pega healthcare industry foundation

Pega Healthcare Industry Foundation

BUSINESS USE CASE GUIDE 7.23

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Pega Healthcare Industry Foundation

Document: Business Case Use Case Guide

Software Version: 7.23

Updated: March 2017

CONTENTS

Healthcare Common Codes Solution overview ....................................................... 1-1

Business overview ..................................................................................................................... 1-1

Using and creating code sets and code groups ........................................................................ 1-1 Code sets .............................................................................................................................. 1-1 Code groups .......................................................................................................................... 1-2

Code manager portal ................................................................................................. 2-1

Overview .................................................................................................................................... 2-1

Personalized dashboard ............................................................................................................ 2-1

Code Manager Portal – Dashboard ........................................................................................... 2-2

Code Manager Portal – Code Groups ....................................................................................... 2-3 Code Manager Portal – Code Sets ........................................................................................... 2-4

Code manager portal - search use cases ................................................................. 3-1

Code searches .......................................................................................................................... 3-1 Use Case 1: Search code sets ............................................................................................. 3-1 Use Case 2: Search code groups ......................................................................................... 3-2 Use Case 3: Search ICD mapping ........................................................................................ 3-3

Code manager portal - code sets use cases ............................................................ 1-1

Use Case 1: Search codes in a code set .................................................................................. 1-1

Use Case 2: Update metadata .................................................................................................. 1-3

Use Case 3.1: Manage code set – add code ............................................................................ 1-4

Use Case 3.2: Manage code set – edit code ............................................................................ 1-5

Use Case 3.3: Manage code set – edit (in Excel) ..................................................................... 1-6 Use Case 4: Uploading code files ............................................................................................. 1-9

Use Case 5: Accessing audit trail, attachments and notes ..................................................... 1-11

Use Case 6: Create a custom code set ................................................................................... 1-13

Dynamic Class Referencing in Code Management Layer ...................................................... 1-15 Configuration ....................................................................................................................... 1-15

Code manager portal - code group use cases ......................................................... 5-1

Use Case 1: Configure code group ruleset ............................................................................... 5-1

Use Case 2.1: Create code group ............................................................................................. 5-3

Use Case 2.2 Approve/reject code group ................................................................................. 5-8

Use Case 3.1: Update code group metadata ............................................................................ 5-8

Use Case 3.2: SaveAsNewVersion for CodeGroup ................................................................ 5-10

Use Case 3.3: Create a copy from a code group .................................................................... 5-12 Use Case 4: Import Code Groups ........................................................................................... 5-14

Use Case 5: Accessing audit trail, attachments and notes ..................................................... 5-19

Healthcare Common Codes Solution Business Use Case Guide 1-1

Business overview The solution described in this document addresses the creation and maintenance of healthcare codes that you can leverage in business processes. It also describes the ability to create and save custom code groupings that you can use in business processes, for example, definition of benefits. Pega’s Healthcare Product Composer solution leverages the code group capability.

The key features include:

Manage commonly used healthcare code sets

Manage custom code groups to support business objectives such as creation and management of benefit terms and definitions

Using and creating code sets and code groups Code sets The Healthcare Common Codes solution supports the following code set types. You can create additional code set types as needed.

Admission Type ICD 10 to 9 Dx Modifier

Bill Type ICD 10 to 9 Pcs NDC – Product/Package

CDT® ICD 9 to 10 Dx Occurrence Date

CPT® ICD 9 to 10 Pcs Occurrence Span

Condition codes ICD 9 Dx Place of Service

DRG ICD 9 Pcs Patient Relation

DSM ICD 10 Dx Patient Status

Facility ICD 9 Pcs Point of Origin

Field Qualifier Provider Taxonomy

Frequency Revenue

GCN Service Types

HCPCS Value Codes

Provider Type

BETOS

Event Codes

Provider Specialty

Healthcare Common Codes Solution overview


TITLE of INTERNAL DOCUMENT – Arial Bold 12 pt

The solution contains a small sample set of codes for each of these sets. The expectation is that Pega’s customers will use their licensed code sets to populate the database tables shipped with the solution.

Follow the steps mentioned in the Use Case 4: Uploading code files to load your licensed versions of the code sets to the corresponding database tables.

Code groups The solution provides a Code Group Manager Portal that provides the ability to create and maintain custom code groups. Once you establish the code sets and populate the corresponding data tables with code set data, you can build the code groups as outlined later in this guide.


