Healthcare Claims Workstation+ Application - Pega...Healthcare Claims Workstation+ Appli cation Implementation Guide 2-2 TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt This operator

Healthcare Claims Workstation+ Application

IMPLEMENTATION GUIDE

7.21

Copyright 2016 Pegasystems Inc., Cambridge, MA

All rights reserved.

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Document: Healthcare Claims Workstation+ Application

Software Version: 7.21

Updated: July 2016

http://www.pega.com/

CONTENTS About this Document .................................................................................................................... i

Intended audience ................................................................................................................... i Guide organization ................................................................................................................... i

Healthcare Claims Workstation+ Application Overview ........................................................... 1-1 Your application and Pega 7 ............................................................................................... 1-2

What is Already Set Up ........................................................................................................... 2-1 System administrator account ............................................................................................. 2-1 Application rule ................................................................................................................... 2-2 Ruleset hierarchy ................................................................................................................ 2-2 Healthcare Claims Workstation+ Application rulesets ......................................................... 2-3 Data classes ....................................................................................................................... 2-3 Data tables .......................................................................................................................... 2-6 Work object naming conventions ........................................................................................ 2-7 Predefined organizations, divisions, and units .................................................................... 2-8 Default work groups and workbaskets ................................................................................ 2-8 Default operators and access groups ............................................................................... 2-10 Default portals ................................................................................................................... 2-11 Predefined access roles and privileges ............................................................................. 2-13 Predefined skills on operator records ................................................................................ 2-13 Default service level rules ................................................................................................. 2-14 Correspondence templates ............................................................................................... 2-15 Using and modifying correspondence ............................................................................... 2-15 Healthcare Claims Workstation+ reports ........................................................................... 2-17 Drill-down reporting capabilities ........................................................................................ 2-22 Generating a list of properties ........................................................................................... 2-26 Sample claim files to test the Healthcare Claims Workstation+ Application ...................... 2-26 Testing or demonstrating Claims Workstation................................................................... 2-27 Adding new entries to the PegaHC-Data-SampleClaim Data class .................................. 2-29

Understanding the Healthcare Claims Workstation+ Application ............................................ 3-1 Manage incoming claim file ................................................................................................. 3-1 Manage pended claim ......................................................................................................... 3-4 Assign a line of business to the claim ................................................................................. 3-6 Determine priority claims................................................................................................... 3-14 Determine initial claim urgency ......................................................................................... 3-17 Determine required skills................................................................................................... 3-22 Assign a workbasket ......................................................................................................... 3-24 Process pended claim assignment ................................................................................... 3-28 Audit completed assignments ........................................................................................... 3-44

Claim lookup and transfer ................................................................................................. 3-46

Understanding Business Processing ....................................................................................... 4-1 Claim processor (operator) functions .................................................................................. 4-2

Integrating Healthcare Claims Workstation+ ........................................................................... 5-1 Intake processing for Claims Workstation+ ......................................................................... 5-1 Detecting a duplicate claim ID ............................................................................................. 5-9 Parsing and mapping a claim file ...................................................................................... 5-11 Integrating with a host claims adjudication system ........................................................... 5-12 Integrating with PegaIMAGE Viewer ................................................................................. 5-14

Healthcare Claims Workstation+ Framework Implementation Guide i

Intended audience This guide is intended for those who are deploying and extending the Healthcare Claims Workstation+ Application.

Guide organization This guide contains the following sections:

About this Document

Chapter 1: Healthcare Claims Workstation+ Application Provides an overview of the application

Chapter 2: What is Already Set Up

Describes defaults and samples that are set up and ready for use as a basis for extending the Healthcare Claims Workstation+ Application

Chapter 3: Understanding the Healthcare Claims Workstation+ Application

Provides an in-depth understanding of the important features configured in the application

Chapter 4: Understanding Business Processing

Describes the user processes configured in the Healthcare Claims Workstation+ Application

Chapter 5: Integrating Healthcare Claims Workstation+

Describes the fundamental processes involved in processing incoming claims

Healthcare Claims Workstation+ Application Implementation Guide 1-1

The Healthcare Claims Workstation+ Application is a healthcare claims workflow and inventory management application that extends the power of your core claims processing systems. Through flexible work queue (workbasket) design, claim prioritization, processor skill set matching, and automated work delivery, Claims Workstation+ brings tremendous operational efficiencies in your day-to-day claims operations. It provides your management team with improved visibility and control over your organization’s claims management activities and streamlines the claim processors’ tasks.

Claims processing tends to require operations that are manual and paper-oriented — claims managers manually distribute work items to their staff, who manually retrieve claim images and mark each work item as it is completed. This type of process can lead to:

Lack of management control and limited visibility into the claim processing (processors avoiding difficult work items, for instance)

Complex, haphazard work distribution; the inability to dynamically route work

Increasing backlogs of pended claims and reduced compliance with Service Level Agreements (SLAs)

Greater number of duplicated, inaccurate, and overdue claims

With Claims Workstation+, real-time queue management capabilities enable your organization to react to changes quickly and efficiently, eliminating lapses in productivity. Key features include:

Claim Work Object Creation — Manages the lifecycle of the pended claim and allows many tasks to be associated with its management, such as correspondence generation, prioritization and escalation, routing, and service and level management.

Flexible Workbasket (work queue) Generation — Provides the ability to create workbaskets on multiple business parameters such as line of business, claim type and separate queues for employee claims.

Claim Auto-Fetch and Display — Automates work retrieval according to predefined queues to prevent “cherry-picking” of claims by processors. This automation leads to increased compliance with SLAs, resulting in fewer or no late payment penalties and improved timeliness statistics.

Skill- and Rules-Based Routing — Dynamically routes work to claim processors based upon their skill set and the routing logic defined by your organization’s business rules. Claims can be prioritized to react to aggressive SLAs, customers with urgent requests, or other specific criteria. For example, when a preferred provider calls with an urgent request, managers can pull all claims for that provider and re-prioritize them for immediate action.

Healthcare Claims Workstation+ Application Overview


TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt

Correspondence Generation — Automatically generates personalized correspondence and sends it by e-mail, fax, or postal mail.

Management Control and Reporting — Provides extensive reporting capabilities and a standard suite of reports to measure throughput, productivity, compliance, and more. Management can dynamically view and respond to specific claim issues or staffing concerns.

Claims Workstation+ runs in the Pega 7 environment — a business process management platform that dynamically integrates both process and practice rules — and is presented through Microsoft Internet Explorer to provide a familiar, cost-effective user interface. Any necessary software or ActiveX controls are automatically downloaded when first required.

The majority of downloaded ActiveX controls are for developers. Some ActiveX controls depend on the task being performed, such as editing during correspondence generation. If your organization does not allow this capability, ActiveX controls are not downloaded.

Your application and Pega 7 Pega 7 contains a rules engine, database, processing logic, and functions — providing the base upon which the Pegasystems applications are built. Pegasystems applications are layered, making use of underlying technology instead of reinventing process flows. Additional flows and rules are contained in the Application layer and support application-specific functions (such as contact management or customer service). The rules you modify when extending the application are at the top level, as they supersede the Application defaults.

Because the Pegasystems applications all share the same underlying technology, configuration processes (such as creating accounts and copying rules) are identical to those in Pega 7.



You can use the application rulesets as a starting point for extending the application, making it specific to your organizational needs.


This chapter describes defaults and samples that are set up and ready for use. It is expected that you use these as a basis for extending the Healthcare Claims Workstation+ Application. The topics include:

System administrator account

Application rule

Ruleset hierarchy

Data classes

Data tables

Work object naming conventions

Predefined organizations, divisions, and units

Default work groups and workbaskets

Default operators and access groups

Default portals

Predefined access roles and privileges

Predefined skills on operator records

Default service level rules

Correspondence templates

Healthcare Claims Workstation+ reports

Reporting gadgets

Drill-down reporting capabilities

Sample database model

Sample claims files to test Claims Workstation+

Creating sample Claims Workstation+ inventory

System administrator account The Healthcare Claims Workstation+ Application uses the following operator ID as the default system administrator account.

Operator IDs are not case-sensitive, but passwords are case-sensitive.

What is Already Set Up



This operator ID gives you access to all the Healthcare Claims Workstation+ Application functions.

Operator ID: CWSAdministrator@MyHealthPlan

Password: install

Healthcare Claims Automation Suite: The suite also contains an alternative Administrator Operator Record, CLMAdministrator@MyHealthPlan with a password of install, belonging to the CLM: Administrator Access Group.

These rules are configured for use when the Healthcare Claims Automation Suite is installed on the system.

Application rule The Healthcare Claims Workstation+ Application contains application rules. The application rules define an ordered set of rulesets and versions that together identify the parts of the layers of the application. In addition, application rules relate the application's objectives, use cases, and actors to objects created as part of the Direct Capture of Objectives capabilities. The access groups (listed later) are associated with specific application rules.

The Healthcare applications use the following numbering convention for the application rules – xx-yy-zz (for example, CWS 07.05.61) where:

xx – relates to the major version of the application

yy – relates to the minor version of the application

zz – relates to the Pega version on which the application is supported

Healthcare Claims Automation Suite: The application rule for the suite is called CLM and contains all the required rulesets for Healthcare Claims Repair and Healthcare Claims Workstation+ applications.

Ruleset hierarchy You can view a list of the rulesets in the application by selecting the Designer Studio > Application > Structure > RuleSet Stack landing page option.

The RuleSet Stack tab displays the high-level ruleset stack for each application rule defined in the application. Expand an application to list its rulesets.



Healthcare Claims Workstation+ Application rulesets The Healthcare Claims Workstation+ Application rulesets include:

PegaHCCWSLP — rules that specifically pertain to the Claims Workstation landing page.

PegaHCCLMWorkstation— rules that specifically pertain to the Claims Workstation+ functionality.

PegaHCCLM5010 — rules that specifically pertain to the 5010 claims functionality.

PegaHCCLM — the common claims processing rules that are used in Healthcare Claims Workstation + Application as well as the Healthcare Claims Repair Application.

PegaHC — the common healthcare application rules that would be used for any healthcare application. Required for all healthcare functions. The Healthcare Claims Automation Suite shares many of the classes from this ruleset for common objects such as member, provider, and claim. Additionally, PegaHC also contains rules associated with processing X12 messages.

PegaX125010 — rules for X12 5010 functionality.

PegaHealthCodes — rules supporting use of healthcare codes.

Review the PegaRULES application rule to view a complete list of the Pega 7 rulesets.

Data classes Data classes define the data structures for supporting information that the application uses to process work. All the data classes shown below are leveraged from the PegaHC layer of the Healthcare Industry Application (HCIF). Some of the data classes may not be relevant to claims processing but are included below to complete the list.

HCIF and the Healthcare Claims Automation Suite use some of the data classes to store instances of sample data shipped along with the applications.



To extend PegaHC-Data- classes to provide a destination for the results of data input other than what is being provided by the Healthcare Claims Workstation+ Application, use the interfaces to existing data systems. The PegaHC-Data- classes identify data sources and other key variables. To extend one of these PegaHC-Data- classes, open the class form and save it to your ruleset.

The available PegaHC-Data- classes are listed below.

Class Repository for: Instances Included?

