Extending the View Benefits Microjourney

Curator Assigned
Request to Publish
Description	Learn how to extend view benefits microjourney
Version as of	8.5
Application	Customer Service
Capability/Industry Area	Healthcare

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View Benefits Microjourney

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 a member’s cost-share responsibilities 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 visitsremaining 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 this is required.

Stage 1 - Verify

By default, Stage 1 - Verify 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, there is nothing in Stage 2 that applies to member services. This stage is related to provider services only.

Stage 3 – Process request

This 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 re-run so that agents can discuss multiple benefits within one interaction.

Benefit selection

The Benefit search step includes both a search and a list 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 copay amount, is retrieved by using the D_BenefitsByPlanAndPurpose datapage.
• Benefit usage: Usage accumulators, such as how many times a benefit has been used in a benefit year, are retrieved by the D_Getaccumulatorheader datapage.
• 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 datapage, which in turn uses the GetPlanLevelAccumulators report definition. If you add other properties, then 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 given case or a specified time period.

Stage 4 - Resolve

This 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.

One of the business outcomes included in a journey.

A business solution that automates workflows in your organization. Multiple, unrelated applications can be hosted in the same system. You create an application by running the New Application wizard.

A program component that defines and implements an interface between an external application acting as a client, and a Pega Platform system acting as a server. An external system can send a request to a Pega Platform application and receive a response.

For example, the Pega Cloud Services SFTP service provides Pega Cloud clients with simple, secure file transfers to and from their Pega Cloud applications.

One of the business outcomes included in a journey.

A work party that typically initiates a case. In many applications, only one customer can be associated with a case.

A user type that might interact with your application. For example, in an application for hiring job candidates, you can create personas that represent a hiring manager and an HR worker. By creating personas, you analyze what people you need to involve in your business process to reach a successful resolution. You also define what channels you need to provide so the users can interact with your application. For example, job candidates can access a recruitment application through a browser-based web channel or through a mobile channel that relies on a mobile app. At the same time, you can set up a second, more utilitarian web channel to accommodate professional users, such as HR workers.

A digital medium through which users access your application. Depending on your business needs, you can set up various channels for the same application. For example, customers can access an application for booking flights through a browser-based web channel, or through a mobile channel that relies on a mobile app. In addition, you can also build a Facebook chatbot for customers who want to ask questions about their booking. At the same time, you can set up a second, more utilitarian web channel to accommodate professional users, such as travel agents. By making an application accessible over several channels, you can reach a wide variety of audiences, and provide each user group with the most appropriate content and user experience.

Actual work that is performed by application users and automations that consists of a sequence of tasks and leads to an intended business goal. An example of a case is a process of hiring a particular job candidate, where an HR worker collects necessary documents, a hiring manager conducts a job interview, and an application sends an automated email with onboarding information after the candidate is approved. To create a case, you first build a template of your business process that is a case type, and then apply the template in multiple cases, for example, to review applications from many candidates.

An internal background process that operates on the server that runs activities on a periodic basis. In a multinode cluster, an agent can run on multiple nodes.

A program component that defines and implements an interface between an external application acting as a client, and a Pega Platform system acting as a server. An external system can send a request to a Pega Platform application and receive a response.

For example, the Pega Cloud Services SFTP service provides Pega Cloud clients with simple, secure file transfers to and from their Pega Cloud applications.

The low-code development environment of Pega Platform.

A business solution that automates workflows in your organization. Multiple, unrelated applications can be hosted in the same system. You create an application by running the New Application wizard.

A collection of entities and attributes that describes the objects that are modeled in an application, and their relationship to each other.

A data structure that holds name-value pairs. Pages are stored in the system memory or in the database. Various types of pages are defined in the system, such as data pages that are created when the data is referenced, named and unnamed pages, parameter pages, clipboard pages, and so on. Every unit of information in an application is a pairing of a name and a value, known as a data element. For example, a data element that stores the email address of a customer has the name "email," and the value "john.smith@company.com." Pages store data elements so that the application can use it to process the case.

A tool that shows all the business objects, data views, object dependencies, and external systems in an application.

The basic building blocks of an application, rules define the behavior of an application. There are many types of rules, each defining a different type of behavior. For example, rules define the display of a form, the fields that are used in your application, and the flows that define the process of completing work.

The system can reuse rules throughout your application. For example, in an application for ordering replacements parts, you can define a user interface to capture an address, and reuse the same rule for the UI to capture both the mailing address and the billing address for the order.

You define rules in an application to create a business solution for your organization and customers. Rules provide flexibility during the development process and help you design applications more efficiently, so that they can be implemented again in future projects.

The first level of organization of the tasks that are required to complete your business process. By providing stages, you organize work into logical phases that users of your application follow to reach an outcome. Stages visualize milestones or significant events in your business process and can also indicate a transition of work from one person to another. For example, if your business process is to review job applications, you can create Submission, Review, and Approval stages, each of which includes a different set of actions and is performed by a different person. Stages that are necessary to resolve a case through the basic, default path are called primary stages.

In a Microjourney™, stages are the milestones that leads towards an outcome.

(Deprecated) A configuration of panels (areas) in a harness that support a composite portal. Existing panel sets continue to function. As a best practice, upgrade panel sets to screen layouts.