Overview The Common Codes solution in the Healthcare Industry Foundation provides a pre-configured portal for the code manager to perform their daily tasks. The solution also comes with a pre-configured sample operator ID and role. Additional details on the access group, access role, and privileges are available in the Healthcare Industry Foundation Implementation Guide on the PDN.

Login: CodeManager@PegaHealthCodes

Password: install

Portal Name: CodeGroupManagerPortal

Personalized dashboard The Healthcare Industry Foundation provides the ability to personalize the dashboard with pre-configured widgets as desired by the user. This feature allows the code manager to configure the layout of the dashboard on the portal by organizing the pre-configured widgets that are available for their use. In addition to the common work management and other operational widgets available in Pega 7, the Healthcare Foundation also provides the following specialized widgets configured expressly for the code manager role:

Total Code Groups by Category: Shows count of total code groups by category created in the application

Total Code Groups by Purpose: Show count of total code groups by purpose created in application

Code Manager Worklist: current worklist for logged in user

Search Codes in Code Sets: widget to search for codes

Code manager portal


Code Manager Portal – Dashboard

The Dashboard is the default space upon login and can be personalized with available widgets

Navigation Panel for quick access to code sets and code group spaces, recent cases, and cases being followed

User profile menu

Create menu to launch new code

Pega Pulse Collaboration gadget

Weather gadget (personalized)

Team Members in workgroup

Work Queues to access work

User’s Work Queue

Search menu to search code sets, code groups, and ICD Mapping



Code Manager Portal – Code Groups The Code Groups space of the code manager portal displays a list of configured code groups. User can sort and filter the listing by any of the available columns. Clicking on the code group name hyperlink for any of the code group listing will open the code group instance (described later in this document).



Code Manager Portal – Code Sets The Code Sets space of the code manager portal displays a list of available code sets that are being managed in the solution. User can click on the code set type hyperlink to open the code set object (described later in this document).


Code searches This section describes the search capabilities around code sets, code groups, and ICD mapping (General Equivalence Mapping) that are included in the application.

Use Case 1: Search Code Sets

Use Case 2: Search Code Groups

Use Case 3: Search ICD Mapping

Use Case 1: Search code sets This functionality performs a search of selected code sets type using specific search criteria (as code only) and displays the results.

Steps:

1. Log in to the Code Manager Portal using:

User Name: CodeManager@PegaHealthCodes

Password: install

2. Click Search > Code Set.

3. Select the desired code set type.

Code manager portal - search use cases



4. Search with code.

5. Click the expand row icon that display additional available metadata for the selected code.

Use Case 2: Search code groups This functionality performs a search of selected code group type using specific search criteria (matching string in code group name) and displays the results.

Steps:

1. Log in to the Code Manager Portal using:


Password: install

2. Click Search > Code Group.



3. Leave the Code Group Category unselected and search for “ambulance”. The system displays a list of code groups matching the search criteria.

4. Click on the hyperlink for any code group name to view the details of the code group including the code set and the range of codes included in the grouping.

Use Case 3: Search ICD mapping This functionality performs a search of diagnosis or procedure (either ICD9 to 10 or ICD 10 to 9) general equivalence mappings (GEMs) using specific search criteria (either code or description) and displays the results.



The following GEMs mapping code files need to have been loaded and available:

ICD 10 Diagnosis and Procedure

ICD 9 Diagnosis and Procedure

ICD 10 to 9 Diagnosis and Procedure

ICD 9 to 10 Diagnosis and Procedure

Steps:

1. Login to the Code Manager Portal using:


Password: install

2. Click Search >ICD Mappings.

3. On the default dropdown selected item is (ICD-9 to ICD-10), click Diagnosis, and enter the code or description to display the results.

4. Click on expand row in the listing to see the value of the mapping flags and additional metadata as defined in the GEMs mapping tables.


This chapter contains business use cases to aid in searching of specific codes of a code set, update of code set metadata, managing code sets, loading codes, creating your own custom code set.

Use Case 1: Search codes in a code set

Use Case 2: Update metadata

Use Case 3: Manage code sets

− Use Case 3.1: Add code

− Use Case 3.2: Edit code

− Use Case 3.3: Edit in Excel

Use Case 4: Uploading code files

Use Case 5: Accessing audit trail, attachments and notes

Use Case 6: Create a custom code set

Use Case 1: Search codes in a code set This functionality performs a search of select code sets using specific search criteria and displays the results.

Steps:

1. Log in to the system.


Password: install

2. Click Code Sets in the left navigation pane.

Code manager portal - code sets use cases



The system displays a pre-configured list of code sets included in the release.