PegaHC-Data-Attachments Claim attachment information N PegaHC-Data-Authorization Authorization (referral) information Y PegaHC-Data-BatchList Batch list information for prepay edits N PegaHC-Data-BatchStatistics Batch Statistics for Claims repair processing N PegaHC-Data-Benefit Benefits information N PegaHC-Data-BenefitGroup Benefit group information N PegaHC-Data-Claim Claim header information Y PegaHC-Data-ClaimConditionCodes Claim condition code information N PegaHC-Data-ClaimLine Claim line information N PegaHC-Data-ClaimOccurrenceCodes Claim occurrence code information N PegaHC-Data-ClaimPendCodes Pend code listing on claim header and line N PegaHC-Data-ClaimProcedureCodes Facility Claim header level procedure code information N PegaHC-Data-ClaimSpanOccurrenceCodes Claim occurrence span code information N PegaHC-Data-ClaimStatusCategoryCodes Claim status category code information Y PegaHC-Data-ClaimStatusCodes Claim status code information N PegaHC-Data-ClaimTreatmentCodes Claim treatment code information N PegaHC-Data-ClaimValueCodes Claim value code information N PegaHC-Data- EligibilityRequest Eligibility request information N PegaHC-Data-Enrollment Member enrollment information – not likely to be used in

claims N

PegaHC-Data- Issues Issues information N PegaHC-Data- LabResults Lab results information N PegaHC-Data-Language Language code and description Y PegaHC-Data-Measurement Measurement information N PegaHC-Data-MedicalHistory Information about the medical history N PegaHC-Data-Notes Notes information Y PegaHC-Data-Party Common demographic information to work parties N PegaHC-Data-Party-Agency Sales Agency information (not likely to be used in claims) N PegaHC-Data-Party-Broker Sales Broker information (not likely to be used in claims) N PegaHC-Data-Party- Company Company information Y




PegaHC-Data-Party-InformationReceiver Details of the receiver of information N PegaHC-Data- Party-InformationSource Details of the source of information N PegaHC-Data-Party-Member Subscriber / Member / Patient information Y PegaHC-Data-Party-Payer Healthcare Industry Foundation (COB) information N PegaHC-Data-Party-PlanSponsor Employer Group information N PegaHC-Data-Party-Provider Provider (physician, facility) information Y PegaHC-Data-Payment Claim and health insurance premium payment information N PegaHC-Data-Payment-Claim Claim payment information N PegaHC-Data-Payment-Premium Health insurance premium payment information (not likely to

be used in claims N

PegaHC-Data-Policy Health insurance Policy information Y PegaHC-Data-Population Population information N PegaHC-Data-Prescription Prescription information N PegaHC-Data-Procedure Procedure information N PegaHC-Data-Product Benefit Product information (not likely to be used in claims) Y PegaHC-Data-RemarkCodes Claim Remark Code information Y PegaHC-Data-Risk Risk information N PegaHC-Data-Service Healthcare service related information – Claim, ClaimLine,

and Authorization inherit from this class since they share many common properties

N

PegaHC-Data-ToothCodes Tooth codes used in dental claims Y PegaHC-Data-PPECCI Pre Payment Correct Coding Initiative Edit’s Code sets from

CMS (Sample codes) Y

PegaHC-Data-PPEMEE Pre Payment Mutually Exclusive Edits Code sets from CMS (Sample codes)

Y

PegaHC-Data-PPEMUE Pre Payment Medically Unlikely Edits Code sets from CMS (Sample codes)

Y

PegaHealth-Codes-Data-CodeGroup Code group information Y PegaHealth-Codes-Data-CPT CPT codes Y PegaHealth-Codes-Data-Diagnosis-ICD10 Diagnosis codes (ICD10) Y PegaHealth-Codes-Data-Diagnosis-ICD109Map

ICD 10 to 9 mapping of diagnosis codes Y

PegaHealth-Codes-Data-Diagnosis-ICD9 Diagnosis codes (ICD9) Y PegaHealth-Codes-Data-Diagnosis-ICD910Map

ICD 9 to 10 mapping of diagnosis codes Y

PegaHealth-Codes-Data-GCN GCN codes Y PegaHealth-Codes-Data-HCPCS HCPCS codes Y PegaHealth-Codes-Data-NDC NDC codes Y




PegaHealth-Codes-Data-Procedure-ICD10 Procedure codes (ICD9) Y PegaHealth-Codes-Data-Procedure-ICD109Map

ICD 10 to 9 mapping of procedure codes Y

PegaHealth-Codes-Data-Procedure-ICD9 Procedure codes (ICD9) Y PegaHealth-Codes-Data-Procedure-ICD910Map

ICD 9 to 10 mapping of procedure codes Y

Data tables Some data table classes contain sample instances. You can view and maintain the table and the instances by selecting Designer Studio > Data Model > Data Tables > Data Tables.

The PegaHC-Data- data tables listed below contain sample instances.

To view and edit the instances of these data classes, click the edit data icon to the right of data class.



The following is a partial listing of the PegaHC-Data-ClaimStatusCodes class.

HCIF provides many sample data instances for the commonly referenced objects that are used in processing the sample claim files included in the application. See the Healthcare Industry Application Installation and Deployment Guide included in your media for a listing of the sample data instances as well as mechanisms to maintain the data instances to suit your testing and demonstration needs. The following data classes contain the instances for the sample data:

PegaHC-Data-Authorization

PegaHC-Data-Claim

PegaHC-Data-Party-Member

PegaHC-Data-Party-Provider

PegaHC-Data-Policy

Work object naming conventions There are three primary types of work objects: basic work objects, covers, and folders. Applications use basic work objects; some, but not all, may use covers or folders.

Work objects capture and process information about an individual unit of work.

Covers tightly coordinate processing of one or more distinct, but closely related, work objects. The system normally resolves a cover work object after all its component work objects are resolved.

Folders hold one or more work objects (which can be basic work objects, covers, or other folders). In contrast to covers, the relationship between folders and work objects and their contents may be many-to-many. One work object may be associated with multiple folders, but only one cover. When your application initiates a work object, a predefined model populates key property values (such as urgency) that directly affect the work object. As work



objects progress towards resolution, core property values such as priority and status are continually updated to reflect the current stage of processing.

Each work object has a unique ID that is computed by combining a system-assigned number and a prefix defined in a pyDefault Model in the PegaHCCLM RuleSet. For example, CLM-1003 is a work object related to Claims Workstation.

Ruleset: PegaHCCLM

Class: PegaHC-CLM-Work-Claims

Class Group: PegaHC-CLM-Work

PegaHC-CLM-Work serves as a work pool class.

Claim work objects are stored in the HC_CLAIMS_WORK database table. The claim work object created and used in the Healthcare Claims Workstation+ Application is the same as the one used in the Healthcare Claims Repair Application. This allows you to manage the entire lifecycle of the claim if both applications are being used. The claim work object ID has the prefix “CLM” and is automatically generated by the system during the intake process. You can change this prefix or create additional prefixes by copying the default model to your ruleset and making your changes.

Predefined organizations, divisions, and units The Healthcare Claims Workstation+ Application comes with the following predefined organization, division, and units.

Organization: MyHealthPlan Division: Claims

Units:

FEP HMO Indemnity ITS Medicaid

Medicare NASCO Other POS PPO Secure

Default work groups and workbaskets The initial routing of pended claims to a specific workbasket is driven by a combination of parameters: identifying claims for your own employees, line of business (Inter-Plan Teleprocessing Services (ITS), FEP, National Account Service Company (NASCO), Medicare, HMO, PPO, POS) and claim type (Professional or Institutional). Routing for the health plan’s own employees is also handled separately to maintain privacy and security.



All the preconfigured Healthcare Claims Workstation+ Application workbaskets have the following:

End with the Suffix — ‘@MyHealthPlan’

Belong to the Organization — MyHealthPlan

Belong to the Division — Claims

Belong to the Workgroup — Claims@MyHealthPlan

The following table lists the default workbaskets and organization units found in the application. The Org Units for the workbaskets, shown below, are different.

Workbasket Org Unit ClaimsAuditor@MyHealthPlan Other ClaimsCOB@MyHealthPlan Other ClaimsMedicalReview@MyHealthPlan Other ClaimsMemberBenefits@MyHealthPlan Other CustomClaims1@MyHealthPlan Other CustomClaims2@MyHealthPlan Other CustomClaims3@MyHealthPlan Other DuplicateClaimID@MyHealthPlan Other EmployeeHMOInstitutional@MyHealthPlan Secure EmployeeHMOProfessional@MyHealthPlan Secure EmployeeMedicareInstitutional@MyHealthPlan Secure EmployeeMedicareProfessional@MyHealthPlan Secure EmployeeOtherInstitutional@MyHealthPlan Secure EmployeeOtherProfessional@MyHealthPlan Secure EmployeePOSInstitutional@MyHealthPlan Secure EmployeePOSProfessional@MyHealthPlan Secure EmployeePPOInstitutional@MyHealthPlan Secure EmployeePPOProfessional@MyHealthPlan Secure FEPInstitutional@MyHealthPlan FEP FEPOther@MyHealthPlan FEP FEPProfessional@MyHealthPlan FEP HMOInstitutional@MyHealthPlan HMO HMOOther@MyHealthPlan HMO HMOProfessional@MyHealthPlan HMO ITSInstitutional@MyHealthPlan ITS ITSOther@MyHealthPlan ITS ITSProfessional@MyHealthPlan ITS MedicalDirector@MyHealthPlan Other MedicareInstitutional@MyHealthPlan Medicare



Workbasket Org Unit MedicareOther@MyHealthPlan Medicare MedicareProfessional@MyHealthPlan Medicare NASCOInstitutional@MyHealthPlan NASCO NASCOOther@MyHealthPlan NASCO NASCOProfessional@MyHealthPlan NASCO OtherInstitutional@MyHealthPlan Other OtherOther@MyHealthPlan Other OtherProfessional@MyHealthPlan Other PendingVerification@MyHealthPlan Other POSInstitutional@MyHealthPlan POS POSOther@MyHealthPlan POS POSProfessional@MyHealthPlan POS PPOInstitutional@MyHealthPlan PPO PPOOther@MyHealthPlan PPO PPOProfessional@MyHealthPlan PPO

Default operators and access groups The following table contains the operators and access groups in Healthcare the Claims Workstation+ Application. All passwords are set to install.

Operator ID Full Name Access Group CWSAuditor@MyHealthPlan Claims Auditor CWS:Auditor CWSCaseManager@MyHealthPlan Nurse Case Manager CWS:CaseManager CWSJunior1@MyHealthPlan Junior Claims Examiner 1 CWS:JuniorExaminer CWSJunior2@MyHealthPlan Junior Claims Examiner 2 CWS:JuniorExaminer CWSManager@MyHealthPlan Claims Manager CWS:Manager CWSMedicalDirector@MyHealthPlan Medical Director CWS:MedicalDirector CWSSecure2@MyHealthPlan Secure Claims Examiner 2 CWS:SecureExaminer CWSSenior1@MyHealthPlan Senior Claims Examiner 1 CWS:SeniorExaminer CWSSecure1@MyHealthPlan Secure Claims Examiner 1 CWS:SecureExaminer CWSSenior2@MyHealthPlan Senior Claims Examiner 2 CWS:SeniorExaminer CWSSupervisor@MyHealthPlan Claims Supervisor CWS:Supervisor CWSClaimLoader@MyHealthPlan Claims Load - System Agent CWS:Administrator CWSAdministrator@MyHealthPlan Claims System Administrator CWS:Administrator



Default portals The Healthcare Claims Workstation+ Application includes different portals for claims processors, managers, supervisors, and the system administrator. The following is a list of pre-configured portals.

Portal Portal Type Tabs

CWSDeveloper Developer N/A CWSManager Manager Dashboard / Work / Reports CWSUser User Work CWSClaimsExaminer User Work CWSClaimsAuditor User Work

Administrator Portal



Manager Portal

User Portal



Personalizing of dashboard and My Work by using widgets and slots

1. Click the Gear icon open the Edit dashboard panel.

2. Click Switch template, and then select a template based on the number, size, and relative position of slots to display.

3. Add widgets to each slot in your template.

4. In the Edit dashboard panel, click Add widget next to the slot that you are configuring.

5. Select the check box next to a widget to include in the slot.

6. Click Add selected.

7. Drag the widget to change its position in the slot.

8. Click Publish to publish your dashboard for personal use. 9. Click Publish to default for default users.

Gear Icon:



Switch Template:

Add widgets: We have created some widgets which are specific to Claims automation suite. We can choose any widget for this list.



Publish or Publish to default:

SYSTEM-USER-DASHBOARD: A DB record will be created at backend, on publishing the customizations done.

Predefined access roles and privileges The application includes a set of predefined access roles and privileges.



Aud

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Man

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Dire

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Privileges CWSActionComplete x x x x x x x CWSActionHold x x x x x x x CWSActionNotify x x x x x x x CWSActionReassign x x x CWSSetClaimNote x x x x x x x x x CWSActionSetOwner x x x CWSActionTransferCOB x x x x x x CWSActionTransferManager x x x x x x x CWSActionTransferMedicalDirector x x CWSActionTransferMedicalReview x x x x x x x CWSActionTransferMemberBenefits x x x x x x CWSActionTransferOwner x x x x x x x CWSAuditReview x

Predefined skills on operator records The Get Most Urgent process used by Claims Processors to pull the next available claim to work on uses the operator’s skill to determine if the claim is appropriate for the operator.

