Read only

Create New

User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section to capture additional information for the subscriber.

• Member ID -- Required

• First Name -- Required

• Last Name -- Required

• Date of Birth -- Required

• Gender – Required - select desired value from the available options (Male/Female / Unknown)

Add/Edit PCP

User Clicks ‘Add PCP’ or ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section to capture additional information for the subscriber.

• PCP

• Reason for PCP change -- select desired value from the available options (Dissatisfaction with Office staff/Dissatisfaction with Medical Care or Services Rendered / Inconvenient Office location/Dissatisfaction with Office Hours/Unable to Schedule Appointments in a Timely Manner/ Dissatisfaction with Physician’s Referral Policy/Less Respect and Attention Time Given than to Other Patients/Patient Moved to a New Location/No Reason Given/Appointment Times not Met in a Timely Manner)

Review Policy Specification –Review Policy

Short Description: Review Policy


Status: New



Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a Policy data instance

Business impact:

Description

User clicks on the Policies tab member panel of the portal.

System retrieves and displays a list of Member data instances with the following columns:

• Policy ID

• Subscriber name

• Group name

• Plan type

• Effective date

• End Date



User clicks on desired Policy from the list to review details.

System retrieves the details of the selected Policy and presents a review screen organized as follows:

• Policy metadata

• Contract details



• Plan details

• Subscriber details

• Members

Policy Metadata

• Policy ID

• Insurance Type

• Policy coverage type

• Policy effective date

• Policy term date

• Policy elected amount

• Policy used amount

• Policy remaining amount

• VIP indicator

• Reason for policy Cancellation

Contract details

• Contract ID

• Contract identifier

• Contract type

• Group ID

• Group Name

• Effective date

• End date

Plan Details

• Plan ID

• Category

• Plan type

• Plan name

• Effective date

• End date



• Network ID

Subscriber details

• Subscriber ID

• Subscriber

• Policy Role

• Effective date

• Term Date

• PCP

Members

• Member ID

• Dependent ID

• Policy Role

• Effective date

• End date

• PCP



Update Policy Specification – Update Policy

Short Description: Update Policy


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update a Policy data instance

Business impact:

Description

Pre-condition: Policy instance is created and available in the system. Search and open the desired member review screen.

User clicks Edit on the Policy header and selects one of the available link from four options

• Add member

• Update Member PCP

• Cancel Member

• Cancel Policy

Add Member



System displays the Policy Metadata screen with the following fields in edit mode.

• Policy coverage type

User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section with the following fields in edit mode

• Member ID

• First Name

• Last Name

• Date of Birth

• Gender

User Clicks ‘Edit PCP’ next to Primary Care Physician to create/edit primary care physician data, system displays a new section with the following fields in edit mode

• PCP

• Reason for PCP change

User clicks on Update to update the information


Update Member PCP



• PCP


User clicks Update to update the information


Cancel Member


• Cancellation Reason



User Clicks ‘Create New’ next to subscriber to create a new subscriber, system displays a new section with the following fields in edit mode

• Member ID

• First Name

• Last Name

• Date of Birth

• Gender


• PCP




Cancel Policy


• Policy Term date

• Reason for policy cancellation





Employer Group Contract.

A Contract helps with the association of the Member’s Policy to the Group. A

Contract is specific to a Group / Company.

Payer

Company

Company ID, Effective Date and End Date.

Company A Company can also be defined as a Employer Group.

Address Information

Generic Information

• Company ID• Company Name• Tax ID• Marketing Segment• SIC Code

Subgroup Information (Need

to be added)

Company / Group

Member Contracts

Generic Information

• Contract ID• Contract Type (Group, Individual,

Cobra)• Product Category

• Financial Billing Info• Sales Info• Performance Guarantee

Contracted Plans (Available Plans for Members within

this Group)

5 Member contracts relationships and specifications



Create Membership Contract Specification – Create Membership Contract

Short Description: Create membership contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new contract data instance

Business impact:

Description

Pre-condition: Active Payer, Group and Plan are required during membership contract generation

User selects Contract (Membership) from Plan & contract grouper portal header.