3. Click the Bill Type code set.

4. Filter and Search options.

Filter code set: To filter the search results, click the column level filter list, and provide the filter criteria, for example, episode, and click Apply.



The system displays codes matching the filter criteria.

Search code set: Enter code or description in textbox provided for search and click the Search button.

The system displays codes matching the search criteria.

Use Case 2: Update metadata This functionality allows you to update the metadata of a code set.



Steps:

1. Repeat steps 1 through 3 of Use Case 1: Search codes in a code set.

2. Select Other Actions > Update Code Set metadata.

3. Make your changes and click Submit to save the changes related to metadata.

Use Case 3.1: Manage code set – add code This functionality allows you to add a code to a code set.



Steps:


2. Click Add Code and click Submit to persist data in the system.

Use Case 3.2: Manage code set – edit code This functionality allows you to edit code.

Steps:


2. Click Expand on the grid rows, and make necessary changes.

3. Click Save to persist the data in the system.



Use Case 3.3: Manage code set – edit (in Excel) This functionality allows for updating multiple codes using the Edit (in Excel) feature. This feature is available with 32-bit version of Excel.

Steps:


2. Review code set data.

3. Select Other Actions > Edit > Export to download the file to be edited in Excel.

4. Make necessary data changes to the rows of data in the downloaded file without making any changes to columns and column formats.



5. Save the file locally for importing back into the application. Maintain the csv format.

6. Select Other Actions > Edit > Import to upload the updated file.

7. Select the updated file and click Upload.



The system prompts to upload the data records with a summary of updates.

8. Click OK to submit the updates to the system.

9. The system saves the changes to the code set file.



Use Case 4: Uploading code files This functionality allows you to upload set of codes. For more information on the supported file formats for each of the code sets, refer to the HCIF Common Codes – Supported File Formats document available on the PDN. The following example shows the functionality in the context of UB04 Frequency code set.

Steps:

1. Log in to the system using


Password: install

2. Click the on Code Sets link on the navigation panel to view a list of all code sets available in the application.

3. Select the desired code set to open the object.

4. Click on the Other Actions link on the header to view the options. Click on Upload code set file option.



5. In the Upload code set file window, click Choose File to browse for and select the desired code set file.

6. Click Upload. The system loads the code set data and displays the newly uploaded codes.



7. Review the information and click Submit to save the codes to the respective database table.

Note: Every code set work object maintains a history of uploaded files.

Use Case 5: Accessing audit trail, attachments and notes This functionality allows you to view the audit details of updates to the code set, attachments, or updated notes.

Steps:

1. Log in to the system using:


Password: install

2. Click on Code Sets in the navigation pane on the portal and click on the desired code set (example shows Frequency Code Set).

3. Click on the Other Actions link on the header to view the options. Click on View history option.



The system displays the Case Audit Details.

4. Expand the History section to review the audit history details.

5. Expand the Attachments section to review the attachments to the case including the code file used for uploading the codes.



Optionally, you can click the Add button under the Attachments section to add any desired attachments to the case.

6. Click Close to close the Case Audit Details window.

Use Case 6: Create a custom code set This section illustrates the creation of a custom code set.

To configure a custom code set, you must create or modify the rules listed in the following table.

Rule Type Name Details Data Class PegaHealth-Codes-Data-XXXX Create a data class that extends the abstract class

“PegaHealth-Codes-Data-”. Create the necessary properties.

DB Table <database table name> Create a table in the database. Database Table mapping

<PRPC database mapping rule> Map the data class to the DB table using an instance of “Data-Admin-DB-Table”.

Parse Delimited Name space: ParseCode

Record Type: ParseCode

Create parse delimited rule, in lines with the format of the incoming data in the code set file.

Decision Table GetCodeSetClass UPDATE this decision table by adding a row, to return the code set class.

Decision Table GetCodeSetDateFormat UPDATE this decision table by adding a row, to return the format of the effective and expiration dates in the codes.

Property CodeSetType UPDATE this property, present in the code set work type ‘PegaHealth-Work-CodeSet’, to have the appropriate value and label for the custom code set.

The following rules are optional and are for configuring additional features such as add a single code, delete a code, and Save edited code. Modify these rules for your custom code set depending on the functionality that you want.



Rule Type Rule Name Create or Update

Details

DataTransform AddSingleCode Create Create this DataTransform in the code set data class, which sets the properties of the new code. (Refer to the DataTransform, with the same name, in other code set classes.)

Activity DeleteCode Create Create this activity in the code set data class, to delete a single code. (Refer to the activities, with the same name, in other code set classes.)

