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1 Pegasystems 2009
Overview of CTI & PegaCALLalong with
CPM for Healthcare
Matt Ruffing – [email protected] Rob Mills – [email protected] Hahn – [email protected]
2 Pegasystems 2009
Agenda
CTIØ CTI – What and whyØ PegaCALL architectureØ Integration with PRPCØ Application FlowØ Terminology
CPM for Healthcare
Ø Generic CPM HC DEMOØ CPM HC Class structureØ Enabling CPM HC WizardØ CPM Wizard to create flowØ Show new flow in HC workingØ Under covers of flow design and structureØ Changing User Interface of flowØ Overview of integration to external systems with CPM
Questions
3 Pegasystems 2009
What is CTI?
Computer Telephony Integration
ØTechnology that allows telephony events (call delivered to agent, call transferred, etc) to be coordinated or integrated with a computer
ØThe timing of events is such that telephony and computer events occur practically simultaneously
Ø
4 Pegasystems 2009
Rules-Driven Computer TelephonyIntegration (CTI) with PegaCALL for PegaRULES
■ - Legacy pre fetch to drive IVR processing and call routing
■ - Re use rules to drive IVR decisioning■ Adaptive screen pop for effective coordination
of call arrival■ - Desktop and workflow based telephony controls
for improved call management■ !Implement individually or incrementally
5 Pegasystems 2009
CTI Functions
• Call Control Ø Customer data
pre-fetchØ Call routing Ø Adaptive screen
pop
• Desktop Telephony Ø ACD/PBX Login/Ø Make available/Ø Hold/Un-hold Ø Answer call Ø Make call Ø Disconnect call Ø Conference call Ø Blind transfer Ø Warm transfer
6 Pegasystems 2009
Telephony Technology in a Contact Center
Ø Interactive Voice Response (IVR) Ø Interactive phone system that can respond to a callers input
(voice / keypad) and either complete pre-determined services or assist in properly routing the call to the appropriate agent.
Ø Common Vendors: Avaya, Genesys, Syntellect, NuanceØ
Ø ACD/Call Routing Ø Automatic Call Distributor – a device that distributes large
volumes of incoming calls to agents. The ACD contains logic that drives routing decisions based on multiple input parameters. Routing parameters can include a combination of data about available agents and their skills, and specific information about the call/caller
Ø Common Vendors: Avaya, Aspect, CiscoØ
Ø Computer Telephony Integration (CTI) Ø Technology that allows interactions on a telephone and a
computer to be integrated or coordinated. This allows for an agent to receive both the voice call and the supporting data at the same time. Supporting data may come from the IVR, the phone switch or other sources
Ø Common Vendors: Genesys, Cisco, Envox
Ø
7 Pegasystems 2009
Why implement CTI?
• Cost SavingsØ Avg. savings of 20 seconds/call (Gartner)Ø A contact center that handles 10Kcalls/day can
save over 20,000 agent hours/year just by implementing a successful screen pop
• Increased customer satisfactionØ Customers don’t have to repeat information they
have provided to the IVRØ Agents start the call more focused on the
customer’s issue• Promotes self-service use:
Ø Adds perceived value to entering data in the self-service IVR, once customers learn they will not have to repeat information to an agent
• Increase agent productivity:Ø Prefetch and screen pops make agents more
efficientØ Integrated telephony features simplify agent
tasksØ
8 Pegasystems 2009
PegaCALL Enables PRPC applications with Computer Telephony Integration (CTI)
Ø Increased Agent Productivity:ØRetrieve customer information in advance
of the agent receiving the callØDeliver the call and the customer
information simultaneouslyØRules driven screen pop delivers the right
customer data based on the agent, the customer and the call
ØLower Customer Frustration: • Close the IVR Gap:
Ø Eliminate the need for the customer to repeat information to an agent - IVR data is passed to the agent as the call arrives
Ø Agents can know the point at which the customer ‘zeroed’ out of the IVR
Ø BPM-enabled CTI allows the agent to continue service from that point
• Transfer the call and the data:Ø Provide the agent receiving the call with
details they need to continue serviceØ Allow an agent to pick up at the point in
the process where the last agent ended
9 Pegasystems 2009
CTI Integration Approach
C u s t o m e r S e r v i c e
Oracle DBMainframe, OS/390
SQLNet
MQ orSQL
IVR may access legacy systems if
desired
Productionapplications
CTI middle ware may request data from Pega for pre-
route
CTI Middleware requests adjunct
route from PegaCall
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5
6
7
8
9
4
Rules retrieve & evaluate data & determine when/if telephony functions are
required by CSR
PegaCALL maintains connection for POP
and CTI events
CTI middleware places caller in ACD queue as
instructed & notifies PegaCALL upon call
offering event
Member dial 800 # and is directed to IVR for ID prompt
Caller is directed to IVR and prompted for information needed to access profilePegaCALL monitors call arrival on premise and may begin customer lookup by ANI.