The following skills and skill levels are configured for each of the operators in the application.

Skill and Skill Rating

Operators General Benefits COB Medical Review Provider

CWSManager 10 10 10 10 10 CWSSupervisor 10 10 10 10 10 CWSJunior1 10 10 5 5 10 CWSJunior2 10 10 5 5 5 CWSSenior1 10 10 10 10 10 CWSSenior2 10 10 10 10 10 CWSSecure1 10 10 10 10 10 CWSSecure2 10 10 10 10 10 CWSAuditor 10 10 10 10 10 CWSCaseManager 10 10 CWSMedicalDirector 10



Default service level rules This table contains the default service level rules that come with the Healthcare Claims Workstation+ Application, along with the default goals, deadlines, and activities.

Key Description

Goal / Deadline

Days Goal Activity

Deadline Activity

CWSAutoHoldProviderLetter Applied when a Provider Letter is sent manually

15 / 25 CorrNew UpdateStatus

CWSHoldOther Applied when an operator holds a claim for "other" reason; operator can specify goal/deadline times

15 / 25 SendEmailToAssigneeOnGoalTime

SendEmailToAssigneeOnDeadlineTime

CWSHoldPendingPatientEligibility Applied when an operator holds a claim pending Patient Eligibility information.



CWSHoldPendingProvider Applied when an operator holds a claim pending Provider information.



CWSHoldPendingSubscriber Applied when an operator holds a claim pending Subscriber information.



CWSProcessAssignment Default Assignment SLA.

15 / 30 Urgency +5 Urgency +10

CWSWork Default Work SLA 15 / 30 Urgency +5 Urgency +10

Correspondence templates The Healthcare Claims Workstation+ Application comes with both correspondence templates and fragments. Templates are defined as instances under Rule-Obj-Corr. Fragments are defined as instances of Rule-Corr-Fragment and are used in compiling correspondence templates. The Healthcare Claims Workstation+ Application comes with a set of sample



correspondence templates and fragments. The following table contains the templates that come with the application. These templates are defined under PegaHC-Claims-Work.

Correspondence Name Label/Description RequestAdditionalMedicalInfo Request additional medical information RequestAdditionalMedicalInfoTickler Request additional medical information (reminder) RequestAdditionalPatientInfo Request additional patient information RequestAdditionalPatientInfoTickler Request additional patient information (reminder) RequestAdditionalProviderInfo Request additional provider information RequestAdditionalProviderInfoTickler Request additional provider information (reminder) ClaimReferenceInfo Fragment rule containing HTML for the claim reference information Footer Fragment rule containing Footer (signature, etc.) for letters HeaderSubscriber Fragment rule containing Header (salutation, address, etc.) for

subscriber letters HeaderRenderingProvider Fragment rule containing Header (salutation, address, etc.) for

rendering provider letters Logo Fragment rule containing the Logo image use don letter templates Stylesheet Fragment rule applying stylesheet to letter formatting

Using and modifying correspondence The Create Correspondence processing option in the workflow uses the pre-configured correspondence templates. Copy the appropriate rules to the production work class and modify them as necessary.

Some correspondence rules are called top-level rules (indicated on the Prompts tab of the rule form). Master templates are based on a top-level correspondence rule and can include other rules or references to other rules. The correspondence type — whether email, mail, phone, or fax — is defined in the top-level correspondence rule when it is created.

The rules define various correspondence segments such as the header, footer, and body. Each segment (or stream) provides a piece of the HTML code needed to generate a complete piece of correspondence. The advantage of defining Correspondence fragments as separate rules is that they can be re-used in many correspondence templates. Because the correspondence is HTML-based, it lets you create a professional look and feel to letters, emails, and faxes that are sent to customers and banks.

Emails are generated through capabilities built into Pega 7. The routing, printing, and faxing of correspondence are handled by interfacing with the PegaDISTRIBUTION MANAGER. However, it is not necessary to have the PegaDISTRIBUTION MANAGER installed when updating and testing changes to the templates. Correspondence is generated, attached to the case, and can be reviewed online in its printed form. It does not print until the interface is active.

http://se45001:8080/ixbdev/PRServlet?pyActivity=Rule-Query-List.List&Class=Rule-Obj-Corr&ListName=RuleList&PageName=pyQueryResultPage&SF1=%22PegaCheck-Adj-%22&ST1=&queryCategory=QueryRules&queryName=ByBaseClass&pyQueryTimeStamp=20030404T124954.566+GMT&pyShowWindowHeader=true&Refresh=N&SortBy=pyLabel



To copy and customize the templates in your ruleset, maintain the same Correspondence Rule name to avoid unnecessary updates to workflow elements that call specific templates. Add templates only when no alternative is available.

The following is an example of the correspondence generated by the application.

Healthcare Claims Workstation+ reports A wide variety of standard reports and graphs are available and provide the breadth and depth of information necessary to understand and respond quickly to your organization’s dynamic operations. Features include full drill-down capability, rapid report generation, and customization tools that enable you to create your own reports using familiar drag-and-drop techniques. This chapter describes the reporting capabilities available and covers the following topics:



Reporting gadgets

Drill-down reporting capabilities

Reporting gadgets Access to reports and reporting tools depends on your role and privilege level. The Dashboard bar provides access to realtime Claims Inventory Reports for the claims managers and supervisors.

Dashboard reports The Claims Manager’s Dashboard provides a realtime view into the claims inventory. The four reports available on the dashboard are:

Claims Inventory Aging

Aging Inventory by line of business (LOB)

Workbasket Inventory Summary

Aging Inventory by Hold Code

Reports tab In addition to the standard Pega 7 reports on Processes, Process Assignments, Process Quality, and Process Performance, the Claims Processing gadget contains reports customized for the Healthcare Claims Workstation+ Application.

Report Description Batch Statistics Report on key batch processing statistics Operator Statistics Report on operator’s productivity by day Operators By Workbasket Report to view the operators assigned to a selected workbasket and the rank

of the workbasket on the operator’s profile Claims on Hold List of claims that has been put on hold by claims processors Claims Inventory Aging Aging inventory of claims assignments Claims Inventory Aging By Line of Business

Aging inventory of claims assignments by LOB

Workbasket Inventory Summary Claims inventory reported by the workbasket that the claim is assigned to

Batch Statistics report This report provides a summary of the batches of claims that were submitted for processing. The data for this report is stored the HC_CLAIMS_BATCHSTATISTICS.



Operator Statistics report This report provides daily productivity metrics for the claims processors. The report has two views:

Claims Processor View

Claims Manager / Supervisor View

Each claims processor can view their productivity metrics in the My Productivity section of the My Work screen.

Claims Managers and supervisors can review the productivity statistics for all the processors that report to them or select a specific operator record or date to review.



Operators by Workbasket report This report allows the managers and supervisors to select a workbasket and see the claims operators that have been assigned to the workbasket. The report also provides the workbasket priority (ranking) on a specific operator profile.

Along with the workbasket inventory report, the claims manager can use this report to ascertain the amount of work sitting in a given workbasket and whether or not there are enough operators assigned to the workbasket to be able to handle (process) the inventory in a timely manner.

This report lists all the workbaskets. When you click on a workbasket, it drills down and retrieves all the operators related to the workbasket



Claims on Hold report This report provides a list of the claims that are on hold. It provides:

The name of the operator that the put the claim on hold

The expected date of release

The number of days remaining to release the claim based on the service level that was assigned to the assignment when the claim was put on hold

Claims Inventory Aging report This report provides a realtime view into the aging of the claims inventory.



Claims Inventory Aging by Line of Business report This report provides a realtime view into the aging of the claims inventory by LOB.

Workbasket Inventory Summary report This report provides a realtime view into the aging of the claims inventory by workbaskets to which they are assigned.



Drill-down reporting capabilities Claims Inventory reports incorporate a powerful drill-down structure of report data that enables you to move from a summary or executive view of the information down to the details of a single claim.

Selecting the report Select a report from the Management Reports workspace. The following is an example of the Workbasket Inventory Report.



When you select a report, the associated graph (if any) appears at the top of the report display.

You can export report data to an .xls file by clicking Export to Excel at the top of a report window.

If a line item represents a total of underlying subcategories, you will see a “+” at the beginning of the line.

Drilling down to detail To drill down to a detailed report from a summary report:

10. Click the + and - prefixes to expand and contract individual rows of the summary report, or click the Expand All link at the top to view the entire breakdown of subcategories such as individual business units or products.

11. Click a line of the summary report to drill down to the associated detail list.



12. Click an individual item to drill down to view the claims details as shown below.



Sample database model

The Healthcare Claims Workstation+ Application comes with pre-configured database tables. You can use the sample database tables as delivered without additional configuration, or you can add or modify the data to meet your needs.

To view database table information:



Do one of the following:

Click the number following the Columns in this table to view a table of database columns along with their data type and size.

Click the number in the Properties Set to be visible column to view a detailed table of database properties.



Consult your database administrator to customize and tune the database tables for optimal performance.

Generating a list of properties You can create a list of properties from the Healthcare Claims Workstation+ Application using standard rule reports.

To generate a list of properties:

1. Click the Monitor Activity sliver (facility) on the Developer portal.

2. In the Rule Reports section of the workspace, click the Rules per RuleSet, Version Rule Type.

3. Select Class (pyClass) from the Field list, leave the Condition set to Is Equal, and enter Rule-Obj-Property in the Value field.

4. Click Submit.

A report displays the grand total of rules of class Rule-Obj-Property in all rulesets.

5. Click the + sign to expand the ruleset you want to examine.

6. Optionally, you can click Export to Excel to export the data to a spreadsheet-format file.

Sample claim files to test the Healthcare Claims Workstation+ Application The Healthcare Claims Workstation+ Application accepts pended claim files in the XML format. Sample files to test or demonstrate the application are stored in Pega 7 as Rule-File-Text instances. This facilitates packaging the samples for easy installation. Additional details on the intake, parsing, and initial workbasket routing of these claim files is provided in Chapter 5.

The following is a list of pre-configured XML samples for testing and demonstrating the application. The claim file names are also the names of the Rule-File-Text instances and follow the naming convention cwsxx such as cws10 and cwsBatch10.



cwsbatch10HMOI (Batch of 10 claims - Employee and Other LOB Institutional Claims with varying Skills)

cwsbatch10POSI (Batch of 10 claims - Institutional Claims with varying LOBs and Skills)

cwsbatch10HMOP (Batch of 10 claims - Employee and Other LOB Professional Claims with varying Skills)

cwsbatch10POSP (Batch of 10 claims - Professional Claims with varying LOBs and Skills)

Testing or demonstrating Claims Workstation As mentioned earlier, the application contains sample XML claim batch files that can be loaded into the system to create a working inventory of pended claims. All sample claim files are stored as Rule-File-Text instances with the xml extension.

Loading sample claim batch files To load sample XML claim batch files to create a working inventory of claims:

1. Log in as the CWSManager@MyHealthPlan with the password install.

2. Click Demo Claims in the left navigation pane.

3. From the Scenario drop-down list, select an appropriate scenario with a batch of claims and click Run.

This picks up the relevant batch file from the system, parses it and launches the flow for processing the pended claims. Once the processing is complete, the application displays the Claims Processing Summary confirmation screen showing key statistics of the processed



batch file as well as a listing of the claims within the batch – (the original claim number, Pegasystems work ID, and the workbasket to which the claim was routed and the status).

4. Click the Work Item ID to display the claim in a read-only mode.

5. Click Process Claim to open the relevant flow action, for a claim that is routed to a workbasket. If the claim is resolved, the Process Claim button is not visible.



6. Click the workbasket name to display the list of assignments in the selected workbasket.

Adding new entries to the PegaHC-Data-SampleClaim Data class The PegaHC-Data-SampleClaim data class holds the data entries for different claim batch scenarios. To add entries in the local storage for PegaHC-Data-SampleClaim

1. In the Data Explorer, open the PegaHC-Data-SampleClaim data class.



2. Click Records in the left navigation pane.

3. Click on the + icon to add an entry with details of the sample demo claim.

4. Enter values for the following:

Field Description DemoClaimID Identifier for the demo claim DemoClaimDescription Short description of the sample DemoClaimFileName Name of the Rule-File-Text which contains the claim data DemoclaimName Display name of the Demo Claim Name DemoClaim Type Specifies the type of claim: P for Professional and I for Institutional Scope Flag to check which adjudication to occur on submitting demo claim. Enter

“CWS” XMLOrEDI Indicates whether the demo claim is XML or X12 standard. If XML enter “XML”; if

EDI, enter “EDI”

5. Create a text file with the data for the scenario to be created.

Use the value for the DemoClaimFileName as used in step 4.

