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1 Pegasystems 2009 Overview of CTI & PegaCALL along with CPM for Healthcare Matt Ruffing [email protected] Rob Mills [email protected] Frank Hahn [email protected]

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Page 1: Pega CPMHC Training

1 Pegasystems 2009

Overview of CTI & PegaCALLalong with

CPM for Healthcare

Matt Ruffing – [email protected] Rob Mills – [email protected] Hahn – [email protected]

Page 2: Pega CPMHC Training

2 Pegasystems 2009


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


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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


Page 4: Pega CPMHC Training

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

Page 5: Pega CPMHC Training

5 Pegasystems 2009

CTI Functions

• Call Control Ø Customer data

pre-fetchØ Call routing Ø Adaptive screen


• 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

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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


Page 7: Pega CPMHC Training

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


Page 8: Pega CPMHC Training

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

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CTI Integration Approach

C u s t o m e r S e r v i c e

Oracle DBMainframe, OS/390



IVR may access legacy systems if



CTI middle ware may request data from Pega for pre-


CTI Middleware requests adjunct

route from PegaCall










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.













Page 10: Pega CPMHC Training

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PegaCALL for PegaRULES High Level Architecture

PegaCALL Installation with Genesys




Windows Server


Routing Point

Queue A



SOAP Connectors

PegaRULES Process Commander

SOAP Services

Back-End Systems and DatabasesContaining Real-Time Customer Information

Queue B

Queue C












5 6


Page 11: Pega CPMHC Training

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

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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.

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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.

Page 14: Pega CPMHC Training

14 Pegasystems 2009

CPM for Healthcare

Page 15: Pega CPMHC Training

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

Page 16: Pega CPMHC Training

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. . 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

Page 17: Pega CPMHC Training

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Execution Gaps Closed by Our Customers

Medical Management

FDA & OIG Compliance

HIPAA, CMS & Blues Compliance

Subrogation, Collections &


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


Tailored Offerings

Time to Market

Risk, Fraud, & ComplianceManagement

Servicing Backbone

Customer Relationship Management

New Business

Page 18: Pega CPMHC Training

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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 &


CPM for Healthcare





Sales ProcessManager

HC Product HC Product ConfigurationConfiguration


Claims Backbone











CPM HC FoundationCPM HC Foundation Claims FoundationClaims Foundation

SmartBPM for Healthcare

Care Mgmt Backbone*NEW*



Clinical FoundationClinical Foundation

New Member Enrollment

Authorization Management

Appeals & Grievances Manager

Page 19: Pega CPMHC Training

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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

Page 20: Pega CPMHC Training

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


§ , & 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

Page 21: Pega CPMHC Training

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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

Page 22: Pega CPMHC Training

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


§ 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


§ 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

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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


§ - Customer based service level



§ 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


§ & Create modify templates

§ , , & Mail email fax


§ , & 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


§ Workbasket assignments

§ Secure login

§ & Random manual work selection

§ , & Employee review rating scoring

§ & - Coaching sessions real time

coaching tips


& Work Assignment Service Level Management


Quality PerformanceManagement

/ Access Roles Operator


CPM-HC (Representative Functionality)

Knowledge Management

§ Knowledge content rules and usage


§ & Knowledge inquiry response

§ User suggestions for content


* 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


Page 24: Pega CPMHC Training

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

Page 25: Pega CPMHC Training

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

Page 26: Pega CPMHC Training

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



§ , & 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

Page 27: Pega CPMHC Training

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

Page 28: Pega CPMHC Training

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


§ , & 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


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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

Page 30: Pega CPMHC Training

30 Pegasystems 2009

Finalized Claims











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





HealthNowPost-Adjudication, BPM

BCBSXXCore AdjudicationRules

NASCOPost Repair

NASCOAdjudication RulesIn Data Entry UB04



HealthNowExtended AdjudicationXC Rules






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


Great West LifeService Payment RulesSEPY/BSBS

CSCCustomer Service

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31 Pegasystems 2009

Claims Repair (Representative Functionality)

§ Code Translations§ Member§ Provider§ Timely Filing§ Duplicate Claim§ Routing Rules§ Accident Claims§ – Revenue CPT Code


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


§ - Pre adjudication Claim Repair Count Report§ - Post adjudication Claim Repair Count Report§ Custom Report Generation Wizard

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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


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

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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

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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


Interaction Management

Case Management & Control

Work Automation

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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


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



§ , & 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


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36 Pegasystems 2009

SmartBPM Healthcare Sales Solutions Driving & Membership Growth Retention

Quoting & RatingManage Sales Opportunities


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


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


Collect Enrollment Data

Verify Eligibility & Contract Terms

Upload Systems w/Group / Subgroup

Fulfill & Activate Contract


§Streamlined Quoting & Rating for Group & Individual Sales

§Sales Channel & Broker Management

§Automated Proposal Generation

§Component-based Product Creation & Maintenance

§Group & Prospect Management


§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

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37 Pegasystems 2009

CPM for Healthcare In Action

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38 Pegasystems 2009

CPM Configuration Setup

Create a rule set and version

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39 Pegasystems 2009

CPM ruleset for new additions

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40 Pegasystems 2009

CPM Setup – update application

Be sure to add both rulesets

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41 Pegasystems 2009

Sample – PRPC Configuration

Be sure Profile reflects changes

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42 Pegasystems 2009

CPM setup – Work Pools

Work Pool update needed

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43 Pegasystems 2009

CPM Wizard setup



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44 Pegasystems 2009

CPM setup – Wizard is now available

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45 Pegasystems 2009

CPM setup – Service Process Accelerator

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46 Pegasystems 2009

CPM wizard – Select ruleset and version

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47 Pegasystems 2009

CPM Wizard – name the new process

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48 Pegasystems 2009

CPM Wizard – When and where would you like it?

This will direct where your new process will be placed

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49 Pegasystems 2009

CPM Wizard – something special needed?

This will make it easy to change screen content later

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50 Pegasystems 2009

CPM Wizard – start enhancing

You are ready to test & refine!!

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51 Pegasystems 2009

Standard PRPC – update the UI

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52 Pegasystems 2009

CPM Wizard – Flow Action defaults

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53 Pegasystems 2009

CPM Wizard – Flow Action defaults

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54 Pegasystems 2009

CPM – New process in action

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55 Pegasystems 2009

CPM – add/update dialog defaults

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56 Pegasystems 2009

CPM – update new flow