Information is gathered to satisfy IVR data requirements from any available source (see #5)
IVR, Pegasystem, or caller request opt out and IVR attaches data to the call for handling by the CTI middle ware. Call is directed to ACD or is managed by CTI middle ware to the correct ACD.
CTI Middleware may optionally request final route input from PegaCALL
Pegasystems uses any data available to drive rules engine to determine possible route for call
PBX places call in queue and maintains update with PegaCALL via link. Call is offered to next available agent in queue
PegaCALL obtains message of call offering, starts rules engine with relevant data.
Pegasystem drives data needed for POP to the desktop using data obtained in step 5 based on business rules.
Desktop requests CTI functions (conference, transfer, hold, etc) via PegaCALL interface methods
Pegasystem rules engine instructs CTI Middleware as need via PegaCALL to perform needed functions requested by desktop application.
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ACD
10 Pegasystems 2009
PegaCALL for PegaRULES High Level Architecture
PegaCALL Installation with Genesys
IVR
PBX / ACD
T-Server
Windows Server
PegaCALL CTI Link
Routing Point
Queue A
PSTN
PegaCALL
SOAP Connectors
PegaRULES Process Commander
SOAP Services
Back-End Systems and DatabasesContaining Real-Time Customer Information
Queue B
Queue C
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7
Workstation
7
5 6
Telephone
11 Pegasystems 2009
PegaCALL for PegaRULES
• CTI support for most major ACD’s using industry standard CTI middleware and routing platforms:
Ø Envox CT Connect Ø GenesysØ Aspect Contact ServerØ Cisco ICM
• Server-side CTI integration Ø Provides seamless integration of telephony events and
business processesØ No desktop DLL’s to install
• Real time adaptive screen popsØ Puts the right customer information in front of the
agentsØ Eliminates need for the customer to repeat to the
agent what they just entered into the IVRØ Fully configurable – can trigger different processes
based on the agent and customer profiles for enhanced customer service
• Voice and Data TransferØ Transfer customer and work object data with the callØ
•
12 Pegasystems 2009
Coming soon…….
• Configuration Wizard – should allow basic connectivity and features (screen pop) to be configured and running in 30-45 minutes, including call data mapping, custom screen pop, etc. This will be a huge help during POC’s where CTI is required.
•
• Stateful telephony (Genesys only) – allows state to be synchronized between PegaCALL and the phone, so that actions taken at the phone (ie put a call on hold) will be reflected in the PegaCALL UI. This also introduces the concept of a CTI Toolbar that can be embedded in CPM.
•
• CTILink Hot Failover – ability to have a hot standby CTILink that will detect a failure in the primary link and take over automatically
•
• The CPM 6.1 release (2009) will include pre-configured voice/data transfer capability, so that when a user transfers the call, the active case(s) go with the call automatically.
13 Pegasystems 2009
Terms you need to know:• Telephony
Ø ANI – Automatic Number IdentificationØ DNIS – Dialed Number Identification ServiceØ ACD – Automatic Call DistributorØ Skills Based Routing – A feature of many ACD’s that provide the ability to route calls based
on call type and agents skill setØ VDN/Application – Vector Directory Number (Avaya) – an extension that directs incoming
calls to a specific vector or application. Calls are tracked by vector, the vector drives a specific message and queues. The VDN or App can indicate to the agent (and the software) the type of call
Ø Availability – Agent driven indication that they are available to receive calls, usually entered into the phone set or the soft phone, but can be software controlled
Ø Auto-In/Auto-Ready – An indication of the agent state that is automatically established upon release of a phone call. An ‘auto-ready’ agent will become available as soon as a call is released, versus having to manually indicate availability
Ø Whisper –a message from the ACD that is whispered to the agents headset just prior to the call being established, typically indicates the call type to the agent
• CTIØ IVR/VRU – Interactive Voice Response / Voice Response UnitØ Screen Pop – Screen PopulationØ CTI Server/Middleware – Server component that provides a layer of abstraction between
the ACD and client software. Pega supports Envox, Cisco ICM, Genesys and Aspect Contact Server
Ø CTILink – Pega component that sits between PRPC and the CTI ServerØ Soft Phone – Software based phone that allows agents to control telephony functions from
their computerØ
• Call CenterØ Wrap Up – Agent state after release of a call that allows them to finalize any work, enter
notes, etc. Auto-Ready call centers will have no wrap-up periodØ Idle – Agent state where they indicate that they are Unavailable to take phone calls. Many
call centers measure idle time and force agents to indicate idle reason prior to going idle (ie Bathroom, etc)
Ø Call Disposition/Call Coding – Feature of many ACD’s that allow the agent to indicate the disposition of a call during the wrap up using either the phone set or the soft phone. Many ACD’s provide Call Center dashboards that leverage this data in real time
Ø Handle Time/AHT – Average Handle Time is the time it takes to handle an interaction. This typically includes wrap and any after call work.