Enter webwb for the App Name (Directory).

For File Type, enter XML if file type is XML or EDI if file type is EDI

6. Click Create and open the text file rule.

7. Copy the Claim content (XML or EDI) to the text file and click Save.

8. Open the Manager Portal.

9. In the left navigation pane, click Demo Claims.



The new DemoClaimName appears in the Scenario drop-down list.

10. Select the new scenario from the drop-down list and click Run to execute the scenario.

You can see that the sample demo claim is processed and the claim file summary is displayed.


This chapter provides an in-depth understanding of the important features configured in the application. It provides a description of the process, screenshots of key rules, lists the key rules, and provides design and customization tips. The features described in this chapter include:

Manage incoming claim file

Manage pended claim

Assign claim line of business

Determine priority claims

Determine initial claim urgency

Determine required skills

Assign a workbasket

Process pended claim assignments

Audit completed assignments

Claim lookup and transfer

Manage incoming claim file The Claims Workstation+ Application provides an XML claim batch input and parsing mechanism that is described in detail in Chapter 5, Integrating Claims Workstation+.

When the incoming claim file is parsed, every claim is processed by the main high-level flow, CWSManageIncomingClaim.

Understanding the Healthcare Claims Workstation+ Application



The first step of the Incoming Claim process determines whether the incoming claim is finalized. This is a placeholder step if the application is extended to include finalized claims processing.

Tip: Use this step as a starting point placeholder to extend the application to include a separate finalized claim feed to synchronize the claims inventory in Pegasystems and the host claims adjudication systems.



The main flow also sets up work parties and correspondence preferences for the key parties on the claim object: Billing Provider, Rendering Provider, Subscriber, and Patient.



The flow assigns an overall SLA called CWSWork to the work object. The overall SLA is stored in the pyDefault model for the work object.

Key Rules for Manage Incoming Claim The key rules used in the high-level incoming claim management process are listed below.

Rule Name Rule Type

Function

CWSManageIncomingClaim Flow High-level flow to manage incoming claim file ClaimIsFinalized When Determines if claim is finalized (not pending) CWSCorrSetup Activity Sets up parties for the claim work object MapBillingProviderParty Activity Creates a work party and sets correspondence preference MapRenderingProviderParty Activity Creates a work party and sets correspondence preference MapSubscriberParty Activity Creates a work party and sets correspondence preference MapPatientParty Activity Creates a work party and sets correspondence preference CWSWork SLA Overall SLA for the claim work object

Manage pended claim After the initial management of the incoming claim file, the CWSManageIncomingClaim flow calls the CWSManagePendedClaim flow. CWSManagePendedClaim begins the process of routing the claim to an appropriate workbasket.





The key aspects of the initial claim routing are managed by subprocesses in the main flow. These key aspects are as follows:

1. Determine and assign a claim line of business (including own employee claims, which can be processed separately to ensure security and privacy).

2. Determine priority contracts (employer and provider groups).

3. Determine claim age and assign initial urgency.

4. Determine and assign the skills that the claims processors will need to process the claim.

5. Determine the appropriate workbasket for the claim.

6. Route the claim to the appropriate workbasket.

The main flow also contains a spin-off flow to randomly flag certain processed claims for audit. Refer to Audit Complete Assignments for details.

Key rules for pended claim work object The key rules used in the high-level management of the pended claim work object are listed below.

Rule Name Rule Type

Function

CWSManagePendedClaim Flow High-level flow to manage pended claim CWSSetLOB Flow Process to set the Line of Business CWSSetPriorityGroup Flow Process to set priority groups and providers CWSSetRequiredSkill Flow Process to set required skills for the claim CWSSetInitialUrgency Flow Process to set the claim urgency CWSSetWorkbasket Flow Process to assign the claim to an appropriate workbasket

Assign a line of business to the claim The claim line of business is used in determining the appropriate workbasket for the claim, as well as other important processes such as segregating claims so that they can be managed securely. The LineOfBusiness property is exposed on the claim work object and is used in reporting.

The CWSSetLOB flow initiates the process of determining the claim line of business and setting a value on the LineofBusiness property.



Determining employee claims Employee claims are determined by evaluating the subscriber’s group number. The DetermineEmployee decision table evaluates a group number based on the sample data provided with the application.

If the decision evaluates values as true, the LineOfBusiness property on the work object is set to Employee.



Customize the decision table to evaluate your own group numbers or other criteria to determine your employee claims.

Determining the line of business If the claim is not for an employee, the Line of Business (LOB) determination process continues by evaluating the Subscriber ID or the Plan Name.

The DetermineLOBBySubscriberID decision tree rule evaluates values for ITS, FEP, and NASCO plans (LOBs).



It references the following decision rules, which evaluate the specific values for Subscriber ID Prefix:

SubscriberIsFEP — to evaluate claims belonging to FEP plans

SubscriberIsITS — to evaluate claims belonging to ITS plans



SubscriberIsNASCO — to evaluate claims belonging to NASCO plans



The DetermineLOBByPlanName decision tree rule evaluates values for HMO, POS, PPO, and Medicare plans (LOBs).

It references the following decision rules, which evaluate specific values for the Plan Name Prefix:

SubscriberIsHMO — to evaluate claims belonging to HMO plans.



SubscriberIsPPO — to evaluate claims belonging to PPO plans.

SubscriberIsPOS — to evaluate claims belonging to POS plans.



SubscriberIsMedicare — to evaluate claims belonging to Medicare plans.

ManageOtherLOB is a placeholder utility that can used to create site-specific decision rules for determining the LOB.

Claims for certain LOBs may be processed in separate claims adjudication systems. Customize the decision rules based on your requirements. You can use the LOB to call different claims systems when the claim operators pull up a claim for processing. You can also use the LOB in categorizing claim inventory reports.

Key rules for determining claim LOB The key rules used in determining the claim line of business and employee status are listed below.

Rule Name Rule Type Function CWSSetLOB Flow Process to set Line of Business DetermineEmployee Decision Table Evaluates values for employee group

numbers DetermineLOBBy SusbcriberID

Decision Tree Evaluates values for FEP, ITS, and NASCO claims

SubscriberIsFEP When Evaluates FEP Plans SubscriberIsITS When Evaluates ITS Plans SubscriberIsNASCO When Evaluates NASCO Plans DetermineLOBByPlan Name

Decision Tree Evaluates values for HMO, PPO, POS, and Medicare claims



SubscriberIsHMO When Evaluates HMO Plans SubscriberIsPPO When Evaluates PPO Plans SubscriberIsPOS When Evaluates POS Plans SubscriberIsMedicare When Evaluates Medicare Plans

Determine priority claims Claims belonging to certain employer groups or providers may require additional prioritization in the work queues to satisfy contractual service-level obligations. The following set of rules provides a mechanism to evaluate values for specific employer groups and providers which are then used to assign priority status to the claim. The following shows the main flow which determines priority claims.



Determining priority employer groups The SetEmployerGroupPriority utility rule calls the SetSubscriberPriority decision table rule that evaluates values for the subscriber’s group number.

If the subscriber belongs to the priority group, the PriorityType property value on the Subscriber step page is set to ‘P’. The decision table currently evaluates values for group numbers based on sample data provided in the application.

Customize the decision table to evaluate your own group numbers or other criteria to determine priority employer groups.

Determining priority providers The SetProviderPriority utility rule calls the SetSubscriberPriority decision table rule that evaluates values for the Billing Provider ID.

If the billing provider belongs to the priority group, the PriorityType property value on the Provider step page is set to ‘P’. The decision table currently evaluates values for billing provider IDs based on sample data provided in the application.



Customize the decision table to evaluate your own priority provider numbers. You can create similar rules to evaluate values for other provider types; for example, Rendering Provider or Service Facility.

Determining claim priority level The DeterminePriorityLevel decision table rule sets the value of the PriorityLevel property (found on the claim work object). The decision table rule sets this value by evaluating the priority values of the subscriber and provider step pages. These priority values are used later in the overall process while setting the initial urgency on the claim as described in the following section.



Key Rules for Determining Priority Claims The key rules used in determining priority claims are listed below.

Rule Name Rule Type Function CWSSetPriorityGroup Flow Main flow to determine priority claims SetEmployerGroupPriority Activity Calls the SetSubscriberPriorty decision SetSubscriberPriority Decision Table Evaluates values for the priority subscriber groups SetProviderPriority Activity Calls the SetProviderPriorty decision SetProviderPriority Decision Table Evaluates values for priority providers DeterminePriorityLevel Decision Table Sets the claim priority level

Determine initial claim urgency The initial urgency on the claim is computed using three separate urgency values in the following sequence:

1. Priority Group Urgency

2. Line of Business Urgency

3. Initial Age Urgency



Determining priority group urgency The DeterminePriorityLevelUrgency decision table uses the subscriber and provider priority type values set in the CWSSetPriorityGroup process to set a value for the PriorityGroupUrgency property (found on the claim object).



Determining LOB urgency The DetermineLineOfBusinessUrgency decision table uses the LineofBusiness value set in the CWSSetLOB process to assign a value to the LineOfBusinessUrgency property (found on the claim object).



Determining initial claim age urgency The CWSSetInitialAgeUrgency decision table uses the value of the InitialClaimAge property set during the claim file intake process (see Intake Processing for Claims Workstation in Chapter 5) to set an urgency value based on the claim’s age.

The activity that computes the initial age of the claim



Computing claim work urgency The values of the Priority Group, Line of Business, and Initial Age Urgencies are used to declaratively compute the work urgency adjustment called pyUrgencyWorkAdjust.

The standard PRPC Declare Expression rule called pxUrgencyWork uses the value of the pyUrgencyWorkAdjust to compute the overall claim work urgency.

Key rules for determining initial claim urgency The key rules used in determining initial claim urgency are listed below.

Rule Name Rule Type Function CWSSetInitialUrgency Flow Main flow to determine initial claim urgency DeterminePriorityGroup

Urgency

Decision Table Determines priority group urgency

DetermineLineOfBusiness

Urgency

Decision Table Determines line of business urgency

DetermineInitialAge

Urgency

Decision Table Determines initial claim age urgency

FinishCWSBatch Activity Activity used in file intake process that calls - GetClaimServiceDates

GetClaimServiceDates Activity Used to set claim start and end dates and calls the Activity SetInitialClaimAge activity

SetInitialClaimAge Activity Computes the difference in days between the claim received date and the current date

pyUrgencyWorkAdjust Declare Exp Computes the work urgency adjustment



Rule Name Rule Type Function pxUrgencyWork Declare Exp Computes the overall work object urgency

To suit your business requirements, you can customize individual decision rules that determine individual priority levels and the logic for calculating the urgency points. You can also extend the process to include additional prioritization and escalation criteria.

Determine required skills The following set of rules determines the skill required to process the claim. The required skill is matched to the claim processor’s profile in the Get Most Urgent process to determine if the claim is appropriate for the operator to work on. The following flow is used to set the required skill.

Determing claim priority pend code The required skill is determined based on the priority pend code evaluations on the pend codes available on the claim header and lines. The claim adjudication system could assign multiple pend codes at the header or the line level. The business generally provides some sort of prioritized order that the claims processors need to follow when fixing the pend codes manually.

The CWSPrioritizePendCodes utility assembles the pend codes from the claim header and lines and calls the CWSEvaluatePriorityPendCode decision tree rule to determine the priority pend code.

The pend code values and the prioritization logic configured in the application is based on the sample data packaged with the application. It is intended to provide a template, which should be customized based on your business rules.



The Priority Pend Code property is exposed on the claim work object and can used for reporting and other purposes. The following is the decision tree rule that evaluates values for the Priority Pend Code.

Assigning required skill The CWSSetRequiredSkill decision tree rule evaluates values for the priority pend code to determine the skill required to process the claim. The SkillRequired property is updated with the appropriate skill value, and is referenced in the ToSkilledWorkbasket routing rule described in the ProcessPendedClaim assignment of the CWSManagePendedClaim flow.