System launches a new Create membership flow as a three step process:

• Contract details

• Contract information

• Contracted plan

Step 1: Contract details




• Contract ID – Required – this is used as the key for the policy instance and is auto generated

• Contract Type – Required - select desired value from the available options

• Product category – Required - select desired value from the available options (Medical/Dental / Pharmacy/Vision)

• Payer ID – Required -- User search by Payer ID or Payer Name and then selects

• Payer Name – Read only

• Group ID – Required --User search by Group ID or Group Name and then selects


• Effective date – Required

• End Date

PCP Configuration

Add configuration – User clicks to add configuration. User can add multiple configuration.

User clicks Continue to proceed to the next step to add contract information

Step 2: Contract information

User enters the following contract information.

Financial/Billing

• Contract state- select desired value from the available options

• Funding arrangement - select desired value from the available options (Fully Insured/Self Insured)

• Claim fiduciary -- select desired value from the available options (Yes/No)

• Enrollment type

• Billing cycle -- select desired value from the available options (Monthly/Quarterly)

Sales Info

• Sales representative name

• Sales representative phone

• Preferred broker



• Open enrollment period

Performance guarantees

• ID card turnaround time

• Enrollment app turnaround time

• PCP assignment turnaround time

• Timely filling days

• Claims processing SLA

User clicks Continue to proceed to the next step to select contracted plan

Step 3: Contracted plan

User clicks on the ‘Add plan(s)’, system open a new window where users selects the plan

• Plan ID –User search by Plan ID or Name and then selects








Or it displays following for Plan benefits in contract

• Product number– Read only


• Plan Type– Read only

• Product name– Read only

• Start date– Read only

• End date– Read only



Review Membership Contract Specification – Review Membership contract

Short Description: Review membership contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review contract data instance

Business impact:

Description

User clicks on the Contracts (Membership) tab on Plan & Contract panel of the portal.

System retrieves and displays a list of Membership contracts data instances with the following columns:

• Contract ID

• Contract Type


• Group Name

• Payer Name

• Effective date



• End date



User clicks on desired membership contract from the list to review details.

System retrieves the details of the selected membership contract and presents a review screen organized as follows:

• Summary Plan benefits(PCS) in contract Plan Benfits in contract

• Financial/Billing

• Sales Info

• Performance guarantees

Header

• Contract ID

Contract summary

• Contract Type


• Effective date

• End Date

• Payer ID

• Payer Name

• Group ID

• Group Name

• Plan benefits in contract Product number

• Category

• Product Name

• Start Date

• End Date

Plan Benefits (PCS) in contract



• ID

• Category

• Name

• Effective date

• End date

Financial/Billing

• Contract state

• Funding arrangement

• Claim fiduciary

• Enrollment type

• Billing cycle

Sales Info











PCP Configuration

• Configuration

• Priority



Update Membership Contract Specification – Update membership Contract

Short Description: Update membership contract


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update membership contract data instance

Business impact:

Description

Pre-condition: Membership Contract instance is created and available in the system. Search and open the desired membership contract review screen.

User clicks on the Edit button on the Membership contract header.

System displays the Membership Contract Metadata screen as a three step process with the following fields in edit mode.

• Contract Details

• Contact Information

• Contracted plans

Contract details



• Contract ID –Read Only

• Contract Type


• Payer ID

• Payer Name – Read only

• Group ID


• Effective date

• End Date

• PCP Configuration.

Contract information

Financial/Billing

• Contract state

• Funding arrangement

• Claim fiduciary

• Enrollment type

• Billing cycle

Sales Info













Contracted plan

User clicks on the ‘Add plan(s)’, system open a new window where users selects the plan

• Plan ID








User clicks on Submit to update the information



Overview • Company – A company is an Account / Group / Employer that is associated with

Membership Contracts.

• Payer – A Payer is the health plan entity that has contracts with employer groups and provider business entities.

6 Company and payer specifications



Create Company Specification – Create Company

Short Description: Create company instance


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new company instance

Business impact:

Description

User selects New Compan from the Plan & Contract grouper portal header.