Ø Service Levels – usually measured as the % of calls that actually make it to an agent without abandoning. A 50% service level means half the calls never get to an agent.
•
14 Pegasystems 2009
CPM for Healthcare
15 Pegasystems 2009
Pegasystems – The Healthcare BPM Leader
Target MarketLarge Payers > 2MM MembersTop Pharma / LifeScience CosHealthcare Government Selective Providers/IDNs/PBMs
Market Momentum17 new customers in past 18 months90% licensed our solution frameworksSignificant repeat businessEnterprise backbone commitmentsOver 95M covered lives4 of top 5 payers55% of BCBS Plans
HC Practice Overview40% of Pega BusinessDeep domain expertise
Results - ROI75% reduction Claims Backlog30% increase 1st pass rate98% reduction in group enrollment costs20% increase issues handled per contact 20% reduction call handling time50% reduction in training times
16 Pegasystems 2009
. . 4 of top 5 Largest U S Payers - % 34 of Blues Network - % 55 of Blues Members - 95 million covered lives
Marquee Healthcare Clients Transforming Healthcare
Across The Globe
17 Pegasystems 2009
Execution Gaps Closed by Our Customers
Medical Management
FDA & OIG Compliance
HIPAA, CMS & Blues Compliance
Subrogation, Collections &
Recovery
Internal Servicing Backbone
Claims and Adjustments
Service Exceptions Processing
Enterprise Case & Event Management
Cross-Sell, Up-sell
Web Self-Service
360 Degree View of the Customer
CSR Desktop
Sales Process Management
Enrollment
Tailored Offerings
Time to Market
Risk, Fraud, & ComplianceManagement
Servicing Backbone
Customer Relationship Management
New Business
18 Pegasystems 2009
New Business Backbone
PegaRULES Process Commander (PRPC)
Healthcare Industry Foundation Healthcare Common Object ModelX12 EDI Message Support
Sample Simulated DataSample Organizational Model
New BusinessNew Business CRMCRM Servicing BackboneServicing Backbone
RiskRiskFraud & Fraud &
ComplianceCompliance
CPM for Healthcare
Member
Services
Provider
Services
Sales ProcessManager
HC Product HC Product ConfigurationConfiguration
*NEW**NEW*
Claims Backbone
Claims
Repair
Claims
WS+
BuildBuildRiskRisk
FraudFraud&&
CompliaCompliancence
RulesRulesInIn
IndustryIndustryBackbonBackbon
eses
CPM HC FoundationCPM HC Foundation Claims FoundationClaims Foundation
SmartBPM for Healthcare
Care Mgmt Backbone*NEW*
Care
Management
Clinical FoundationClinical Foundation
New Member Enrollment
Authorization Management
Appeals & Grievances Manager
19 Pegasystems 2009
Healthcare Industry Foundation
Healthcare Common Object & Data Model
HC Enterprise Organization Structure
HIPAA X12 EDI Message SupportHealthcare PortalsHealthCare Object Search & Retrieval HealthCare Standard SLAs HIPAA Standard Code Sets
New Business Member Enrollment
C R MAuthorization Management
Servicing Backbone Appeals and Grievances
Risk and Fraud MgmtAuthorization Management
Interaction Management
Case Management & Control
20 Pegasystems 2009
HC Industry Framework (Representative Functionality)
§ ( , , , Work Parties member provider broker plan, , )sponsor agency etc
§ HIPAA EDI x12 Support
§ ( , , Healthcare Common Objects claims authorization, , , , )premium benefits COB policy etc
- Pre configured Healthcare Components
Reusable Work Templates
§ & Member Search Review§ & Claim Search Review§ & Provider Search Review§ & Authorization Search Review§ & Policy Search Review
- Pre built HIPAA Functionality
Correspondence Generation
§ - Reusable standard letter templates compiled dynamically when needed
§ - ; Automated or on demand choose to require review or allow edits
§ Maintained as part of inalterable audit trail for compliance reporting
§ ( & - )Automated file input batch real time§ & x12 message parsing mapping§ HIPAA property validation§ HIPAA x12 EDI samples
Reporting
§ , & Out of the box productivity quality aging reports§ - Drill down review capabilities§ Custom report wizard
Automated Authorization Request Management
§ Provides Web Service SOAP Message for providers to - submit x12 278 transactions through Self service
portal§ - - Facilitates straight through processing of x12 278
based on easily customized sample business rules§ & Routes prioritizes pending transactions for
manual processing
& Member Application Enrollment Processing
§ , Sample enrollment workflows driving intake data & entry output
§ - ; Intent led data entry automated data population for PDF and email applications
§ Intelligent enrollment application routing§ & Per member risk factor computation underwriting
