Health Insurance

Project

Organisation Name-Alere

Application name-PAS(Prior Authoroization system)

Operators and access groups for below.

Developer

Admin

CSR

Pharmacist

MD

Create a new application

Login as Administrator@pega.com / install and

Name application as PAS. Which means Prior authorization system.

In advance window name organization as Apollo.

Create a new operator as PASadministrator@Apollo.com

Later logoff n login with new operator.

Configuring stages in PAS application

Go to cases explorer and create a new case type named as PA.

Create primary stages as below

Provider search
Member search
Drug search
Questionnaire
Pharmacist Approval
Medical director Approval
Resolve

Under provider search stage configure view with below fields

Provider ID
Provider name
Provider address
Provider email
Provider Phno

For member search configure below fields

Member ID
Member name
Member email
Member address
Member Phno

Drug search stage fields

Drug name
Dosage
Taken through
NO of days to be taken
Formulary alternatives

Data classes creation:

Create data classes in PAS application.

Go to data explorer

Add new data type and create a new data class as Members

Add below fields

Memberid
Member Name
Member email
Member phone number
Member address

Add new data type and create a new data class as Drugs

Fields as BElow

Gpc
Ndc
Drug name
Dosage
Formulary alternative

Follow the above instructions and create another data class for providers

Add below fields

Providerid
ProviderName
Provideremail
Providerphonenumber
Provider address

1. Provider Search Requirement:

User should enter provider id and hit on search button, then provider details like provider
name , address, email , phone number should display in repeating grid or table layout

Code Configuration:

In provider search section add a text box for entering provider id and a search button.

Add Repeating grid(Table Layout) to display all provider details

Create a datapage of type list and source as activity which can hit the database and get the
provider details based on provider id.

Add “on click” Refresh action on Search button. On click of search the table layout should
refresh and display provider details.

In the repeating grid add a select button and name it as “Select Provider”.

Onclick of “Select Provider” button trigger a datatransform name it as copyproviderdetails and

copy the data from primary page to pyWorkPage as below.

pyWorkPage.ProviderID = Primary.ProviderID
 Trigger the data transform from the “select Provider” button using onclick event.

Copied details will be displayed in Approve section.

2. Member search:

Follow the same steps above for member search

3. Drug search:

Follow the same steps above for Drug search

4. Task on questionnaire stage:

Create paragraph rules for each question (Right click on class  Create  User Interface 
Paragraph (write your question here and save it))

Q1. Is this a formulary drug?

Q2. What is the intake of this drug?

Q3. Number of drugs required

Q4. What dosage of drug was required?

Q5. What is the duration of the drug to be issued?

Once the paragraph rules are created, open questionnaire question and drag paragraph control
and map paragraph rule in it , then the question will display.

5. Create Answers for above questions.

A1. Create a property and give local list values, Yes NO (Refer network property in banking
project)

A2. Create a property with local list values with Mouth or Intraveinal

A3. Create a property of type text and no local list values

A4. Create a local list values with 25 Mg, 50 Mg , 75 Mg and 100 Mg

A5. Create a date property with name as duration

Map the above created answer properties to the questionnaire section below the corresponding
Question

6. Logic to auto approve or reject the case.

Create a decision table with below conditions

If the drug Mg is less than or equal to 50 Mg and if taken by Mouth  Approve the case

If the drug Mg is greater than 50 Mg and taken either by mouth or Intraveinal  Pend the case
7. Add a decision shape in the questionnaire flow and trigger the above created decision table

8. The outgoing connector from the decision table with the result as approve should be connected
to end shape and the other connector with result pend should be connected to “ChangetoStage
“ Smart shape to route to Pharmacist approval stage

9. Create a section and flow action named Approve with read only fields to display selected
provider, member, drug details.

10. Create a section and flow action named Reject to capture Reject reason.

11. In pharmacist approval stage add approve and reject screens from same assignment on its 2
outgoing connectors.

12. Upon case approval end the flow by connecting it to end shape.

13. If case is rejected add change to a stage smart shape and route to Medical director approval
stage.

14. Add above created approve reject screens on same assignment in medical director approval
flow like we configured above.

15. Upon approve or reject connect to end shape.

16. Add status as Resolved approved on approve connector and status as resolved rejected on
reject connector.

Configuring Routing:

17. Create a new workbasket named as PharmacistPendingCases.

18. Create a new work group as HealthCareTeam.
19. Add work group name in Work basket and vice versa.
20. Now create a new operator named as Pharmacist and map the work group and work basket in
that operator instance.
21. In the pharmacist approval flow on assignment shape configure work basket routing to route to
PharmacistPendingCases basket.
22. Create a case and testing routing.
23. Configure similar routing in Medical director Flow by creating a basket named as
MDPendingCases and an operator named as MedicalDirector. Use same old work group
HealthCareTeam in work basket MDPendingCases and in operator record.
 Reporting:

Create a report definition rule in work class to display Resolved –Rejected cases and plug it in
manager portal under Reports category using category and shortcut rules.

SLA

Create a SLA rule named as “PharmacistApprovalSLA” , when deadline time expires resume flow on
approve flow action, which means it should auto approve.

Create a SLA rule named as MDApprovalSLA when goal expires send reminder email, when deadline
expires auto approve case.

Agents

Create a advanced agent which triggers an activity which identified the cases whose pystatuswork is
“Resolved Approved” sends email to all the approved cases with subject holding case id approved and
body of mail holding all details.