Extend the prioritization logic as required. If priority pend code logic is not used for determining the required skill, consider alternative decision rules to set the value of the SkillRequired property.

Key rules for determining required skill The key rules used in determining the skill required to process the claim are listed below.

Rule Name Rule Type Function CWSSetRequiredSkill Flow Main flow to determine required skill CWSPrioritizePendCodes Activity Utility that assembles header and line pend

codes to be used to determine priority pend code PrioritizeLinePendCodes Activity Assembles pend codes from all claim lines CWSEvaluatePriorityPendCode Decision Tree Determines priority pend code CWSSetRequiredSkill Decision Tree Determines required skill

Assign a workbasket The initial routing and appropriate workbasket determination for a given claim is based on a combination of the line of business (FEP, ITS, NASCO, HMO, POS, PPO, and Medicare) and the claim type (professional, institutional, or other).



The CWSSetWorkbasket flow calls a utility by the same name that sets the workbasket name for employee as well as non-employee claims. The CWSDetermineClaimType decision tree rule determines the claim type.



The DetermineLOBByPlanName decision tree determines the LOB by Plan name.

The DetermineWorkBasketName decision table determines the appropriate workbasket using the following naming convention.



The naming convention for the workbasket is:

Non-employee Claims: “LOB Name” + “Claim Type” + “Workbasket Org Name” (such as HMOProfessional@MyHealthPlan)

Employee Claims: “Employee” + “LOB Name” + “Claim Type”

+ “Workbasket Org Name” (such as EmployeeHMOProfessional@MyHealthPlan)

For a list of pre-configured workbaskets, refer to Chapter 2.

Extend the flow and utility rules to accommodate requirements for additional workbaskets. It is important to maintain a balance between the total number of workbaskets and the total number of processors that work on the inventory. The desired workbaskets and their order need to be assigned to each claim processor’s profile.



In general, the application uses workbaskets for reporting and organizing the claims inventory based on major business segments. The processor skill match during the Get Most Urgent process provides an additional dimension to match the work to the workforce.

Refer to the Help system for fine tuning the workbasket management to suit your specific needs.

Key rules for assigning a workbasket The key rules used in assigning a workbasket to the claim in the initial routing are listed below.

Rule Name Rule Type Function CWSSetWorkbasket Flow Main flow to assign a workbasket CWSSetWorkbasket Activity Determines the workbasket name for non-employee

claims CWSDetermineClaimType Decision Tree Determines the claim type DetermineLOBByPlanName Decision Tree Determines the LOB by Plan name DetermineWorkBasketName Decision Table Determines the pre-configured workbasket name

Process pended claim assignment The Healthcare Claims Workstation+ Application is a pended claim workflow management application. It provides many processing options such as putting a claim on hold, creating and sending correspondence to providers and patients, and seeking feedback from other departments (sending a claim for medical review, for example).

The physical updates to and processing of the claim takes place in the host claims adjudication system. You can customize the Healthcare Claims Workstation+ Application to simultaneously and automatically retrieve a given claim in the host claims adjudication system (in a separate window) when the corresponding assignment is “served” to the user in the Claims Workstation+. Refer to Chapter 5 for information on integrating the Healthcare Claims Workstation+ Application with a Host Claims Adjudication System.

The following sections describe the pre-configured workflow processing options on the claim assignment in the application.

As seen in the main CWSManagePendedClaim flow, after the claim has gone through the automated steps of LOB, Priority, Require Skill, Urgency, and Workbasket determination, it is routed to a ‘skilled workbasket’ (determined in earlier processing) through the ProcessPendedClaim assignment and the ToSkilledWorkbasket router rules. The goal and deadline times for the assignment are tracked with the CWSProcessAssignment service level rule. The assignment carries a work status of Pending – Qualification and is associated with the Perform Harness for manual processing.



Key rules for process pended claim assignment The key rules used in the Process Pended Claim assignment are listed below.

Rule Name Rule Type

Function

CWSManagePended Claim

Flow Main flow that contains the assignment

ToSkilledWorkbasket Router Routes the assignment to the appropriate workbasket with required skills

Perform Harness Harness rule for processing the assignment CWSProcessAssignment SLA Default SLA for the assignment



Flow actions – processing options The ProcessPendedClaim assignment has the following flow actions options available for processing the claim:

Complete Claim Processing (closes the assignment)

Hold (Puts claim on hold)

Transfer to another processor or workbasket (Re-assign)

Notify (Creates Correspondence)

Transfer to Manager

Transfer to Medical Review (Workbasket)

Transfer to Medical Director

Transfer to Member Benefits (Workbasket)

Transfer to COB (Workbasket)

Transfer to Owner (Originating Claim Processor)

Set Owner (Originating Claim Processor)

Set Claim Note







Each of the flow actions is associated with a corresponding privilege. The Access Role – Privilege matrix for the pre-configured operators in the Application is listed in Chapter 2.

The business processing associated with the flow actions is discussed in Chapter 4, Understanding Business Processing.

Complete claim processing When you complete processing the claim in the host claims adjudication system, the CWSComplete Activity allows you to:

Update the claim notes (conversation log tab on the Perform Harness)

Resolve the claim (and close the assignment)

Update the user’s claim processing productivity statistics



Put claim on hold This option lets you put the claim assignment on hold. When you put the claim on hold, the HoldClaim Activity allows you to:

Update the assignment status to Pending-Hold

Update the work object status to Pending-Hold

Update the assignment SLA based on the selected ‘Hold Reason’

Update the user’s claim processing productivity statistics



Transfer (reassign) This option is available for managers and supervisors to manually transfer the assignment to an operator or a workbasket. When you select Reassign, the CWS Reassign activity:

Updates the claim notes log (conversation log)

Initiates PRPC Reassign activity to the selected operator or workbasket

Updates user’s claim processing productivity statistics



Notify (create correspondence) Users select this option to generate correspondence to request additional information. The lists of correspondence templates included in the Application are listed in Chapter 2. The flow action is a modified version of the PRPC flow action called Notify.

When you select Create Correspondence, the CWSCorrUpdate activity:

Prompts for a party role selection

Prompts for a list of valid correspondence templates

Opens the selected correspondence template for edit

Sets an SLA rule based on the decision rule





Changes the assignment status to Pending – Hold

Updates the user’s claim processing productivity statistics

Transfer to manager Select this option to transfer the assignment to the manager. When you select Transfer to Manager, the CWSTransferToManager activity:

Updates the claim notes (conversation log tab on the Perform Harness)

Calls standard Pega 7 ActionTransferToManager activity




Transfer to medical director This option is only available for the Case Manager role and is meant to escalate an assignment that is transferred for medical review to the medical director. When you select Transfer to Medical Director, this option:

Updates the claim notes (conversation log tab on the Perform Harness)

Calls the ActionTransferToMedDirector activity, which transfers the assignment to MedicalDirector@MyHealthPlan




Transfer to specific workbaskets The following flow actions are examples of manually routing the assignment to specific workbaskets. This may be useful when input from other departments is required (such as Medical Review). The application contains three examples of generic workbaskets for such interdepartmental routing. Choosing any of these options routes the assignment to the corresponding workbasket.

Transfer to Med Review (ClaimsMedicalReview@MyHealthPlan)

Transfer to Member Benefits (ClaimsMemberBenefits@MyHealthPlan)

Transfer to COB (ClaimsCOB@MyHealthPlan)

A common process, CWSActionTransfertoWorkbasket, takes the workbasket parameter set in the flow action to transfer the assignment to the specified workbasket.



Transfer to owner (originating claims examiner) When you first pick the claim assignment, the PerformDefaults activity sets you as the ‘owner’ of the pended claim assignment. As seen later, the ownership can be re-assigned by managers and supervisors using the Set Owner option.

When you select Transfer to Owner (only available if you are not the owner), this option:

Updates the claim notes (conversation log tab on the Perform Harness).

Calls the CWSReassign activity, which transfers the assignment to the owner.



Updates the user’s claim processing productivity statistics.

Set claim note (common process) The claim processing notes or communication between various users working on the claim assignment are captured and maintained as part of the work object. They are displayed in the claim work object harness under the Conversation Log tab.

As seen earlier, the common process is leveraged in other processing options (transfer, hold, create correspondence, reassign, complete processing, and so on). You can also independently select this option to set a note on the work object.

The SetClaimNote activity adds a page to the ClaimNotes page list with the text of the note, the operator name, and the date and time the note was added.



Key rules for flow actions The key rules used in the Process Pended Claim assignment flow actions are listed below.

Rule Name Rule Type Function CWSComplete Activity Processes the selected option SetClaimNote Activity Updates claim notes Hold Flow Action Puts the claim on hold HoldClaim Activity Puts the claim on hold ActionChangeAssignmentSLA Activity Common process to change the SLA on the assignment

based on the flow action Transfer Flow Action Initiates transfer (reassign) of the assignment CWSReassign Activity Initiates transfer (reassign) of the assignment Notify Flow Action Creates correspondence CWSCorrUpdate Activity Updates a correspondence record and puts the

assignment on hold CWSGetCorrPartySLA Decision Tree Selects the appropriate SLA based on the selected party CWSAutoHoldProvider Letter

SLA SLA pending information from provider

CWSOther SLA Generic SLA pending requested information TransferToManager Flow Action Transfers assignment to the manager CWSTransferToManager Activity Transfers assignment to the manager TransferToMedDirector Flow Action Transfers assignment to the medical director



Rule Name Rule Type Function ActionTransferToMed Director

Activity Transfers assignment to the operator -MedicalDirector@MyHealthPlan

TransferToMember Benefits

Flow Action Transfers assignment to a workbasket - ClaimsMemberBenefits@MyHealthPlan

TransfertoCOB Flow Action Transfers assignment to a workbasket - ClaimsCOB@MyHealthPlan

TransferToOwner Flow Action Transfers assignment to the owner CWSReassign Activity Transfers assignment to the owner SetOwner Flow Action Assigns ownership to the claim assignment ActionSetOwner Activity Assigns ownership to the claim assignment SetClaimNote Flow Action Adds a row (note) to the conversation log SetClaimNote Activity Adds a row (note) to the conversation log

The Process Pended Claim assignment and all the flow actions associated with it are meant to provide you with examples of commonly used workflow processing options (routing to another individual or queue, automatically or manually escalating the work, putting a claim on hold, assigning service levels, generating correspondence, seeking feedback from other departments, and so on).

Add to or customize the flow action rules, correspondence templates, and SLAs to meet your claim processing needs.

Audit completed assignments The application contains a placeholder process to audit a percent of the claims that have been processed. The CWSManagePendedClaim workflow contains a spin-off flow to audit certain claims after the assignment for processing the pended claim is completed.



The process uses the RandomSelection Pega 7 activity to select a pre-defined percent of assignments and route them to the ClaimsAuditor@MyHealthPlan workbasket. The work and assignment statuses are set to Pending-Investigation. Operators belonging to the CWS: Auditors access group have access to the assignment. The auditors can complete the assignment or transfer the assignment to the manager.

Key rules for auditing completed assignments The key rules used in auditing completed claim assignments are listed below.

Rule Name Rule Type

Function

CWSAuditClaim Flow Main flow to manage the random audit process RandomSelection Activity Randomly selects a pre-defined percentage of assignments



Rule Name Rule Type

Function

CWSAuditReviewBeforeAction Activity Prepares for the audit assignment CWSCompleteReview Activity Completes audit review assignment

The Audit Review process is a placeholder for you to customize and extend the workflow based on your needs. Modify the flow, assignment, and flow action rules to provide additional processing based on your requirements

Claim lookup and transfer Claim processors, supervisors, and managers can manually search the claims inventory to review a desired claim. Supervisors and managers can additionally transfer one or more of the searched claims to specific processors or workbaskets. This functionality is configured specifically for claims workstation and is separate from the standard Pega 7 functionality to look up work objects based on certain parameters.

The Claims Lookup option is available on the Process Work gadget of the claim processor portal. Similarly, the supervisor and manager portals contain a link for Claims Lookup and Transfer.

When you click the link, the ClaimLookup activity displays the claim search screen which comprises the search parameter section and the results section.