approval recommendation based on medicalunderwriting
& Appeals Grievances Management
§ - - , , Multi channel guided intake for web phone email andfax
§ Comprehensive member composite§ - , , Pre packaged workflows for Appeals Grievances
& / Requestor Party Information service claimsinformation
§ Concurrent assignments to multiple departments for & research response
§ - Secure one time link for external parties to provide data and work cases
21 Pegasystems 2009
Web
Customer Process Manager for Healthcare
Contact Center Object & Data Model
Phone Interactions CTI Interaction DriverDialog
ManagementInteraction Tracking
HC Customer ID & Verification HC 360 Degree View Customer ProfileManagement
Interaction Coaching Knowledge Management
Customer Linking Customer Alerts Interaction Analytics Customer Surveys Campaign Management
Contact Center Portals Email Response Fax & Mail Interactions Web Self-Service InteractionsCC Configuration Wizards
CC Queue Management Customer SLAs CC Quality Mgt CC Productivity Analytics Customer Security
Dispute Claim Payments /Denial
HealthCare - FAQs
Diagnose Problems Prior Authorization Review
Materials Fulfillment
Send CorrespondenceSchedule Activities
Complaint / Compliment
General Service Requests
Claim Status Review
Add Newborn
Order ID Cards
Add / Update PCP
Manage Privacy Settings
Appeal Prior Auth Denial
Request Pre-certification / Prior Authorization
Manage Group Participation
Manage Provider Participation
Mange Provider Credentialing
Manage National Provider ID
Healthcare Common Object , Data Model & Policy Structure
HC Payer Enterprise Organization Structure
Member Eligibility
Interaction Management
Case Management & Control
Work Automation
Both Member & Provider ServiceMember Service Provider Service
Multi-member / Multi – policy inquiry
Member Healthcare diagnostic
22 Pegasystems 2009
CPM-HC (Representative Functionality)
§ Inbound Customer Call
§ & Automated email receipt casecreation
§ Manual inbound correspondence case creation
§ Customer verification *
§ Interaction Driver TM with & suggested customer processes
offers
§ Smart Dialog TM interactionscripting
§ & Interaction log audit trail *
§ -Automated interaction wrap up
§ Communication workflow
§ Contact Priority Note
§ - Multi policy servicing including inactivity logic
§ Designee management *
§ - Role based authority management *
§ Reference Utilities for Reference, Materials Location Finder and Find
Provider
§ Smart View TM customer data composite( , , , , policy member provider facility
, ,claims authorizations & )contact plan sponsor
§ & General Informationprofile§ - Multi channel interactionhistory§ Service history§ Benefit Review§ & Claim search review§ & Authorization searchreview§ Notes
§ Add a Contact
§ Quick Contact Add
§ & Update Contact Name Profile*
§ & Update Contact Address Profile
§ Add Attachment
§ /Complaint Compliment
§ Dispute Claim
§ Frequently Asked Questions
§ General Service Case
§ Materials Fulfillment
§ Member Eligibility
§ Member Search
§ ( , Schedule Activity call
, )appointment task
§ Send Correspondence
* Facilitates HIPAACompliance
Interaction Management Customer Management General Service Request Processing
Member Service RequestProcessing
§ Add a Newborn
§ Order ID Card
§ , Update Member Address Birth
, date Name
§ Update Primary Care Physician *
§ Update Privacy Settings*
§ - / – Multi member Multi policy
inquiry facilities
Provider Service RequestProcessing
§ Appeal Prior Auth Denial
§ Enroll in a Provider Network
§ Manage National Provider ID
§ Request Prior Authorization
§ Update Provider Credentials
§ Update Provider Profile
CTI Facilities§ & CTI Login Availability
§ - Screen pop with data collection
from IVR
§ Desktop telephony controls
23 Pegasystems 2009
§ - System assigned routing based on
case urgency§ , & Service level goals deadlinesescalation events
§ User work lists
§ System workbaskets
§ Get Most Urgent Work functionality
§ - Work re assignment
§ - Customer based service level
profiles
§ - Customer based service level
override
§
§ Interaction reports
§ Productivity reports
§ Quality reports
§ Aging reports
§ Campaign reports
§ & Pipeline opportunity reports
§ Quality Performance Reports
§ Knowledge Management Reports
§ Custom report wizard
§ - Drill down review capabilities
§ & Automatic manual
generation
§ & Create modify templates
§ , , & Mail email fax
capabilities
§ , & Review editing
verification privileges
§ , & Access groups privileges user portals for*:
Ø , & Member Provider UniversalCSRs
Ø , & Member Provider UniversalManagers
Ø Sales RepresentativesØ Sales ManagersØ System Administrators
§ , & Operator profile schedule skills
management
§ Workbasket assignments
§ Secure login
§ & Random manual work selection
§ , & Employee review rating scoring
§ & - Coaching sessions real time
coaching tips
Reporting
& Work Assignment Service Level Management
CorrespondenceGeneration
Quality PerformanceManagement
/ Access Roles Operator
Maintenance
CPM-HC (Representative Functionality)
Knowledge Management
§ Knowledge content rules and usage
statistics
§ & Knowledge inquiry response
§ User suggestions for content
update
* Facilitates HIPAACompliance
, & Offer Opportunity Territory Management
§ - , , Cross sell retention, &restitution reward
wellness campaigns§ - & Campaign set up wizard scriptdefinition
§ Suggested offer processing
§ , Opportunity creation assignment
& resolution
§ & Named customer territory
assignments
24 Pegasystems 2009
The CSR desktop is intent-driven and The CSR desktop is intent-driven and configured to optimize every customer configured to optimize every customer interaction and overall CSR efficiencyinteraction and overall CSR efficiency
Smart Dialog™Context-sensitive, Context-sensitive, personalized dialogpersonalized dialog
Interaction Driver™Context-sensitive, Context-sensitive, personalized taskspersonalized tasks
Smart Views™Context-sensitive, Context-sensitive, summary information summary information enables research & enables research & review review concurrent with concurrent with processprocessfulfillmentfulfillment
Smart Scripting™Dynamic scriptingDynamic scriptingminimizes training and minimizes training and ensures service ensures service consistencyconsistency
Member SpecificProcesses
Member SpecificViews
25 Pegasystems 2009
The Interaction Driver™ anticipates The Interaction Driver™ anticipates customer requests, suggests next steps customer requests, suggests next steps & queues tasks for more effective service& queues tasks for more effective service
PegaHEALTH™PegaHEALTH™Member Member ServicesServices
Customer data available on demandCustomer data available on demandInteraction logInteraction logwhere CSR’s been and goingwhere CSR’s been and going
Scripting guideScripting guideuser with minimaluser with minimalCSR trainingCSR training
Anticipates customer intent and guides CSRAnticipates customer intent and guides CSR
26 Pegasystems 2009
Grievances & Appeals (Representative Functionality)
§ , , Phone email fax or Web
§ / / Original email fax stored w work item
§ Guided data entry
§
- Multi Channel Intake
Historical Composite Member View
§ Automatic retrieval of relevant legacy dataØ Member BenefitsØ Provider Contract
§ ’ User s access group controls information display
- Pre Packaged Workflows
Correspondence Generation
§ - Reusable standard letter templates compiled
dynamically when needed
§ - ; Automated or on demand choose to require review or
allow edits
§ Maintained as part of inalterable audit trail for
compliance reporting
§ Appeals Management Processes
§ Grievance Management Processes
§ Case Creation
§ Requestor Party Information
§ / Service and or claims information
- Multi Party Processing
§ Concurrent assignments to multiple departments for
& research response
§ - Secure one time link for external parties to provide
data and work cases
§ Easily attach supporting documents including
medical notes
§
Reporting
§ , & Out of the box productivity quality aging reports
§ - Drill down review capabilities
§ Custom report wizard
Compliance Features
§ Automated service levels to ensure compliance and move cases towards timely resolution
§ Comprehensive audit trail documents all human and system generated activities
27 Pegasystems 2009
Comprehensive Care Management
Care Plan Management
Goal Management
Alert Management
Task Management
Care Management Framework
HealthCare Payer Object and Data Model
Patient 360 Portal
Authorization System Interface
ICD-9 Code Lookup CPT Code Lookup HCPCS Code Lookup NDC Code Lookup
HC Payer Enterprise Organization Structure
HC Clinical Object and Data Model
X12 278 STP Patient Event Visualizer
Campaign Management
Authorization Management
Care Plan Template Management
Goal Template Wizard
Alert Template Wizard
Task Template Wizard
Code Group Management
Assessment Management
Pharmacy Claim System InterfaceMedical Claim System Interface
Correspondence Templates