System launches a new company flow

Create Company

User enters the following information to capture the Company

Company

• Company ID – Required – this is used as the key for the policy instance and is auto generated

• Company Name – Required



• Tax ID

• Market segment -- select desired value from the available options (HIX/Individual/Large Group/Medium Group/National Accounts/Small Group)

• Customer industry -- select desired value from the available options (Communications/Entertainment/Financial Services/Government/Healthcare/High Tech/Insurance/Manufacturing/Media/Retail)

Industry

• Standard Industry Code – User selects the value by searching using link ‘Don’t Know the SIC Code’

Don’t Know the SIC Code – System opens a window allowing user to enter following to select industry standard code

− Select Division – search and select the value

− Select Group – search and select the value

− Select Industry Code – search and select the value

• Description – Read Only

Addresses information

Add Address

User enters the Address for the company by clicking on Add Address button. User can add multiple records for each contact type.


• Address Line1

• Address Line 2

• Zip




• Phone

• Email

• Fax



Review Company Specification – Review Company

Short Description: Review company instance


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a company instance

Business impact:

Description

User clicks on the Companies tab Plan & Contract panel of the portal.


• Company ID

• Company Name





User clicks on desired membership contract from the list to review details.

System retrieves the details of the selected membership contract and presents a review screen organized as follows

Company data

• Company ID

• Company Name

• Tax ID

• Market segment

• Customer industry

Industry details

• Standard Industry Code

• Description


• Address Type

• Address Line1

• Address Line 2

• Zip

• City

• State

• Phone

• Email

• Fax



Update Company Specification – Review Company

Short Description: Update company instance


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update a company instance

Business impact:

Description

Pre-condition: Company instance is created and available in the system. Search and open the desired membership contract review screen.

User clicks on the Edit button on the Company header.

System displays the Company Metadata screen with the following fields in edit mode.

Company data

• Company ID

• Company Name

• Tax ID



• Market segment

• Customer industry

Industry details

• Standard Industry Code

Don’t Know the SIC Code – System opens a window allowing user to enter following to select industry standard code

− Select Division

− Select Group

− Select Industry Code

• Description – Read Only


Add Address


• Type

• Address Line1

• Address Line 2

• Zip

• City

• State


• Phone

• Email

• Fax

User clicks on Submit to update the information




Create Payer Specification – Create Payer

Short Description: Create Payer


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a new payer instance

Business impact:

Description

User selects New Payer from Plan & Contracts tab of the portal header.

System launches a new Payer flow as a twostep process:

• Payer details

• Address Details

Step 1: Payer details

User enters the following information to capture the payer information

Payer header



• Payer ID – Required – this is used as the key for the policy instance and is auto generated

• Payer Name – Required

• Federal Tax ID – Required

• National plan ID

• External payer -- User checks the option if applicable

User clicks Continue to proceed to the next step to add address details

Step 2: Address details


Add Address



• Address Line1

• Address Line 2

• Zip




• Phone

• Email

• Fax



Review Payer Specification – Review Payer

Short Description: Review Payer


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a payer instance

Business impact:

Description

User clicks on the Payers tab on Plan & Contract panel of the portal.


• Payer ID

• Payer Name





User clicks on desired payer from the list to review details.

The system retrieves the details of the selected payer and presents a review screen organized as follows:

Payer header

• Payer ID

• Payer Name

• Federal Tax ID


• External payer


• Type

• Address Line1

• Address Line 2

• Zip

• City

• State

• Phone

• Email

• Fax



Update Payer Specification – Update Payer

Short Description: Update Payer


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update payer instance

Business impact:

Description

Pre-condition: Company instance is created and available in the system. Search and open the desired membership contract review screen.

User clicks on the Edit button on the Payer header.

System displays the Payer Metadata screen with the following fields in edit mode.

• Payer Header

• Address Information

Payer header

• Payer ID



• Payer Name

• Federal Tax ID


• External payer

Address details

Add Address


• Type

• Address Line1

• Address Line 2

• Zip

• City

• State


• Phone

• Email

• Fax




Overview • Claim -- A claim is a detailed invoice that your health care provider (such as your doctor,

clinic, or hospital) sends to the health insurer. This invoice shows exactly what services were received.