The ClaimLookupAndTransferList activity performs the search based on the input values and also evaluates values to determine if the employee claims can be displayed in the results list (only displayed if the user’s role is one of Secure Examiner, Supervisor, or Manager).

The Transfer button on the results screen is conditional based on the user’s role, and is available only for the supervisors and managers. It allows the selected claims to be re-assigned. The CWSPrepareReassign activity initiates the transfer of the selected claims to the selected operator or workbasket.





Key rules for claim lookup and transfer The key rules used in claim lookup and transfer are listed below.

Rule Name Rule Type Function ClaimLookup Activity Initiates lookup and displays search screen ClaimLookup Harness Claim search screen ClaimSearchParams Section Claim search section on the screen ClaimSearchResult Section Claim search results section on the screen ClaimLookupAndTransfer List

Activity Performs claim lookup and assembles a list of matched claim work objects

CanTransferClaim When Evaluates values for supervisor and manager roles CWSPrepareReassign Activity Prepares to reassign selected claims SecureExaminer When Evaluates values for secure examiners, supervisors, or

manager roles DetermineEmployee When Evaluates values for employee claims based on group

number


This chapter describes the user processes configured in the Healthcare Claims Workstation+ Application. The automated claim file intake, work object creation, prioritization, required skill identification, and workbasket routing processes are defined in Chapter 3.

The user functions (claim processor and manager tasks) described in this chapter assume that a sufficient pended claim inventory has been created by loading the sample claim files packaged with the application. See Chapter 2 for information on how to load sample claims and how to create a pended claims inventory.

The following user functions are described in this chapter:

Claim Processor (Operator) Functions

Review Own Work List

Process Pended Claim Assignments

Lookup Claim

Review Personal Productivity Metrics

Case Management (Medical Review) Functions

Nurse Case Manager

Reviews Medical Director

Claims Auditor Functions

Claims Auditor Review of Completed Assignments

Claim Supervisor / Manager Functions

Monitor Claims Inventory, Work Quality, and Performance

Monitor batch claim file input statistics

Monitor claims inventory

− Aging Inventory

− Workbasket Inventory

− On Hold Claims Inventory

Monitor Operator Productivity

Monitor Assigned Operators By Workbaskets

Monitor Work Throughput, Quality, and Performance

Understanding Business Processing



Create Custom Reports

Manage Operator Schedules and Profiles

Manage Workbaskets and Workbasket Urgency Threshold

Monitor and Process Claim Assignments (Ad Hoc Processing)

View and process claims from Operator Queues

View and process claims from Workbaskets

Perform custom search and process claims from inventory

Reassign (Transfer) Claims

Claim processor (operator) functions As mentioned in Chapter 2, the application comes pre-configured with a sample organization chart, access groups, access roles, privileges, and sample operator records. The sample operator logins are configured with appropriate skills and workbaskets to process claims from the sample claims inventory.

The following sample claim processors records are configured in the system. All logins end with suffix ‘@MyHealthPlan’ (CWSJunior1@MyHealthPlan, for example) and have a password of install.

CWSJunior1

CWSJunior2

CWSSenior1

CWSSenior2

CWSSecure1

CWSSecure2

The two Secure Claims Examiner logins are configured to process claims belonging to the organization’s own employees.

Log in using one of the claim processor logins listed above. The Claims Processors Portal provides the following functions:

My Work

Next Assignment



My Work

Claims assigned to you appear in the My Work section of the workspace. Claim assignments can appear on a work list when you put claims on hold or when the assignments have been transferred to you by a supervisor or manager.

Processing Tip: Although you can access any assignment that appears in a work list, you should use the Next Assignment process described below. It is configured to serve work objects from the work list as appropriate, that is, their assigned goal times have been reached.

Next Assignment

Click Next Assignment to receive the next most appropriate claim for processing. The function takes into account the operator’s work access profile and the skills, skill levels, and name and order of the workbaskets assigned to their profile. The next most appropriate claim assignment appears.



You can customize this option to automatically retrieve the claim in the host claim processing system so that the processor can work on the claim. See Chapter 3 for more information.

The alternative methods of looking up work objects and searching for work are discussed later.

If you click Next Assignment and there are no claim assignments appropriate for processing, you are notified with a message. Click Close to return to the portal home page.

Review pended claim assignment After clicking Next Assignment to retrieve work, the application finds the next most appropriate pended claim assignment for you to work on.

The main claim assignment processing screen (Perform Harness) provides the important claim work object and assignment-related information within easy access. The Perform Harness is logically arranged on the following pages:

Work Object Header — Provides high-level work object information

Claim Work Object and Assignment Section — Provides relevant information on the claim header, Claim line, member, provider, claim history, and conversation log. The information is arranged in a tabbed format.



Other actions -— Provides options to help you process the claim assignment. Claim processors process the claim in the host claims adjudication system and then select an appropriate action in the Other actions drop-down list, based on whether you can process the claim in the adjudication system or need to take some other action, such as putting the claim on hold, adding a note, or creating correspondence.

Review work object header The work object header provides high-level information about the claim work object:

Claim Work Object ID

Claim Work Object Status

Work Object Urgency (Default is 10)

Received Date

Expand the Work Object section to review additional work object information, including how long the work object has been aging, who updated the work object last, and the urgency adjustment (priority) points assigned to the work object.



The buttons to the right of the Work Object header are:

Action > Check Spelling — Allows you to check and correct spelling of free text information typed in notes while using one of the Take Action processing options that contains a free text area to input notes.

Action > View History — Opens the History and Attachments tabs with the History information expanded. Lets you review the system and human processing history on the claim work object.

Action > where am I?— Shows the current position in the flow

Close this item – Closes the work object assignment.

To view letter details, click the attachment.

Review claim work object and assignment information The claim work object and assignment section provides relevant information to review the claim work object and the pended claim assignment. The information is arranged in the following tabs:

Claim Header

Claim Line

Member

Provider

Claim History

Conversation Log



Review claim information The Claim Header tab appears by default and provides the claim header details.

Claim line information

The Claim Line tab provides a list of line numbers and procedure codes. Click on each item to view Claim line Summary.

Review member information The Member tab lets you review important subscriber and patient information associated with the claim.



Review provider information The Provider tab lets you review important Billing Provider, Rendering Provider, and Service Facility information associated with the claim.

Review claim history The Claim History tab lets you review a listing of other claim data instances associated with the Patient. Click on the Pega ID hyperlink of any listed work object to view details of the claim work object.



The POS code is a property in the base PegaHC ruleset. The associated values are located on the property rule.

Review conversation log The Conversation Log tab lets you review processing notes added by previous processors

Review claim image If there is an image associated with the claim, the Image Number field in the Header Summary section of the claim tab displays a hyperlink.



When you click on the hyperlink, the claim image appears in a separate window using the PegaIMAGE Viewer application. See Chapter 5 for details on Claim Image Integration and Image Viewer Configuration.

PegaIMAGE viewer controls You can adjust an image to view a portion of it or compensate for scanning problems. The PegaIMAGE Viewer includes a toolbar for manipulating an image.

The following table describes the functions on the toolbar. Because changes are not saved, you can safely experiment with the functions and click Refresh to cancel your changes.

Icon Function Name Description

Print Prints the entire image. The standard Print window opens.

Copy Copies the entire image to the clipboard.

Zoom In Enlarges the image by ten percent.

Zoom Out Reduces the image by ten percent.

Fit to Width Enlarges the image to the width of the viewer window. (Some portion of the bottom of the image may no longer be visible.)

Fit to Length Enlarges the image to the height of the viewer window. (Some portion of the right of the image may no longer be visible.)

Best Fit Enlarges the image as much as possible within the viewer window.

First Page Displays the first page of a multipage TIFF image. (If this is the only page, this button is dimmed.)

Previous Page Displays the previous page of a multipage TIFF image. (If this is the only page, this button is dimmed.)

Next Page Displays the next page of a multipage TIFF image. (If this is the only page, this button is dimmed.)

Last Page Displays the last page of a multipage TIFF image. (If this is the only page, this button is dimmed.)

Go to Page Displays a specific page of a multipage TIFF image. The Go to Page… window opens. Enter a page number, and click OK. (If this is the only page, this button is dimmed.)

Pan Image Opens the PegaImgViewer window, indicating the visible portion of the image. Drag



Icon Function Name Description the rectangle to view other portions of the image, or use Zoom Out to view more of the image.

Refresh Redisplays the original image, canceling all changes.

Rotate Left Rotates the image 90 degrees left (counterclockwise).

Rotate Right Rotates the image 90 degrees right (clockwise).

Flip Horizontal Reverses the image left to right.

Flip Vertical Reverses the image top to bottom.

Invert color Displays a negative image.

Convert to grayscale Changes the image to up to 256 shades of gray.

Sharpen Opens the Sharpen window. Drag the slider or enter a value, and click OK. (Recommended for TIFF images only.)

Adjust contrast Opens the Change Contrast window. Drag the slider or enter a value, and click OK.

You can also right-click an image to display a pop-up menu that lists the available functions. The pop-up menu includes the additional functions, Hide Toolbar and Show Toolbar.

You can control the position of the toolbar as follows:

To position the toolbar below the image (the default), right-click within the image and select Toolbar > Top from the pop-up menu.

To position the toolbar above the image, right-click within the image and select Toolbar > Top from the pop-up menu.

To hide the toolbar, right-click within the image and select Toolbar > Hide from the pop-up menu.

If you right-click outside the Image Viewer area, the browser’s pop-up menu appears instead.

Process pended claim assignment The Other Action area displays the options available to you when processing the claim assignment. The selection box in the heading defaults to the suggested action to process the claim. The choices available depend on your role and the privileges assigned to each role. You can accept the default or select a different action. After you select an action, if more information is required, the application displays fields in the Other Action area. To take the action, click Submit.



Complete claim processing When you successfully complete the claim processing in the host claims adjudication system, you can select this option to complete the assignment in the Healthcare Claims Workstation+ Application and proceed to the next available assignment. You can also add notes before submitting the action.



Click Get Next Assignment to proceed to the next claim assignment or click Close to close the work object and return to the home page.

Put claim on hold Select this option to put the claim assignment on hold if additional information has been requested from third parties such as the providers / patient / subscriber / or others. The application displays the current goal and deadline times for the work object. The Hold Reason check box lets you specify a reason for putting the claim on hold.

When you select the hold option, the claim work object status changes to Pending – Hold and the assignment is transferred to your personal work list. A service level rule tracks the assignment in your work list until its designated goal time. The application then presents the confirmation screen with an option to Get the Next Urgent claim assignment.

Reassign

This option is available only to supervisors and managers. The Reassign option allows you to select an operator or a workbasket to transfer the assignment. When you click Submit, the assignment is transferred to the selected operator’s personal work list or the selected workbasket; the system displays the confirmation screen.

Create Correspondence

This option allows you to send a letter to the Rendering Provider to request additional provider / patient / or medical information. Select Rendering Provider in the Select Role selection and then select one of the correspondence templates based on the type of information you are requesting.

The Create Correspondence flow action uses the default Pega 7 flow action Notify. This option displays all the work party roles and correspondence templates associated with the work class. Your



implementation may have a custom version of this option that only displays the appropriate correspondence templates.

You can edit correspondence before sending it. You edit the correspondence template d in the preview window or in Microsoft Word.

Upon sending the correspondence, a copy is attached to the work object’s permanent audit trail. The assignment is put on hold and is transferred to your personal work list. The assignment goal and deadline times are tracked by a service level rule.

Manual Route / Transfer

There are many options available to manually transfer or route the assignment to specific operators or workbaskets for follow up. The options in this category include:

Transfer to Manager

Transfer to Originating Claims Examiner (Owner)

Transfer to Medical Director (only available for Case Manager role)

Route to Medical Review (workbasket)

Route to Member Benefits (workbasket)

Route to COB (workbasket)

All these options provide a free text notes area to input follow-up information. The assignment is transferred to the selected operator or workbasket. If you added a note, it is logged in the Conversation Log tab and the application displays a confirmation screen.

Set Originating Claims Examiner

When you first pick up a claim assignment, you are assigned as the owner of the assignment. Claims managers and supervisors can override and re-assign the ownership.

You can select an operator from the selection list and click Submit to set the selected operator as the owner.

Add Note

With this option, you can add a note to the claim processing log that is then logged to the Conversation Log tab. The assignment remains open for any other action you may choose to perform.