Case Management & Control
Work Automation
Interaction Management
28 Pegasystems 2009
Care Management (Representative Functionality)
Comprehensive Call Management
Patient 360
Correspondence Generation
§ - Reusable standard letter templates compiled dynamically when needed
§ - ; Automated or on demand choose to require review or allow edits
§ Maintained as part of inalterable audit trail for compliance reporting
§ , - -Patient 360 degree view provides a complete up to ’ date profile of the member s care and compliance with Care Plans
§ Comprehensive view of patient demographics , , including contacts providers policies/ eligibility benefit information
Reporting
§ , & Out of the box productivity quality aging reports§ - Drill down review capabilities§ Custom report wizard
Automated Monitoring of Care Plans
§ , Automated monitoring of complications exceptions to , - optimal care avoidable utilizations of high cost ( , services emergency department care
, )hospitalizations etc§ ’ Alerts notify Care Managers of a patient s lack of
compliance with a Care Plan§ , Automated creation of correspondence to patients
, providers and case managers
- Wizard Driven Program Creation
§ , Structured wizard driven creation of Care Management programs
§ Reusable components optimize Program creation§ Flexible design allows for Programs to be created
and deployed rapidly by business users§ Automated documentation of Care Plans help ensure
consistency and support meeting operational goals of Care Management programs
Unified Care Management
§ , Single portal for Disease Management Case Management and Utilization Management
§ Supports managing participants across the spectrum of care
§ Improves the delivery of Care Management programs ’ by providing a complete view of the patient s care
§ - Automated straight through processing ofauthorizations
§ Support for creating and routing of authorizationrequests
§ , , Drill down views of medical claims pharmacy claims and authorizations
§ Schedule Call tasks support flexible scheduling of ’ periodic monitoring and assessment of the patient s
health§ Automated scheduling of follow up calls§ Powerful assessments support branching and hide
logic for questions§ Assessments perform risk calculation and automatic
creation of Care Plans based on risk
Automated Case Creation
§ Out of the box support for automated case creation with automatic assignment of Programs and Care
Plans
29 Pegasystems 2009
Healthcare Claims Suite
& Healthcare Payer Common Object Data Model
HC Payer Enterprise Organization Structure
Healthcare Portals
Claim Prioritization and Escalation
Claims 360 degreeDashboard
Claim Edits Claim Inventory Management Automated WorkDistribution Productivity Analytics
XML Inbound Claims Image ViewerIntegration
Legacy Claim SystemConnectors
HIPAA X12 837Outbound
HIPAA X12 837Inbound
Claim File Management
Automated Pended Claim Corrections
Intent Lead – Desktop Claim CorrectionsPre-Adjudication Member Edits / Corrections
Pre-Adjudication -Provider Edits / Corrections
Pre-Adjudication –Professional ServiceEdits / Corrections
Pre-Adjudication –Institutional ServiceEdits / Corrections
Pre-Adjudication – Duplicate ValidationEdits / Corrections
Interaction Management
Case Management & Control
Work Automation
Both claims repair
& workstation +Claims Repair Claims Repair
30 Pegasystems 2009
Finalized Claims
NewClaimFiles
NewClaimFiles
PreProcessing
PreProcessing
Adjudication
Adjudication
Pended
ClaimFiles
Pended
ClaimFiles
Healthcare Claims…
Actual Customer Results§39% improvement in first pass rate (63% to 72%)
§40% increase in staff productivity
§60% STP of previously manually processed work
§75% reduction in training time & expense
§40% throughput increase in first week
§62% reduction in average inventory days on hand (7.8 to 3)
§48% of duplicate claim deferrals repaired automatically
CLAIMS REPAIRCLAIMS REPAIR
CLAIMS REPAIRCLAIMS REPAIR CLAIMS WORKSTATION+CLAIMS WORKSTATION+
Anthem/WellpointPost-Adjudication
BCBSNCPost-AdjudicationDuplicates
HealthNowPost-Adjudication, BPM
BCBSXXCore AdjudicationRules
NASCOPost Repair
NASCOAdjudication RulesIn Data Entry UB04
Anthem/WellpointPre-Adjudication
BCBSMNPre – RX
HealthNowExtended AdjudicationXC Rules
IBCPre-Adjudication
CareFirstPre-Adjudication
Anthem/WellpointBPM
MAJOR PayerBPM
CareFirstBPMAdjudication
Recent Claims Automation Projects§Anthem: Group-Subgroup Load
§CMS: Medicare Enrollment into Core Admin
§New Client: Enrollment COB Mgmt