• Authorization -- A decision by health insurer or plan that a health care’s service, treatment plan, prescription drug or durable medical equipment is medically necessary.

7 Claim and authorization specifications



Create Claim Specification – Create Payer

Short Description: Create Claim


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create a Claim instance

Business impact:

Description

Pre-condition: Active Payer, Provider and member are required during claims generation

User selects New Claim from the Claim tab of Member groper of the portal

System launches a new Claim flow as a five step process:

• claim header

• claim lines

• patient

• provider

• payer



Step 1: Enter claim header

User enters the following information to capture the claim information

Claim header

• Claim type -- select desired value from the available options (Professional/Institutional/Pharmacy/Vision)

Details

• Claim Number -- Required -- this is used as the key for the claim instance and is auto generated

• Status -- Required -- select desired value from the available options

• Status date -- Required

Initial dates

• Received date -- Required

• Initial treatment date

• Current illness onset date

• Statement from date – Required – Information entered only when user select Claim type ‘Institutional’

• Statement to date – Required -- – Information entered only when user select Claim type ‘Institutional’

Admission

• Admission Type – Required – – Information entered only when user select Claim type ‘Institutional’ -- select desired value from the available options (1-Emegency/2-Urgent/3- Elective/4- New born/5-Information Not Available)

• Admission Date -- Required – Information entered only when user select Claim type ‘Institutional’

• Discharge Date

• Discharge hour – Information entered only when user select Claim type ‘Institutional’

• Admission source – Required – Information entered only when user select Claim type ‘Institutional’

• Admission Hour – Information entered only when user select Claim type ‘Institutional’

• Patient discharge status –Required – Information entered only when user select Claim type ‘Institutional’



Accident

• Accident date

• Accident state -- select desired value from the available options

• Trace number

• Authorization number

• Type of Bill – Required –– Information entered only when user select Claim type ‘Institutional’ -- search by code or description and select

Diagnosis information

• Code Type -- Required -- select desired value from the available options (ICD9/ICD10/DSM)

• Code -- search by code or description and select

• Description – Read only

DRG information

• Code

Condition code information – Information entered only when user select Claim type ‘Institutional’

User enters the Condition code information for the Claim. User can add multiple records.

• Code – User Search and selects the code


Occurrence code information – Information entered only when user select Claim type ‘Institutional’

User enters the Occurrence code information for the Claim. User can add multiple records.



Occurrence Span Code Information – Information entered only when user select Claim type ‘Institutional’

User enters the Occurrence Span Code Information for the Claim. User can add multiple records.





Value Code information – Information entered only when user select Claim type ‘Institutional’

User enters the Value Code information for the Claim. User can add multiple records.



Admitting Diagnosis Information – Information entered only when user select Claim type ‘Institutional’

• Code Type -- select desired value from the available options (ICD9/ICD10)



Patient reason for visit diagnosis information – Information entered only when user select Claim type ‘Institutional’




External cause of injury diagnosis information – Information entered only when user select Claim type ‘Institutional’




Principal procedure information – Information entered only when user select Claim type ‘Institutional’




Other Procedure Information – Information entered only when user select Claim type ‘Institutional’

User enters the Other Procedure Information for the Claim. User can add multiple records.





• Description –Read Only

• Date

User clicks Continue to proceed to the next step to add claim line details

Step 2: Add Claims lines

Claim Line

Add claim line

Service information

Information entered only when user select Claim type ‘Professional’

• Line number – Required

• Service from date -- Required

• Service to date – Required

• Service code type – Required -- select desired value from the available options (HCPCS/NDT/CPT)

• Service Code – Required –Search by Code and select

• Code description – Read only

• Service Units – Required

• Place of service -- select desired value from the available options

Information entered only when user select Claim type ‘Institutional’

• Service Date – Required

• Service code type

• Code Description

• Service units

• Line number – Required

• Revenue code -- Required

• Revenue code description

Payment Information

• Charge Amount -- Required



• Paid amount

• Non-covered amount

• Patient co-insurance

• Patient copay

• Patient deductible

Service Provider


• NPI type ---- select desired value from the available options (1/2)