Lookup Claim

The claims lookup function, located in your Transfer Work space, allows you to locate and review a specific claim work object. You can search for a claim by the Claim ID or a combination of the following properties:



Patient ID

Service Provider ID

Total Charge

Service From and To Dates

The Search Results section shows the number of claim work objects that were found using the search criteria and displays a list of the matched results.

The claims search results list filters out claims belonging to your own employees (secure claims) if the access role assigned does not provide the privilege.

Access to claim details in Employee workbaskets is restricted by access role security. If you do not have access to the employee claims, a note appears at the bottom of the list.

Review Own Productivity Metrics (Operator Productivity)

You can review the day’s claim processing metrics from the Operator Productivity section of the dashboard. The report shows the total processing time (in seconds), the total number of claims users completed processing in the adjudication system, the total number of claims put on hold, and the number of claims transferred.

Click Back to return to the default workspace.

Case Management (Medical Review) Functions

The sample organization chart in the application contains access groups, access roles, privileges, and sample operator records for the nurse case manager and medical director. The sample operator logins are configured with appropriate skills and workbaskets to be able to process claims that have been routed for medical review.

The following case management operator records are configured in the system with a password of install:

CWSCaseManager@MyHealthPlan

CWSMedicalDirector@MyHealthPlan

The Case Manager and Medical Director have the same default Claims Examiner portal as the other claim processors. All the portal functions available to the claim processor are available to the Case Manager and Medical Director and are listed below.

Case Manager and Medical Director Portal Functions

Review My Work in Progress

Get Next Assignment



Lookup Claims

Review Own Productivity Metrics

As shown in the Privilege / Access Role Matrix in Chapter 2, the Take Action processing options on the claim assignment are limited to the following:

Case Manager Claim Processing Options

Put Claim on Hold

Create Correspondence

Transfer to Manager

Route to Medical Director

Transfer to Originating Claims Examiner (Owner)

Set Claim Note

Medical Director Claim Processing Options

Transfer to Medical Review (workbasket)

Set Claim Note

Refer to Process Pended Claim Assignment for a description of the claim processing options.

Claims Auditor Functions

The application contains functionality to automatically flag and route pre-defined completed claim assignments for audit. As discussed in Chapter 3, certain numbers of completed claim assignments are routed to a special workbasket for the claim auditor review.

The sample organization chart in the application contains an access group, access role, privileges, and a sample operator record for a claim auditor. The sample operator login is configured with appropriate skills and workbaskets to be able to review the claim assignments that have been routed for audit.

The CWSAuditor@MyHealthPlan claim auditor operator record is configured in the system and has a password of ‘install’:

The Claim Auditor has the same default Claims Examiner portal as the other claim processors. All of the portal functions available to the claim processor are available to the Claim Auditor.

Claim Auditor Portal Functions

Review My Work in Progress

Get Next Assignment



Lookup Claims

Review Own Productivity Metrics

Claim Auditor Claim Processing Options

As shown in the Privilege / Access Role Matrix in Chapter 2, the Take Action processing options on the claim assignment are limited to the following:

Complete Processing

Transfer to Manager

Set Claim Note

Refer to Process Pended Claim Assignment for a description of the claim processing options.

Claims Supervisor and Manager Functions

The sample organization chart in the application contains access groups, access roles, privileges, and a sample operator record for claim supervisors and managers.

The following operator records are configured in the system and have a password of install:

CWSSupervisor@MyHealthPlan

CWSManager@MyHealthPlan

Claim Supervisor and Manager Portals

Supervisors and managers have separate portals that differ from the default Claims Examiner portal. Except for the real time reporting gadgets on their respective dashboards, most of the portal layout (and functionality) is similar between supervisors and managers and contain the following navigation gadgets:

Dashboard

My Work

Transfer Work

Demo Claims

Management Tasks

Log in to the system as CWSManager@MyHealthPlan with the password of install. In addition to the work processing functions mentioned for the claims examiners, supervisors and managers have special privileges and access to special gadgets on their portals to perform certain important managerial tasks as shown below:

Monitor Claims Inventory, Work Throughput, Quality, and Performance

Monitor batch claim file input statistics



Monitor claims inventory

− Aging Inventory

− Workbasket Inventory

− On Hold claims Inventory


Monitor Assigned Operators by Workbaskets

Monitor Claim Processing Quality and Performance

Create Custom Reports

Manage Operator Schedules and Profiles

Manage Workbaskets and Workbasket Urgency Threshold


View and process claims from Operator Queues

View and process claims from Workbaskets

Perform custom search and process claims from inventory


Perform Bulk Processes

Process Pended Claim

Re-assign workbaskets or operators

Set Original Claims Examiner

All the processing options described in the Process Pended Claim Assignment section o are available to supervisors and managers. The ReAssign and Set Originating Claims Examiner options are not available to operators.

Monitor Claims Inventory, Work Throughput, Quality, and Performance

The dashboard and reports workspaces provide access to many reports to view the claims inventory in real time as well as monitor the throughput, quality, and performance of the reporting departments

Monitor Batch File Input Statistics

In the Claims Processing gadget of the Report tab, clicking the Batch Statistics link opens the report. It shows high-level batch file statistics of all the claim files processed by the system.

Monitor Claims Inventory

The following custom reports are pre-configured to provide realtime insight into the claim inventory. You can access these reports by clicking on the respective link in the Claims



Processing gadget of the Reports tab. The manager’s dashboard also has a graphic display of the inventory reports that you can click to access details.

Overall Claims Aging Inventory

Aging Inventory by Line of Business

Inventory by Workbasket

On Hold Inventory

Clicking on the desired report link on the gadget displays a report. The reports are available in report definitions.

Report Definitions: These aging and workbasket inventory reports are available as report definitions with a graphic view.

Overall Claims Aging:

Aging By LOB:

Workbasket Inventory:


Clicking the Operator Statistics link in the Claims Processing gadget of the Reports tab opens the operator productivity report. Unlike the claims processors who can only view their own productivity metrics, managers can view productivity metrics for all operators who report to them. You can filter the list by a specific operator or processing date. As in other list view reports, you can sort the report by any column and export it to Excel for external communication.

Monitor Assigned Operators by Workbasket

As mentioned earlier, the Get Most Urgent process evaluates the operator’s assigned workbaskets and the order in which they are assigned to determine the next most appropriate claim.

This report provides an insight into all the operators assigned to a given workbasket and the order number of the workbasket assignments on their profile. This view is useful while fine-tuning a claims inventory distribution and matching it to a resource pool (operators). Managers use the data to determine if an adequate number of operators have been assigned to handle the workload for a given workbasket.

Clicking the Operators by Workbasket link in the Claims processing gadget of the Reports tab displays the report. Selecting a workbasket from the selection list shows the operators assigned to workbasket and the priority (assignment order) on the operator profile. You can sort this list by any column and export it to Excel for external communication and processing.

Monitor Claim Processing Quality and Performance



In addition to the custom claim processing reports mentioned above, you can access many Pega 7 reports that monitor work throughput, quality, and performance. These reports are available on the Reports tab as separate gadgets. Examples of reports in each category are shown below:

Monitor Process Assignments

Monitor Process Reports

Analyze Process Quality

Analyze Process Performance

Monitor Process Assignments Reports

This category of reports provides timeliness metrics by operator, work queue, and task.

Monitor Processes Reports

This category of reports provides a view into the work throughput and status.

Analyze Process Quality Reports

This category of reports provides a view into the daily and weekly process creation and resolution metrics and the average time elapsed per status.

Analyze Process Performance Reports

This category of reports provides a view into the processing time metrics by specific tasks and actions. Since the application contains only one task – Process Pended Claim, the Task reports are not useful metrics.

The Action processing metrics provide a good analysis of the average time taken for each of the claim processing options discussed earlier.

Managing Operator Schedules and Profiles

To manage operator schedules and profiles in a workgroup, click the Manager Operator Schedules and Profiles link in the Dashboard.

Managers select an operator from the list to perform the following tasks:

Update Operator Availability & Designate Substitute Assignee

Update Operator Assigned Skills and Skill Rating

Open the Operator Record

Update Operator Profile

Update Operator Assigned Workbaskets

Update Operator Password



Update Operator Availability and Designate Substitute Assignee

The Availability button enables you to change the operator’s schedule. The operator can be made inactive by setting the Active? flag to No. This prevents any system or manual routing of assignments to the operator. This is useful when the operator is on leave or has been assigned some important tasks and should not be disturbed by other tasks routed by the system or the person.

A timeframe when the operator is selected should be inactive.

A substitute operator or workbasket from the selection list is selected as the default assignee. Any assignments routed to the operator are automatically routed to the substitute assignee.

The routing based on a decision tree option is not pre-configured in the application. Your specific implementation may provide custom decision logic for determining a substitute assignee.

Update Operator Assigned Skills and Skill Rating

The Get Most Urgent delivery mechanism matches the operator’s assigned skills and skill rating to the required skill to process a specific claim.

Managers can click on the Skills button to review and update the operator’s assigned skills and skill rating.

Open Operator Record

While the above two methods provide quick access to update the availability and skills, the Open button provides access to these and other options associated with the operator profile such as:

Updating the operator’s demographic profile:

Do not modify other settings on the Operator tab (other than personal information) without consulting your system administrator.

Updating the operator’s assigned workbaskets and their order of assignment. The Get Most Urgent process evaluates the operator workbasket assignments to deliver the most appropriate claim

Updating the operator’s password:

Do not modify other settings on the Security tab (other than password) without consulting your system administrator.

Manage Workbaskets



The following sections describe how to manage workbaskets.

The application contains pre-configured workbaskets for the automated routing of claims during the intake process and for manual routing of claims to specific departments for review.

To manage workbaskets:

1. From the Reports tab click the Operators by Workbasket link

2. Select a desired workbasket.

3. Click Open to review the workbasket record.

4. If appropriate, click Save As in the toolbar to create a clone of the workbasket (with similar organization settings). By assigning (access) roles to the workbasket, restrictions can be placed on those who can work on the claim assignments in the workbasket.

5. Click Save to save the record.


Similar to the claim processors, managers can process pended claim assignments using the Get Most Urgent process.

Unlike the claims processors, managers have privileges to review queues belonging to other processors or workbaskets and perform ad hoc processing of any claim in the queues. Similarly, managers can search for a specific claim using search criteria and process the selected claims.

Review and Process Claims from Operator and Workbasket Queues

To review operator and workbaskets queues:

1. Choose the desired operator from the list of team members selection list or workbasket from the list of work baskets selection list in the right panel of the My Work workspace.

2. Select the desired Work Object ID in the results list to start processing the claim.

Search Claim Inventory and Process Selected Claim

1. Use the Search Claims gadget in the Transfer Work workspace to search the claims inventory for claims matching a selected status and variable.

2. Select the desired claim from the results list to review work object information.


As described earlier in the Process Pended Claim Assignment section, one of the processing options while working on a claim assignment, available only to managers, is to reassign the claim to another operator or workbasket.

Perform Custom Claims Search and Transfer



This option provides a way to filter the claims inventory by specific search criteria and transfer all or selected claims to specific workbaskets or operators. This feature can be useful to respond to emergencies or to create custom queues for training or other purposes.

To perform custom claims searches and transfers:

1. Click the Transfer Work tab to access the Transfer Claims gadget.

2. Enter the claim search criteria and click Search.

3. Select the claims to be transferred.

4. Select the receiving operator or workbasket record from the selection list.

5. Click Transfer.

The system performs the transfer and refreshes the list with the appropriate name in the workbasket column.

The resolved claims are not available for selection.

The custom claim search and transfer functionality excludes claims that belong to one’s own employees (secure claims) from the results list.

Claims Search and Transfer — Use Case

Business Challenge:

There is a sudden surge of claims from a specific provider. There are already a large number of claims from this provider spread across multiple workbaskets and priorities. You would like to give the highest priority to all claims from this provider so that they are processed urgently.

Solution:

1. Create a new Custom High Priority Provider workbasket.

2. Use the Claims Lookup and Transfer feature to search the claims inventory for claims for the given provider.

3. Select all the claims in the results list and transfer them to the Custom High Priority Provider workbasket that you have created for this purpose.

4. Use the Manage Operator Schedules and Profile feature to assign the newly created workbasket to a desired set of your top claim processors.