The first level of organization of the tasks that are required to complete your business process. By providing stages, you organize work into logical phases that users of your application follow to reach an outcome. Stages visualize milestones or significant events in your business process and can also indicate a transition of work from one person to another. For example, if your business process is to review job applications, you can create Submission, Review, and Approval stages, each of which includes a different set of actions and is performed by a different person. Stages that are necessary to resolve a case through the basic, default path are called primary stages.

In a Microjourney™, stages are the milestones that leads towards an outcome.

The top level of the three-level organization hierarchy that is available for use in all of your applications. The organizational structure affects the management reports, statistics, and rules that are available to users in that organization. One system can support multiple organizations. An organization is an instance of the Data-Admin-Organization class.

A table that consists of one or more rows that contain test conditions and a result to return. Evaluation proceeds from top to bottom; when the conditions in all cells in a row are true, the result of that row is returned. If no row returns a value, the table provides the Otherwise row result. Decision tables are instances of the Rule-Declare-DecisionTable class.

Actual work that is performed by application users and automations that consists of a sequence of tasks and leads to an intended business goal. An example of a case is a process of hiring a particular job candidate, where an HR worker collects necessary documents, a hiring manager conducts a job interview, and an application sends an automated email with onboarding information after the candidate is approved. To create a case, you first build a template of your business process that is a case type, and then apply the template in multiple cases, for example, to review applications from many candidates.

An independent review in a workflow by one person of some part of another person's work (and of the system's work), before that work becomes final. Verification is common in financial workflows involving large dollar amounts or sensitive legal commitments.

An independent review in a workflow by one person of some part of another person's work (and of the system's work), before that work becomes final. Verification is common in financial workflows involving large dollar amounts or sensitive legal commitments.

The smallest element of your business process, a step represents a single task. A step can be a user action, such as collecting information from a customer, or an automation that an application performs, for example, sending an email to a customer when a business process reaches resolution. When you visualize your work, you order steps in a sequence that communicates what actions are required to reach your business objective. You can select from a wide choice of steps to ensure that you reach your goals in the most efficient way.

An entity that you use to cache data on demand to a clipboard page for use by one or more applications. A data page rule defines the source, scope, refresh strategy, editability, and structure of the cached data. Data pages were previously known as declare pages.

(Pega Platform version 7.2.2. and later) A rule for creating advanced reports that show detailed information. Replace the Summary View Rule. A report definition rule provides more advanced options for displaying and managing data than the standard reports that you can create in App Studio.

The rules that define the behavior of your application. You can create classes to gather rules related to a specific object in your application. For example, in a recruitment application, you can create a class that contains rules that define the flow of the recruitment process. Classes can contain other classes, hence a class that contains another class is called a parent class, while a class that is contained by another class is called a child class. A child class can reuse, or inherit, any of the rules that are defined for its parent class, which helps to build your application faster and more efficiently.

The basic building blocks of an application, rules define the behavior of an application. There are many types of rules, each defining a different type of behavior. For example, rules define the display of a form, the fields that are used in your application, and the flows that define the process of completing work.

The system can reuse rules throughout your application. For example, in an application for ordering replacements parts, you can define a user interface to capture an address, and reuse the same rule for the UI to capture both the mailing address and the billing address for the order.

You define rules in an application to create a business solution for your organization and customers. Rules provide flexibility during the development process and help you design applications more efficiently, so that they can be implemented again in future projects.

(Pega Platform version 7.2.2. and later) A rule for creating advanced reports that show detailed information. Replace the Summary View Rule. A report definition rule provides more advanced options for displaying and managing data than the standard reports that you can create in App Studio.

Applications have users, though not all users perform the same tasks. Roles define how users interact with the application by, for example, determining the user interface, page permissions, and routing that are available to a user. For example, in Pega Workforce Intelligence there are several user roles, including administrator, analyst, and report user.

Any source of data that an application uses, such as a connector, report definition, or lookup. Data sources are referenced in data pages.

The primary data source for a data object, such as a connector, external database, or local data storage. For example, for an Employee data object, you might connect to a system of record that populates the data object with employee information fields such as Name, Department, and Start Date.

A digital medium through which users access your application. Depending on your business needs, you can set up various channels for the same application. For example, customers can access an application for booking flights through a browser-based web channel, or through a mobile channel that relies on a mobile app. In addition, you can also build a Facebook chatbot for customers who want to ask questions about their booking. At the same time, you can set up a second, more utilitarian web channel to accommodate professional users, such as travel agents. By making an application accessible over several channels, you can reach a wide variety of audiences, and provide each user group with the most appropriate content and user experience.

The process of assigning tasks in a business process to an individual or group of individuals who are the most capable of completing those tasks.

For example, when creating an expense report, an employee creates the report, a manager approves it, and a payroll employee then sends the payment. To process employee compensation payments, you can route the task to the work queue of the payroll team, in which any member of that team can access, select, and process the work item.

If you need a specific person to work on the assignment, you can route the assignment to a work list. For example, when a human resource manager needs to approve employee time off requests, you can route the assignment to the worklist of the human resources manager.

If you need a person with a particular skill set to work on the assignment, you can route the assignment using business logic to a skilled group by defining a specific condition. For example, in an automobile quote request, a prospective customer fills in a form and selects an Electric vehicle check box. The request is then routed to the electric car insurance underwriters work queue, members of which specialize in electric cars.