• Rendering provider ID –Search by NPI and select

• Last Name – Read only

• First Name – Read only


Modifiers and diagnosis information


• Diagnosis pointer1 -- Required

• Modifier 1

• Diagnosis pointer2

• Modifier 2


• Modifier 3


• Modifier 4

User clicks Continue to proceed to the next step to add patient details

Step 3: Add Patient

Patient

• Select patient ID – Required -- Search by Member ID and select

System displays a subsection of details of member after user selects patient ID




• Gender – Read only

• Date of Birth – Read only

• Policy Number – Read only

• Policy role/relationship – Read only


• Phone – Read only

• Email – Read only

• Address – Read only

User clicks Continue to proceed to the next step to add provider details

Step 4: Add Provider

Billing provider

• NPI type -- select desired value from the available options (1/2)

• Provider ID – search by NPI and select



Referring provider





Rendering provider





Service facility







Attending provider


• NPI type -- select desired value from the available options (1/2) • Provider ID – search by NPI and select • Specialty – Read only • Address – Read only

Operating provider







Step 5: Add Payer

Payer

Primary payer

• Primary payer name – Search by Payer Name and select

• Payer ID – Read only

• Health plan ID – Read only

• Prior payment amount – Read only

• Secondary Payer? – user checks if applicable

Secondary payer

System displays a subsection of details of secondary payer after user checks ‘Secondary Payer?’

• Secondary payer name






Review Claim Specification – Review Claim

Short Description: Review Claim


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review a Claim instance

Business impact:

Description

User clicks on the Claims tab l on the Member panel of the portal.

System retrieves and displays a list of Claims data instances with the following columns:

• Claim number

• Claim type



• Member name

• Received Date

• Total Charge



User clicks on desired Claim from the list to review details.

System retrieves the details of the selected payer and presents a review screen organized as follows:

• Claim header

• Claim lines

• Provider

• Patient

• Payer

Claim Summary

• Claim Number

• Claim type

• Status

• Received date

• Status date

• Claim headerClaim Number

• Trace number

• Status

• Received date

• Status date



• Statement from date

• Statement to date



Admission

• Admission Type

• Admission Date

• Discharge Date

• Discharge hour

• Admission source

• Admission Hour

• Patient discharge status

Accident

• Accident date

• Accident state

• Trace number


• Type of Bill


• Code

• Description

DRG information

When Claim type is ‘Institutional’

• Code

• Description

Occurrence code information -- When Claim type is ‘Institutional’



Occurrence Span Code Information – When Claim type is ‘Institutional’



Value Code information – When Claim type is ‘Institutional’



• Code

• Description

Admitting Diagnosis Information – When Claim type is ‘Institutional’

• Code

• Description

Patient reason for visit diagnosis information – When Claim type is ‘Institutional’

• Code

• Description

External cause of injury diagnosis information – When Claim type is ‘Institutional’

• Code Type

• Code

• Description

Principal procedure information – When Claim type is ‘Institutional’

• Code Type

• Code

• Description

Other Procedure Information – When Claim type is ‘Institutional’

• Code Type

• Code

• Description

• Date

Claim Line

When Claim type is ‘Professional’

• Line number

• Service from date

• Service to date


• Service Code



• Code description

• Service Units

• Place of service


• Service Date



• Service units

• Line number

• Revenue code


Payment Information

• Charge Amount

• Paid amount



• Patient copay


Service Provider


• NPI type

• Rendering provider ID

• Last Name

• First Name

• Specialty






• Modifier 1


• Modifier 2


• Modifier 3


• Modifier 4

Patient

• Patient ID

• Name

• Gender

• Date of Birth

• Policy Number

• Policy role/relationship

• Plan name

• Phone

• Email

• Address

Provider

Billing provider

• NPI type

• Provider ID

• Specialty

• Address

Referring provider

• NPI type

• Provider ID

• Specialty

• Address



Rendering provider

• NPI type

• Provider ID

• Specialty

• Address

Service facility

• NPI type

• Provider ID

• Specialty

• Address

Attending provider


• NPI type

• Provider ID

• Specialty

• Address

Operating provider


• NPI type

• Provider ID

• Specialty

• Address

Payer

Primary payer

• Primary payer name

• Payer ID

• Health plan ID

• Prior payment amount



Secondary payer – If applicable


• Payer ID

• Health plan ID


Update Claim Specification – Update claim

Short Description: Update Claim


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update a Claim instance

Business impact:

Description

Pre-condition: Claim instance is created and available in the system. Search and open the desired claim review screen.