§Anthem: Benefit Plan Mgmt and Core Admin load
§Great West Life – Service Payment Rule load
§Vendor of Choice for four additional new clients
Anthem/WellpointGroup-Subgroup
Great West LifeService Payment RulesSEPY/BSBS
CSCCustomer Service
31 Pegasystems 2009
Claims Repair (Representative Functionality)
§ Code Translations§ Member§ Provider§ Timely Filing§ Duplicate Claim§ Routing Rules§ Accident Claims§ – Revenue CPT Code
Validations
Pre-Adjudication Business Edits
§ Routine Eye Exams§ Common Eye
Surgeries§ Chiropractor
Services§ Podiatry Services§ Anesthesia Services§ Inpatient Services§ Ambulance Services§ –Lab Tests
Prostate Screening Hemoccult Blood
Post-Adjudication Business Edits
§ – Pending Benefits Emergency Room Services§ – Pending Benefits Cardiac Rehab Services§ – Pending Pricing Home Health Injectable Drugs§ Pending Potential Duplicate Claim
Claims Input & Output Process
Correspondence Generation
§ – Critical Error Claims Member Not Found
§ - ( )837 Claim Pre Processing Flat File XML Conversion§ 837 XML Input Process§ Pended Claim XML Input Process§ & Claim Mapping Work Object Creation§ Repaired Claim Output File
Pre-Built Interface Capability
§ Claim Repository§ Member Eligibility§ Provider Data§ DRG Agreement Data§ ITS Prefix Data§ – Revenue Code CPT Code List§ & Diagnosis Procedure Code Data
Authorization Data
§ & Referral Authorization Data Retrieval
Reporting
§ - Pre adjudication Claim Repair Count Report§ - Post adjudication Claim Repair Count Report§ Custom Report Generation Wizard
32 Pegasystems 2009
Claims Workstation+ (Representative Functionality)
§ Secure Login§ : Access Groups Claims
, , Examiner Mgr SysAdmin§ : Custom Portals Claims
, , Examiner Mgr SysAdmin§ - Role based workflow
: / privileges Examiner Mgr
Sign-On / Sign-Off & Security
Automated Routing to Workbaskets
§ Duplicate claim detection§ Routing to specified workbasket§ - -Primary routing by line of
business§ Secondary routing by pend code§ : & Tertiary routing claim type
total charge amount
Correspondence Generation
§ - Auto correspondence for rejected ( & )claims Subscriber Provider
§ - Auto correspondence option for requesting additional info
( / / )patient provider medical§ - Pre configured templates for
info requests
§ Published Claim XML DTD§ - - ( )File Service Intake Listeners§ XML Parser to parse claim
elements§ Claim work object creation§ Finalized claim reconciliation
( & updating resolving work)objects
§ Prioritization for select pend ( & - )codes header line level
§ Primary points by claim age§ Additional points by Provider
, Groups Preferred Subscriber & Groups dollar total charge
thresholds
Service Level Management
Claim File Feed Intake
Claim Prioritization
§ : Overall pended claim assignment Provider Information Request/ Patient Subscriber Info Request Medical Info Request
§ Other Hold Reason
Automated Work Assignment
§ ’ Primary determination by user s personal worklist assignments
§ Secondary determination by workbasket assignments on
’ user s profile§ Tertiary determination by
thresholds set on workbaskets
Claims Adjudication System Integration Tools
§ SysAdmin tools for managing / desktop w multiple claim
systems§ Automatic retrieval of claim
from adjudication system§ - Split screen desktop display
during claim processing
Random Claims Audit
§ Random selection of completed claims for audit
§ Selected claims transferred to Audit Review workbasket
§ Auditor review of selectedclaims
33 Pegasystems 2009
Managed Desktop “Manage” the core systems
Control workflow with
Pega Dashboard of
the claim work
object and
processing optionsHost claimsadjudication system
Imaging system
Pegasystemclaim work object
•Integrate with claims
adjudication system
and imaging system
•Use PegaIMAGE Viewer
or third party tool to
view the claim image
34 Pegasystems 2009
Sales Process Manager
Opportunity Management
Census Management
Large Group Management
Agency And BrokerProfile Management
Company Profile Management
Small Group Quote Management
Small and Large Group Rating
Renewal Management
Sales Task Management
Proposal generation Group and Subgroup Application Generation
Healthcare Payer Common Object & Data Model
HIPAA X12 EDI Message Support Healthcare Portals
HealthCare Object Search & Retrieval HealthCare Payer Standard SLAs HIPAA Standard Code Sets
HC Payer Enterprise Organization Structure
ProductConfiguration
Interaction Management
Case Management & Control
Work Automation
35 Pegasystems 2009
Sales Process Manager (Representative Functionality)
