Benefit and plan lifecycle management and configuration

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Benefit and plan lifecycle management and configuration

Description Benefit and plan lifecycle management and configuration
Version as of 8.7
Application Pega Product Composer for Healthcare
Capability/Industry Area Healthcare and Life Sciences



Benefit and plan lifecycle management and configuration[edit]

For any payer organization, the creation and ongoing maintenance of benefits and plans takes up a large portion of the operations and business team's time. Any mistake here can prove to be very costly, and hence both speed and accuracy are the foundational pillars. With the PCS application, there are various features designed to alleviate the challenges of managing and updating an extremely large portfolio of benefits and plans. Having a clear understanding of these features allows the business teams to have a sound operational policy for configuring and updating the repository. Using the combination of advanced configuration pages and built-in features like Smart Update, PCS allows the operations team to make quick adjustments to the plan repository with surgical precision while maintaining clear tracking and reporting.

Use case examples[edit]

Below are some of the common business scenarios which require the business teams to update the plan repository.

  1. Change in policy resulting in waiving of the copay for a particular benefit
  2. Change in policy resulting in introduction of new benefits mid-year
  3. Change in policy resulting in updates to the end dates of benefits and plans

All these scenarios require updating key business properties for the configured plans. These updates need to be carefully planned and executed as they have high impact on the downstream systems. Using the built-in PCS configurations and features, all of the above use cases can be achieved very easily.

Before you begin[edit]

The PCS application provides preconfigured stages and statuses along with several workbaskets to manage the overall flow of the business entities. Details of those can be found at https://wiki.pega.com/index.php/Configuring_and_extending_stages,_statuses,_and_work_queues

Detailed information about managing the versioning across various stages can be found at https://community.pega.com/knowledgebase/articles/pega-product-composer-healthcare-implementation-guide/86/versioning

Smart Update allows the users to achieve all of the use cases listed above. More information about Smart Update can be found at https://community.pega.com/knowledgebase/articles/pega-product-composer-healthcare-implementation-guide/86/smart-update

Process/Steps to achieve objective[edit]

Now that you have a good foundation of the topics listed above, let us walk through the steps to implement the three scenarios listed above. All changes with Smart Update would be implemented as a batch.

For the first use case where a change in policy is resulting in waiving of the copay for a particular benefit, this can be achieved by updating all the plans which use that particular benefit. The Smart Update feature allows you to search for all the plans with a particular benefit, and then update the cost share (copay) to reflect the latest change. Detailed steps can be found at https://community.pega.com/knowledgebase/articles/pega-product-composer-healthcare-implementation-guide/86/updating-plans

For the second use case where we would like to introduce new benefits mid-year, we are going to rely on the Smart Update feature that allows us to update the benefit set. We will update the benefit set for all the plans to which we would like to add the new benefit. Detailed steps can be found at https://community.pega.com/knowledgebase/articles/pega-product-composer-healthcare-implementation-guide/86/updating-benefit-sets

For the third use case where we would like to make updates to the end dates of benefits and plans, we can achieve that by updating the plan metadata via Smart Update, resulting in new versions of the plan being created.

The Smart Update dashboard provides detailed information about all updates made to the plans, thereby allowing users to track all of their changes.

Results[edit]

The PCS application has multiple configurations and features to allow quick updates to the plan repository with advanced tracking and reporting. Having a solid understanding of these concepts allows the business and implementation teams to move faster with confidence and achieve operational agility.