User clicks on the Edit button on the Claim header.

System displays the Claim Metadata screen as a three step process with the following fields in edit mode.

• Enter claim header

• Add claim lines

• Add patient

• Add provider

• Add payer

Enter claim header

Claim header

• Claim type

Details

• Claim Number

• Status

• Status date

Initial dates

• Received date



• Statement from date

• Statement to date

Admission

• Admission Type

• Admission Date

• Discharge Date

• Discharge hour

• Admission source

• Admission Hour



• Patient discharge status

Accident

• Accident date

• Accident state --

• Trace number


• Type of Bill


• Code Type

• Code

• Description

DRG information

• Code

For Claim type ‘Institutional’.

• Code

• Description

Occurrence code information -- For Claim type ‘Institutional’



Occurrence Span Code Information -- For Claim type ‘Institutional’



Value Code information -- For Claim type ‘Institutional’



Admitting Diagnosis Information -- For Claim type ‘Institutional’

• Code Type

• Code




Patient reason for visit diagnosis information -- For Claim type ‘Institutional’

• Code Type

• Code


External cause of injury diagnosis information -- For Claim type ‘Institutional’

• Code Type

• Code


Principal procedure information -- For Claim type ‘Institutional’

• Code Type

• Code


Other Procedure Information -- For Claim type ‘Institutional’.

• Code Type

• Code

• Description –Read Only

• Date

Add claim line

Service information

For Claim type ‘Professional’

• Line number

• Service from date

• Service to date


• Service Code

• Code description

• Service Units



• Place of service

For Claim type ‘Institutional’

• Service Date



• Service units

• Line number

• Revenue code


Payment Information

• Charge Amount

• Paid amount



• Patient copay


Service Provider


• NPI type

• Rendering provider ID

• Last Name

• First Name

• Specialty




• Modifier 1




• Modifier 2


• Modifier 3


• Modifier 4

Add Patient

Patient

• Patient ID




• Date of Birth – Read only







Add Provider

Billing provider

• NPI type

• Provider ID

• Specialty

• Address

Referring provider

• NPI type

• Provider ID





Rendering provider

• NPI type

• Provider ID



Service facility

• NPI type

• Provider ID



Attending provider


• NPI type

• Provider ID



Operating provider


• NPI type

• Provider ID



Add Payer

Primary payer

• Primary payer name

• Payer ID

• Health plan ID




• Secondary Payer?

Secondary payer







Create Authorization Specification – Create Authorization

Short Description: Create Authorization


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To create Authorization



Business impact:

Description

Pre-condition: Active Provider and member are required during claims generation

User selects New Authorization from the Authorization tab of member grouper portal header.

System launches a new authorization flow as a six step process:

• Authorization

• Requesting provider

• Servicing provider

• Patient

• Look up Facility

• Enter detail request

Step 1: Enter Authorization

User enters the following information to capture the claim information

Request information

• Authorization Number -- Required -- this is used as the key for the claim instance and is auto generated

• Request date -- Required

• Request type – Required -- select desired value from the available options (Inpatient/Outpatient/Pharmacy/Referral)

• Status – Required -- select desired value from the available options (A1- Certified in Total/A3- Not Certified/A4 – Pended/A6- Modified/CT- Contact Payer/NA – No Action Required)

• Contact Channel – Required -- select desired value from the available options (Email/Fax/Letter/Phone/SMS/Web)

• Urgency – Required -- select desired value from the available options (03- Emergency/U- Urgent)

User clicks Continue to proceed to the next step to add requesting provider details

Step 2: Requesting provider



Requesting provider


• ID – Required – Search by NPI and select

System displays a subsection of details of provider after user selects NPI ID




• ETIN – Read only


User clicks Continue to proceed to the next step to add servicing provider details