Activity SaveEditedCode Create Create this activity in the code set data class, to update an existing code. (Refer to the activities, with the same name, in other code set classes.)

Data Page D_XXXX Create Create a data page in code set class, which will data source as Activity named as ‘PrepareQueryString’. Parameters passed as Code and CodeSetType.

Report Definition AllCodes Create Create a Report Definition in the Code set class, to fetch the codes from the DB. (Refer to the Report definition, with the same name, in other code set classes.)

Data Transform pySearchModel Create Create a data transform to set all properties to “” which all needs to be fetch through report definition and display on listing.

Section ReviewAllCodes_XXXX_InSearch Create Create a section with repeat Grid layout to

show the codes fetched using the source as data page created in above step as ‘D_XXXX’.

Section ReviewAllCodes_XXXX Create Create a section with repeat Grid layout to show the codes fetched using the source as data page created in above step as ‘D_XXXX’.

Section ReviewAllCodes Update Include the section ‘ReviewAllCodes_XXXX’, to show conditionally, when the CodeSetType is the custom code set.

Section ReviewAllCodesInSearch Update Include the section ‘ReviewAllCodes_XXXX_InSearch’, to show conditionally, when the CodeSetType is the custom code set.

Activity PrepareForEditableDisplay Update Update this activity to create a page, which is used to show the parsed codes. (Refer the other steps, which are created for other code sets.)



Rule Type Rule Name Create or Update

Details

List EditList Create Create a list rule, with the properties of the code set. This rule will be used during ‘Edit in excel’. (Refer to List rules, with the same name, in other code set classes.)

Data Transform RemoveCodeListPages Update Update to remove the Page that has the codes of the code set. This page was created in ‘PrepareForEditableDisplay’ and ‘OpenDefaults’ activities.

Activity ParseCodeSet Update This is the main activity that handles the parsing. If the custom code has any other dates, apart from effective and expiration dates, edit the java step (with label ‘Format the Dates’) in this activity.

Control OpenWO Update Update this control, which displays the label for the code set.

Dynamic Class Referencing in Code Management Layer Dynamic Class Referencing (DCR) is a pattern to avoid hardcoding of class names, flow names, workbasket names and so on at an application level so that the implementation layers can easily extend the application.

HCIF has implemented the DCR approach using a data page and data transforms. Using this approach, any specialized layer that is built on the PegaHealthCodes layer, need to only Save-As the data transform rules in the specialized layer ruleset to update the class names, flow names and add any additional property mappings. This approach will dynamically set the specialized layer’s class names, flow names and any other values to the appropriate clipboard pages at run time.

Configuration Follow the steps to configure DCR:

1. Search for the Data Page: D_AppExtension and copy the above data page into your implementation ruleset.

2. Enter the field details as per your configuration settings. Enter Object type as PegaHealth-Codes-Data-AppExtension class or implementation class in the specialized layer extended class from PegaHealth-Codes-Data-AppExtension.

3. In the Data sources section:

a. Select Source type as Data Transform from the drop-down list and b. Select Data transform AppExtension from above selected or its parent classes. c. Update the properties in the Data transform as per your implementation layer settings.



Note: As a best practice, you can create a new class extending from PegaHealth-Codes-Data-AppExtension in the implementation layer and configure Data Transfer in the implementation layer with only required properties to easily consume base layer settings coming in future releases.


This chapter contains the business use cases to aid in configuring a code group ruleset; creating code groups; managing code groups; and performing bulk updates to code groups.

Use Case 1: Configure code group ruleset

Use Case 2: Create code group

− Use Case 2.1: Create code group

− Use Case 2.2: Approve/reject code group

Use Case 3: Manage code groups

− Use Case 3.1: Update metadata

− Use Case 3.2: SaveAs New Version for CodeGroup

− Use Case 3.3: Create a copy from code group

Use Case 4: Import code groups

Use Case 5: Accessing audit trail, attachments and notes

Use Case 1: Configure code group ruleset

Note: An open ruleset version must be available to create and maintain custom code groups.

The Solution includes a MyCustomRules locked ruleset which contains pre-configured sample code groups. To use the sample code group instances in your application, add the MyCustomRules ruleset to the PegaHealthCodes application stack as shown below:

To create new code group instances in your implementation, configure an open ruleset version.

