Extending View Benefits Microjourney

Extending View Benefits Microjourney

Description	Learn how to extend View Benefits Microjourney.
Version as of	8.5
Application	Pega Customer Service
Capability/Industry Area	Healthcare and Life Sciences

The View Benefits Microjourney™ answers questions about a member's coverage. Agents can quickly access critical, personalized information, and focus on the customer's needs. For example, it might be a simple eligibility check or a complex scenario that requires multiple types of coverage information, such as cost share responsibilities, claims, and limits.

Personas, channels, and use cases

The following table shows the personas and channels for each use case in this Microjourney.

Persona	Channel	Use case
Member services representative	Agent-assisted	A member services representative assists health plan members in understanding and using their benefits, for example, whether an authorization is required for a procedure, whether members are covered for a benefit, whether they have visits remaining in the benefit year, or what a member’s cost-share responsibilities are for an upcoming service.
Provider services representative	Agent-assisted	A provider checks whether an authorization is required for a procedure. A provider checks whether a member is covered for a benefit or whether they have visits remaining in the benefit year. A provider checks a member’s cost-share responsibilities for an upcoming service, for example, whether a deductible applies and how much the doctor's office should collect as a co-payment.
Health plan member	Agent-assisted	Members try to understand the cost impact of their provider selection, for example, in-network versus out-of-network, or if their network is tiered. Members want to know whether they are covered for a benefit or whether they have visits remaining in the benefit year. Members check their cost-share responsibilities for an upcoming service, for example, whether a deductible applies and how much the doctor's office should collect as a co-payment.

Data model

Use the Data model page in App Studio to quickly view and understand the relationship between all data objects in the application. You can add, update, and delete data objects without exiting the visual data model. For information about the Data model page, see Data modeling. For information about connecting to external data entities, see Managing data and integrations with the Integration Designer.

The figure shows the entity relationship diagram (ERD) for this Microjourney. For each data object, the ERD shows only the properties that apply to this Microjourney.

Extending the Microjourney

In App Studio, open the View Benefits Microjourney (Case types > View Benefits). Certain rules require switching to Dev Studio in order to update them. App Studio indicates when switching to Dev Studio is required.

Stage 1 - Verify

By default, the Verify stage is set to “skip stage”.

To extend this stage to meet your organization's business needs:

1. Use the DetermineEligibilityToRun decision table to specify individuals who call on behalf of a member, for example, an office manager from the provider service, to launch a case.
2. In App Studio, set the Allow user to bypass verification switch (Tools > Verification) and configure the steps in the stage to include an additional verification step.

Stage 2 - Intake

The Intake stage handles the member searches upon provider request. The D_Search_Member data page retrieves the member information and related plan information. To retrieve data from your own implementation-layer classes for member, subscriber, and plan tables, override the LoadMembersBasedOnSearchCriteria report definition, save the rule into your implementation-layer member class, and update the subscriber, policy, and plan data classes in the Data Access tab of the LoadMembersBasedOnSearchCriteria rule. For more information, see Learning about report definitions.

Note: By default, nothing in Stage 2 applies to member services. This stage is related to provider services only.

Stage 3 – Process request

The Process request stage includes steps to select a benefit to review, display coverage information, display related claims, and review the information with the customer. The steps in this stage can be rerun so that agents can discuss multiple benefits within one interaction.

Benefit selection

The Benefit search step includes both a search and a list of common benefits, which are bookmarked to save agents time. Operators with the role of CS:ExpressMgrTools can define these bookmarks in the Interaction Portal by clicking Application Tools > View Benefits > Configure.

Both the Benefit search and the common benefits configuration tool use a type-ahead search that is populated by the D_BenefitNamesByPlanPurposeAndName data page. Update the data source to point to your plan benefits system of record.

The Benefit search step retrieves the benefits that are bookmarked in the configuration tool by using the read-only D_GetCommonBenefits data page.

Display of coverage information

This step displays rich coverage information to enable highly personalized interactions:

• Plan benefit coverage by network or tier: Information about the selected benefit, such as whether a deductible applies or a copay amount, is retrieved by using the D_BenefitsByPlanAndPurpose data page.
• Benefit usage: Usage accumulators, such as how many times a benefit has been used in a benefit year, are retrieved by the D_Getaccumulatorheader data page.
• Plan level cost shares: Also displays the member’s plan-level cost shares and statuses, such as what types of deductibles are in a plan and how much has been accumulated to date. This information is retrieved by using the D_GetPlanAccumulators data page, which in turn uses the GetPlanLevelAccumulators report definition. If you add other properties, you must update this report definition and the MapAccumulatorsData data transform.

Claims

Claims are retrieved by using the D_FetchClaimsUsingSearchCriteria data page, which should point to an organization’s claims system of record.

Review

If you maintain your history table for auditing the reviewed benefits, use the D_ReviewedBenefitsHistoryList data page to retrieve the benefit summary information that was captured in a specific case or a specified time period.

Stage 4 - Resolve

The Resolve stage completes the inquiry and provides options to send information to the customer. Email is the default setting.

You can modify the IsDistributionMethodEmailcondition when rule in Dev Studio if your organization requires another communication channel. You can also use this stage to extend your workflow if your organization requires a post-inquiry follow-up.

a. Click the Is communication channel selected email step.

b. In the right pane, add a path, and then add the steps that are specific to your routing logic.