Step 3: Servicing provider

Serving provider



System displays a subsection of details of provider after user selects NPI ID







Step 4: Patient

Patient

• Select patient ID – Required – Search by Member ID and select



• Date of Birth– Read only





• Plan name

• Phone

• Email

User clicks Continue to proceed to the next step to add look up details

Step 5: Look up Facility

Facility




• Organization Name– Read only

• Tax ID – Read only

• Type – Read only

• City – Read only

• State – Read only

User clicks Continue to proceed to the next step to add detail request

Step 6: Enter detail request

Authorization details

• Service type – Required -- select desired value from the available options

• Place of service code – Required -- select desired value from the available options

Admission information

• Admission Date -- Required

• Request length of stay -- Required

• Approved length of stay -- Required

• Facility Name -- Required

• Facility type – Required -- select desired value from the available options




• Code Type – Required -- select desired value from the available options (ICD9/ICD10/DSM)

User enters the Diagnosis Information for the Claim. User can add multiple records.

• Date -- Required

• Code -- Required

• Description

Procedure information

User enters the Other Procedure Information for the Claim. User can add multiple records.

• Line number

• Date

• Code Type -- select desired value from the available options (CPT/HCPCS/ICD9/ICD10/Revenue Code)

• Code – Search By code and select

• Description

• Requested units

• Approved Units

• Denied units

Certification information

• Certification eff date

• Certification end date



Review Authorization Specification – Review Authorization

Short Description: Review Authorization


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To review Authorization

Business impact:

Description

User clicks on the Authorization tab on the member panel of the portal.

System retrieves and displays a list of Authorization data instances with the following columns:


• Authorization type

• Service type

• Member last name

• Member first name

• Request date

• Status





User clicks on desired Authorization from the list to review details.

System retrieves the details of the selected payer and presents a review screen organized as follows

• Authorization request

• Provider

• Patient

Authorization request

• Authorization Number

• Request date

• Request type

• Status

• Contact Channel

• Urgency

• Service type

• Place of service code


• Admission Date

• Request length of stay

• Approved length of stay

• Facility Name

• Facility type


• Code Type

• Date

• Code



• Description


• Line number

• Date

• Code Type

• Code

• Description

• Requested units

• Approved Units

• Denied units




Provider

Requesting provider

• NPI type

• ID

• Specialty

• Phone

• Email

• ETIN

• Address

Servicing provider

• NPI type

• ID

• Specialty

• Phone

• Email



• ETIN

• Address

Patient

• Patient ID

• Gender

• Date of Birth

• Policy Number

• Policy role/relationship

• Plan name

• Phone

• Email

Update Authorization Specification – Update Authorization

Short Description: Update Authorization


Status: New

Actors: Any


Complexity: Medium

Release:

Iteration:

Primary business objective: To update Authorization



Business impact:

Description

Pre-condition: Authorization instance is created and available in the system. Search and open the desired authorization review screen.

User clicks on the Edit button on the Authorization header.

System displays the Authorization Metadata screen as a six step process with the following fields in edit mode.

• Authorization

• Requesting provider

• Servicing provider

• Patient

• Look up Facility

• Enter detail request

Authorization

Request information

• Authorization Number

• Request date

• Request type

• Status

• Contact Channel

• Urgency

Requesting provider

• NPI type

• ID








Servicing provider

• NPI type

• ID






Patient

• Select patient ID


• Date of Birth– Read only



• Plan name

• Phone

• Email

Look up Facility

Facility

• ID


• Organization Name– Read only

• Tax ID – Read only

• Type – Read only

• City – Read only

• State – Read only



Enter detail request

Authorization details

• Service type

• Place of service code


• Admission Date

• Request length of stay

• Approved length of stay

• Facility Name

• Facility type


• Code Type

• Date

• Code

• Description


• Line number

• Date

• Code Type

• Code

• Description

• Requested units

• Approved Units

• Denied units








Documents

Pega Foundation for Healthcare · A Business Entity functions in the capacity of a contracting entity, facilitating the relation of Practitioners and Providers to health plan contracts