Extending coverage data to leverage inheritance

Extending coverage data to leverage inheritance

Description	Details for extending coverage data in PCS
Version as of	8.5
Application	Pega Product Composer for Healthcare
Capability/Industry Area	Healthcare and Life Sciences

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During an implementation, based on client requests, you might need to add new properties to the product repository. To leverage the complex Pega Composer for Healthcare inheritance for the new properties, you need to understand how union data structures are organized and be aware of the built-in extension points that enable them to achieve any such functional requirement. Union data are structures in PCS that store the coverage details of networks, groupers, and benefits in the product templates, products, and plans.

Some of the possible scenarios that you might encounter are:

• Providing the ability to configure and capture a carry-over deductible for a plan
• Providing the ability to configure and capture cost sharing reduction for a silver plan
• Adding a property from the client's architecture and surrounding subsystems that should inherit across the product repository

In each of the above scenarios, you can add more classes and develop the inheritance structure to meet the functional requirements. But the downside to that approach includes significant development, testing and maintenance, and update challenges.

The recommended approach is to extend the union data structures that hold the coverage information. By extending the union data structures, you can reuse inheritance that is built into PCS. This approach also reduces the footprint of the overall implementation-layer code base and ensures smoother updates and lower ongoing maintenance.

Union data in PCS

In PCS, the reusable entities such as benefits, networks, and benefit sets are independently defined, and then are used in the creation of product templates, products, and plans. The coverage information, however, is available only in the product template, product, and plans and is not configured with the reusable entities. Union data are structures in PCS that store the coverage details of networks, groupers, and benefits in the product templates, products, and plans.

This coverage information is broadly categorized as follows:

• Cost shares
• Variations
  • Unified variations
  • Benefit policies

• Additional details
  • Compliance and documentation support for benefits and groupers
  • Claim instructions for benefits
  • In/Out indicator for network

Each of these categories follows an independent inheritance pattern, which is described below.

Extension of cost shares

If you need to add more cost shares, accumulators, or any other property that needs inheritance across the product repository, you can extend the out-of-the-box cost shares. For the example of the carry-over deductible mentioned above, the best option is to extend cost shares.

The PCS data model that supports cost shares in the union data is listed below:

• Cost shares
• Accumulators
• Order of cost shares
• Coordination of benefits

Technical details of this data model:

• UnionData (Rule-HC-PCS-UnionData)
  • CostShares page list of Embed-HC-PCS-CostShareo Accumulator page of Embed-HC-PCS-Accumulatoro OrderOfCostShares page of Embed-HC-PCS-OrderOfCostShares
    • CostSharesAssembly page of Embed-HC-PCS-CostSharesAssembly
      • COB page of Embed-HC-PCS-COB
      • <Extension properties>

In addition to the cost shares listed above, to add new fields from the implementation layer, follow the steps in Extending union data for cost shares in the implementation guide.

Extension of variations

You might encounter the requirements to enhance the variation capabilities that are offered by PCS, for example, handling tiered-network cost shares or additional properties needed when capturing the authorization variation. For such scenarios, the recommended approach is to extend the variations.

You can configure variations on the Policies tab for networks, groupers, and benefits in the PCS application.

The following is the data model of the variations under the union data:

• UnionData (Rule-HC-PCS-UnionData)
  • VariationsAssembly page of Embed-HC-PCS-VariationsAssembly
    • UnifiedVariations page list of Embed-HC-PCS-UnifiedVariation
    • <Extension properties>

In addition to the unified variations, to add new fields, follow the steps in Extending union data for variations in the implementation guide.

Extension of additional details

In addition to variation and cost shares extensions, you might need to extend the PCS out-of-the-box capabilities for network, grouper, or benefit-specific data. For these cases, extend the union data (additional details) for network, grouper, and benefit.

Network

The following is the data model of the network additional details in the union data:

• UnionData (Rule-HC-PCS-UnionData)
  • Metadata page of class Embed-HC-PCS-Network

To add properties to the network’s additional details page, follow the steps in Extending union data for networks in the implementation guide.

Grouper

The following is the data model of the grouper additional details in the union data:

• UnionData (Rule-HC-PCS-UnionData)
  • ShortDescription property
  • Metadata page of class Embed-HC-PCS-Grouper

To add properties to the grouper’s additional details page, follow the steps in Extending union data for groupers in the implementation guide.

Benefit

The following is the data model of the network additional details in the union data:

• UnionData (Rule-HC-PCS-UnionData)
  • Metadata page of class Embed-HC-PCS-Benefit

To add properties to the benefit’s additional details page, follow the steps in Extending union data for benefits in the implementation guide..