5. Ensure that you have assigned the workbasket to the top of the list on the processor’s profile.

You can use similar processes to create custom claim queues for training purposes.



Perform Bulk Transfers of Operator Assignments

Managers may use this option to perform bulk transfer of assignments for selected operators. This feature is useful when an operator has taken leave and has pending assignments in their individual queue. In addition, managers can use the Manage Operator Schedules feature to make the operator inactive and designate a substitute assignee for future assignments.

1. Select the desired operator in the Transfer work from operator selection list.

The assignments are pre-selected in the results screen.

2. The manager selects a desired substitute assignee (operator or workbasket) and clicks Process Assignments.


Claims Workstation+ is designed to accept claim files in XML format. This chapter describes the fundamental processes involved in processing incoming claims. It is assumed that your specific processes require customizing the input mechanisms included in the application. The topics in this chapter include:

Intake processing for claims workstation

Parsing and mapping a claim file

Integrating with claims adjudication systems

Integrating with PegaIMAGE Viewer

For detailed information about integrating your Healthcare Claims Workstation+ Application with other systems, see the Help system and the PDN.

Intake processing for Claims Workstation+ Claims Workstation+ accepts claim files in XML format. This section summarizes the two key components in this automated input process.

Listener Rule Files — Monitors the inbound claim file directory or MQ queues and picks up the XML claim files to be loaded onto the clipboard

Parse XML Rules — Parses the incoming XML message and loads the claim onto the clipboard to start the claims workstation process

Listener rule files The XML claim files to be loaded into the system are placed into a directory as specified in the Data-Admin-Connect-FileListener rule. The FileListener then picks up the claim file to be parsed and loads it onto the clipboard. Claims Workstation+ comes with a pre-configured instance called CWSListener.

Integrating Healthcare Claims Workstation+



The listener calls a service file rule that does the following:

Sets up the clipboard

Calls an activity

Parse XML rules The CWSFileService rule calls the CWSSaveClaimBatch activity. The Parse XML rules called by this activity map the tags from the XML claim file to specific data properties.

The Healthcare Claims Workstation+ Application is configured to map a minimal set of claim data elements that are required by the workflows configured in this application. As you build additional workflows, modify these rules to map any additional XML data tags needed to process the workflows.



The CWSSaveClaimBatch activity starts the batch claim parse process.



This activity:

Sets up clipboard pages for capturing batch file statistics

Creates the Pegasystems ID for the claim batch file

Calls the ParseBatchClaim activity that maps the XML claim file to the clipboard



Calls the FinishBatchClaimF activity that starts the workstation process for every claim within the batch file.



Manual claim file load process The Application contains sample XML claim batch files that can be loaded into the system to create a working inventory of pended claims. All sample claim files are stored as Rule-File-Text instances with the extension .xml.



To load sample XML claim batch files to create a working inventory of claims:

1. Log in as the CWSManager@MyHealthPlan with the password install.

2. Click Demo Claims in the left navigation pane.

3. From the Scenario drop-down list, select an appropriate scenario with a batch of claims and click Run.

This picks up the relevant batch file from the system, parses it, and launches the flow for processing the pended claims. Once the processing is complete, the application displays a Claims Processing Summary confirmation screen showing key statistics of the processed batch file as well as a listing of the claims within the batch, including the original claim number, Pegasystems work ID, and the workbasket to which the claim was routed and the status.



4. Click the Work Item ID to display the claim in read-only mode.

5. Click Process Claim to open the relevant flow action, for a claim that is routed to a workbasket.

If the claim is resolved, the Process Claim button is not visible.

6. Click the workbasket name to display the list of assignments.



Key rules for claim file intake The key rules used in the claim file intake process are listed below.

Rule Name Rule Type Function CWSListener File Listener Automatically picks up claim files CWSFileService Service File Loads the new claim file for processing CWSSaveClaimBatch Activity Initiates parsing from Listener RunCWSDemoClaim Activity Launches a manual claim file intake process

Detecting a duplicate claim ID Your business process may resend a claim that was processed earlier and which has a work object created in the Healthcare Claims Workstation+ Application. In such situations, the intake process should account for the duplicate lookup and process the claim accordingly.



The application contains the logic for detecting if incoming claim has already been processed in the application. To allow for re-use of the same sample claim files in demonstrations, the duplicate claim work object detection logic is not hooked into the batch file intake process, described earlier.

Extend the logic to suit your business need and incorporate it into the batch file intake process discussed earlier in the chapter.

The CWSSaveClaimNew activity (created to test individual claim file intake) contains the steps for detecting and processing duplicate claim instances:

1. Performs a search of existing work objects using the Claim ID property on the incoming claim. If there are none, it proceeds with normal processing of the incoming claim (CWSManageIncomingClaim) as explained earlier.

2. If matching results are found, the most recently updated claim from the result set is compared to these four properties from the incoming claim:

Billing Provider ID

Patient ID

Service From Date

Service To Date

If the property values do not match, no duplicate is suspected and the process proceeds with step 4; otherwise a duplicate is suspected and processed as in step 3.

3. The work item with the incoming claim gets a new ID with a prefix of “DUPCLM” and the pyDuplicateID property is updated with the work item ID of the most recently updated claim from the repository. The original incoming claim is withdrawn and the copy of the incoming claim with the new DUPCLM ID is processed through the CWSRouteDuplicateID flow rule where the claim is routed to the DuplicateClaimID@MyHealthPlan workbasket to be researched.

4. If the four property values from step 2 do not match, an updated version of the same claim is assumed. The claim from the incoming work item is then copied into the most recently updated work item with the same claim ID to preserve work item history. The incoming claim work item is then withdrawn. If the most recently updated work item has already been resolved, the CWSManageIncomingClaim flow is run again.

Key Rules for Duplicate Claim ID Validation The key rules used in the duplicate claim ID validation process are listed below.

Rule Name Rule Type Function CWSListener File Listener Automatically picks up claim files CWSFileService Service File Loads the new claim file for processing CWSSaveClaimBatch Activity Initiates parsing from the Listener



Rule Name Rule Type Function RunBatchClaim Activity Launches a manual claim file intake process

Parsing and mapping a claim file The XML file parsing and mapping to a claim work object is handled by a set of Parse-XML rules for the following logical information sections of the claim:

Transaction File

Claim Header

Header Code (Diagnosis, Occurrence, Value, and so on)

Service Line

Subscriber

Patient

Billing Provider

Rendering Provider

Service Facility

Other Insurance

Partial view of the ServiceLine parse XML rule



Use other Pega 7 Parse rule types – Delimited or Structured to parse “flat” text files.

To add new claim data elements to the XML file, determine the appropriate nodes and update the appropriate XML parse rule to map to the claim work object. The claim and claim line (and inherited service) classes provide a comprehensive list of claim properties that can be used for mapping.

Key Rules for Parsing Pended Claim File The key rules used in the pended claim file parsing and work object creation are listed below.

Rule Name Rule Type Function CWSSaveClaimBatch Activity Initiates the batch file parsing process ParseBatchClaim Activity Calls parsing rules for new or pended claim BatchClaimPended Name Space used in Parse XML Rules BatchClaimPended-Main Parse-XML Maps transaction (file) information BatchClaimPended-Claim Parse-XML Calls parsing rules for claim objects BatchClaimPended-Header Parse-XML Maps claim header information BatchClaimPended-ServiceLine Parse-XML Maps claim line information BatchClaimPended-Subscriber Parse-XML Maps subscriber information BatchClaimPended-Patient Parse-XML Maps patient information BatchClaimPended-BillingProvider Parse-XML Maps billing provider information BatchClaimPended-Rendering

Provider

Parse-XML Maps rendering provider information

BatchClaimPended-ServiceFacility Parse-XML Maps service facility information BatchClaimPended-OtherInsurance Parse-XML Maps other insurance information FinishBatchClaimF Activity Calls CWSManageIncomingClaim flow to start workstation GetClaimServiceDates Activity Uses functions to maps service period at claim header

based on claim lines GetEarliestServiceFromDate Function Determines the earliest service from date based on the

claim lines GetLatestServiceToDate Function Determines the latest service to date based on the claim

lines

Integrating with a host claims adjudication system As described in Chapter 4, the actual physical updates and processing of the claim take place in the host claims adjudication system. The application can be customized to simultaneously (and automatically) retrieve a given claim in the host claims adjudication system when the assignment is “served” to users in Claims Workstation+.



The following table contains the key rules for the system.

Rule Name Rule Type Function PerformDefaults Activity Initiates the pended claim assignment processing CWSLoadAdjudicationSystem Activity Placeholder for integrating the host claims adjudication system

The PerformDefaults activity rule initiates the steps that are performed when users start processing the pended claim assignment.

It has a placeholder step calling the activity — CWSLoadAdjudicationSystem that can be customized to automatically invoke the claim in the claims adjudication system.



The value of the ClaimNumber property in the PerformDefaults activity is passed as a parameter to the CWSLoadAdjudicationSystem activity and can be used as the key to retrieve the claim in the host system. Additional parameters, such as System ID, can be passed along as required.

Integrating with PegaIMAGE Viewer The Healthcare Claims Workstation+ Application comes pre-packaged with a standalone application called the PegaIMAGE Viewer, which is used to view the sample claim images stored in the application. The license and code for the software are stored as binary files in the webwb directory. The license file is PegaImageViewer with an .lpk file type extension. The application code is stored as PegaImageViewer with a .cab file type extension. The customization options available on the PegaIMAGE Viewer are described later in this chapter.

The key rules used for integrating with the Image Viewer are listed below.

Rule Name Rule Type Function ImageNumber Property Holds the ID of the Image ImageNumber HTML Property Contains the link and calls retrieval activity CWSGetClaimImage Activity Gets Image and Displays HTML ImgDisplayImage HTML Displays the Image using Image Viewer PegaImageViewer.lpk Binary File PegaIMAGE Viewer license PegaImgViewer.cab Binary File PegaIMAGE Viewer code base ClaimProf001.jpg Binary File Sample professional claim image



Rule Name Rule Type Function P369567.jpg Binary File Sample professional claim image ClaimInst001.jpg Binary File Sample institutional claim image P369583.jpg Binary File Sample institutional claim image

The application contains sample claim images that are also stored as binary files in the webwb directory and have a .jpg file type extension.

ClaimProf001.jpg and P369567.jpg — professional claim (CMS 1500) images

ClaimInst001.jpg and P369583.jpg — institutional claim (UB 92) images

The pended claim XML schema used by the application contains a property for the claim image number. It is assumed that this property can be used as a key to retrieve claim images if the claim processors require viewing the image while processing the assignment.

All sample claim files stored in the application reference these claim image numbers in the ImageNumber property value. The ImageNumber property rule includes a Control that is used to create a hyperlink on the claim harness.





When you click the hyperlink, a new dialog box opens for the image display and calls the CWSGetClaimImage claim retrieval activity. The CWSGetClaimImage activity references the ImgDisplayImage HTML property stream rule to display the image using the PegaIMAGE Viewer application.





The use of PegaIMAGE Viewer is optional. You may customize the image display process to use the standard Windows Image Viewer or a third-party tool associated with your Imaging System.

To use a viewer other than PegaIMAGE viewer, you must change the CWSGetClaimImage activity to retrieve the image from your image systems. You can extend the claim image retrieval process to pass additional parameters required for locating the image assuming that those parameters are available on the inbound claim file, or can be determined by some logic (for example, Image System ID, Directory Path, Operator Login information, and so on). It is recommended that you attach the image to the work object after the initial retrieval from the external image repository to increase performance.

You may also use the Pega 7 work object attachment process to browse for the image and store it in the work object. Refer to the Help system for additional information on work object attachments.



Configuring the PegaIMAGE Viewer toolbar settings The PegaIMAGE Viewer toolbar provides many image manipulation options. Refer to Chapter 4 for a description of the options. You can change the toolbar settings so that the toolbar displays above or below (default) the image, or is hidden. To change the settings, modify your copy of the ImgDisplayImage HTML rule used to display an image.

To change the toolbar location: change the value of the parameter “toolbarLocation” in the template from 0 (place below the image) to 1 (place above the image).

To hide the toolbar: change the value of the parameter “showToolbar” in the template from true (show the toolbar) to false (hide the toolbar).

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