§ , , Company quote opportunity agency and broker profile management
§ Automatic and ad hoc correspondence generation leveraging correspondence templates
§ Activity management
Profile Management
Rating & Pricing
§ - Employee based demographic rating for health and dental products
§ Supports actuarial and underwriting tables( - effective dated for use across multiple rating
)periods§ Manages rating tables through an Excel interface§ - Maintains group specific calculations for later
audits
Quoting & Proposal Management
Correspondence Generation
§ - Reusable standard letter templates compiled dynamically when needed
§ - ; Automated or on demand choose to require review or allow edits
§ Maintained as part of inalterable audit trail for compliance reporting
§ Manages opportunities for multiple brokers working with the same company
§ Creates rate card across multiple lines of business§ Supports both automated and manual census entry§ Automatically suggests products based on customer
& -profile census information to reduce antiselection
§ Packages professional proposals in multiple formats - including PDF for print or e mail to additional
parties§
Reporting
§ , & Out of the box productivity quality aging reports§ - Drill down review capabilities§ Custom report wizard
Group Enrollment
§ Packaged enrollment workflows§ Electronic submission of group application to
legacy systems§ & & Notifies assigns tasks to internal external
parties§ Manages completion via customizable SLAs
Product Configuration
§ Manages complex product hierarchies§ Assembles data entry screens and validation rules
for each product based on the includedcomponents
§ Allows easy definition and modification of the - product structure through custom purposed rule
forms§
36 Pegasystems 2009
SmartBPM Healthcare Sales Solutions Driving & Membership Growth Retention
Quoting & RatingManage Sales Opportunities
Prospecting
Lead Management
Operationalize Sales Channels
Select Benefits
Generate Quotes
Generate Proposals
Verify Inputs
Calculate Rates
Approve Rates and Riders
Develop Solutions
Product Development
Market Segmentation
Premium Rate Setting
Manage Renewals
Cross-Sell/Up-Sell
Campaign Management
Identify Market Opportunities
Regulatory Filings
Materials Creation
Product Load
RFPs: National Acct
Congressional Mandate: Medicare Part D
Preferred Broker: Large Account
Individual: HSA
Close / Optimize Sale
Right Products
Right Price
Right Effort / Cost
Positive Customer Experience
Enrollment
Collect Enrollment Data
Verify Eligibility & Contract Terms
Upload Systems w/Group / Subgroup
Fulfill & Activate Contract
FEATURESFEATURES
§Streamlined Quoting & Rating for Group & Individual Sales
§Sales Channel & Broker Management
§Automated Proposal Generation
§Component-based Product Creation & Maintenance
§Group & Prospect Management
BENEFITSBENEFITS
§1 Million Medicare Part D Members Captured During Initial Open Enrollment
§98% Quote Delivery Time Reduction
§200% Enrollment Processing Improvement
§35% Cost of Sale Reduction
§42% New Member Service Calls Reduction
§75% Manual Steps Eliminated
Product Configuration
SalesProcess Manager
Configure Claims System
37 Pegasystems 2009
CPM for Healthcare In Action
38 Pegasystems 2009
CPM Configuration Setup
Create a rule set and version
39 Pegasystems 2009
CPM ruleset for new additions
40 Pegasystems 2009
CPM Setup – update application
Be sure to add both rulesets
41 Pegasystems 2009
Sample – PRPC Configuration
Be sure Profile reflects changes
42 Pegasystems 2009
CPM setup – Work Pools
Work Pool update needed
43 Pegasystems 2009
CPM Wizard setup
After
Before
44 Pegasystems 2009
CPM setup – Wizard is now available
45 Pegasystems 2009
CPM setup – Service Process Accelerator
46 Pegasystems 2009
CPM wizard – Select ruleset and version
47 Pegasystems 2009
CPM Wizard – name the new process
48 Pegasystems 2009
CPM Wizard – When and where would you like it?
This will direct where your new process will be placed
49 Pegasystems 2009
CPM Wizard – something special needed?
This will make it easy to change screen content later
50 Pegasystems 2009
CPM Wizard – start enhancing
You are ready to test & refine!!
51 Pegasystems 2009
Standard PRPC – update the UI
52 Pegasystems 2009
CPM Wizard – Flow Action defaults
53 Pegasystems 2009
CPM Wizard – Flow Action defaults
54 Pegasystems 2009
CPM – New process in action
55 Pegasystems 2009
CPM – add/update dialog defaults
56 Pegasystems 2009
CPM – update new flow