Code manager portal - code group use cases



1. Log in to the system as: Administrator@PegaHealthCodes / install

2. Create a new rule set, for example: MyCodeGroups version 01-01-01.

3. Add MyCodeGroups ruleset to the PegaHealthCodes application stack as shown with the MyCustomRules example above.

4. Select DesignerStudio > Healthcare > Configuration to navigate to the landing page.

5. Select MyCodeGroups ruleset and its version in the Code Group Settings as shown below, and click Save.

You are now ready to create and save custom code groups.



Use Case 2.1: Create code group This functionality allows you to create a code group.

Steps:

Before you begin, configure a custom rule set to hold the groups as illustrated in the above Use Case 1.

1. Log in to the system as: CodeManager@PegaHealthCodes / install

2. Click the Create link from the header.

3. Create Code Group: Enter Metadata.



4. Click Next to display the Select Codes step. Select desired Code Type and click appropriate option to search and add codes.



5. Search for and add one or more code ranges or individual codes. Click Submit when done with the selection of codes.

The system displays the newly added codes and code ranges.



6. Click Next to review the configured codes.



7. Click Submit to send the code group for approval.



Use Case 2.2 Approve/reject code group This functionality is a continuation to Use Case 2.1, to either Approve, Reject, or “Send To Originator”.

Steps:

1. Click Submit. The system takes you to an approve screen (or “Reject” or “Send To Originator”).

2. Alternatively, the user can reject or send to originator by choosing the appropriate option from the Other Actions menu.

The code group instance is saved to the database and the system displays a confirmation screen. The code group is listed with a status Resolved-Available.

Use Case 3.1: Update code group metadata This functionality allows you the user to update metadata of a code group.

Steps:



1. Log in to the system as: CodeManager@PegaHealthCodes / install 2. Click the Code Groups link in the left navigation pane to see the list of pre-configured code

groups.

3. Click on the code group name to open the instance.

4. Click Modify and we get two options to Update(Metadata) and Save as new version.

5. Click Update Metadata.



6. Make the necessary changes, and click Submit.

Use Case 3.2: SaveAsNewVersion for CodeGroup This functionality provides the option to modify a code group and save a new version.

Steps:

1. Log in to the system as: CodeManager@PegaHealthCodes / install 2. Click the Code Groups link in the left navigation pane to see the list of pre-configured code

groups.

3. Click on the desired code group name to open the instance.



4. Click Modify and select Save as new version

5. Update desired metadata (for example, effective dates), add appropriate Update Note and click Next to advance to the code ranges.

6. Make desired updates to existing codes and code ranges (add / delete codes or ranges) and click Next to submit the new code group version for approval.



See Use Case 2.2, for approve/reject/send-to-originator.

Once the new code group version request is approved, the system saves the new version to the database.

Use Case 3.3: Create a copy from a code group This functionality allows you to create a copy (SaveAs) from an existing code group.

Steps:

1. Log in to the system as: CodeManager@PegaHealthCodes / install 2. Click the Code Groups link the left navigation pane to see the list of pre-configured code

groups.



3. Click on code group name to open the instance.

4. Click Actions and then Create a Copy.

The system opens a new instance with metadata of parent code group.



For n

For the next steps, refer to Use Case 2.1 and Use Case 2.2.

Use Case 4: Import Code Groups This functionality allows you to bulk import the code group instances. This provides the flexibility to organize code group metadata and code ranges in external tools like Excel and bulk import into the system. You can download preconfigured templates available for the process.

Steps:

1. Log in to the system as: CodeManager@PegaHealthCodes / install 2. Click the Import Code Groups link the left navigation pane to see the list of pre-configured

code groups.



There are two pre-configured templates provided. One is specifically configured for uploading code groups for BETOS code type. For all other code types, select the CodeGroup template.

1. Select the appropriate template type and click the Download template button.

2. Follow the Code Group Import Guidelines shown above to complete and save the downloaded template with code group data. See example below:



3. Click on Import button to continue the import process. In the first step, choose the file you want to upload. Click Next.

4. On the Map Fields screen, ensure appropriate Template type is selected. Preserve the default mapping and click Next to proceed with the upload.



5. On the Finish screen, leave the default selections as seen below and click Import.



6. The system starts the import process and shows the progress of the import. Depending on the number of rows in the import file, this can take some time. Click Finish once the rows are successfully imported.

7. You can review the newly uploaded code groups by clicking on the Code Groups navigation link of your portal.



Use Case 5: Accessing audit trail, attachments and notes This functionality allows you to view the audit details of updates to code groups, attachments or updated notes.

Steps:

1. Log in to the system as: CodeManager@PegaHealthCodes / install 2. Open any code group, and click Actions > View History.

You can also view an existing attachments and use the option to add attachments and screen shots.

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