Overview of CTI & PegaCALL along with CPM for Healthcare Matt Ruffing Rob Mills Frank Hahn –
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[email protected] 1 Pegasystems 2009 Agenda CTI Ø Ø Ø Ø Ø CTI – What and why PegaCALL architecture Integration with PRPC Application Flow Terminology CPM for Healthcare Ø Ø Ø Ø Ø Ø Ø Ø Generic CPM HC DEMO CPM HC Class structure Enabling CPM HC Wizard CPM Wizard to create flow Show new flow in HC working Under covers of flow design and structure Changing User Interface of flow Overview of integration to external systems with CPM Questions Pegasystems 2009 2 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 3 Pegasystems 2009 Rules-Driven Computer Telephony Integration (CTI) with PegaCALL for PegaRULES sLegacy pre-fetch to drive IVR processing and call routing sRe-use rules to drive IVR decisioning sAdaptive screen pop for effective coordination of call arrival sDesktop and workflow-based telephony controls for improved call management sImplement individually or incrementally! 4 Pegasystems 2009 CTI Functions • Call Control Ø Customer data pre-fetch Ø Call routing Ø Adaptive screen pop • Desktop Telephony Ø Ø Ø Ø Ø Ø Ø Ø Ø ACD/PBX Login/ Make available/ Hold/Un-hold Answer call Make call Disconnect call Conference call Blind transfer Warm transfer 5 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, Nuance Ø 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, Cisco Ø 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 Pegasystems 2009 the IVR, the phone switch or other sources 6 Why implement CTI? • Cost Savings Ø 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 Ø Customers don’t have to repeat information they have provided to the IVR Ø Agents start the call more focused on the customer’s issue Ø Adds perceived value to entering data in the selfservice IVR, once customers learn they will not have to repeat information to an agent Ø Prefetch and screen pops make agents more efficient Ø Integrated telephony features simplify agent tasks Ø Pegasystems 2009 • Increased customer satisfaction • Promotes self-service use: • Increase agent productivity: 7 PegaCALL Enables PRPC applications with Computer Telephony Integration (CTI) Ø Increased Agent Productivity: Ø Retrieve customer information in advance of the agent receiving the call Ø Deliver the call and the customer information simultaneously Ø Rules driven screen pop delivers the right customer data based on the agent, the customer and the call • 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 Ø Provide the agent receiving the call with details they need to continue service Pegasystems Ø Allow an 2009 agent to pick up at the point in Ø Lower Customer Frustration: • Transfer the call and the data: 8 1 Caller is directed to IVR and prompted for information needed to access profile PegaCALL 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. CTI Integration Approach ACD 6 CTI middleware places caller in ACD queue as instructed & notifies PegaCALL upon call offering event 2 3 1 Member dial 800 # and is directed to IVR for ID prompt 1 4 5 6 7 8 8 9 3 CTI middle ware may request data from Pega for preroute 4 CTI Middleware requests adjunct route from PegaCall 2 IVR may access legacy systems if desired 7 9 Rules retrieve & evaluate data & determine when/if telephony functions are required by CSR 8 MQ or SQL 5 PegaCALL maintains connection for POP and CTI events C u s t o m e r S e r v SQLNet Production applications Mainframe, OS/390 Oracle DB 9 Pegasystems 2009 PegaCALL for PegaRULES High Level Architecture PSTN 1 2 IVR Routing Point PBX / ACD 7 Telephone 5 6 Queue A Queue B Queue C 4 Workstation 7 6 4 T-Server Windows Server PegaCALL CTI Link 3 7 7 SOAP Services SOAP Connectors PegaCALL Back-End Systems and Databases Containing Real-Time Customer Information PegaRULES Process Commander PegaCALL Installation with Genesys 10 Pegasystems 2009 PegaCALL for PegaRULES • CTI support for most major ACD’s using industry standard CTI middleware and routing platforms: Ø Ø Ø Ø Envox CT Connect Genesys Aspect Contact Server Cisco ICM • Server-side CTI integration • Real time adaptive screen pops Ø Provides seamless integration of telephony events and business processes Ø No desktop DLL’s to install Ø Puts the right customer information in front of the agents Ø Eliminates need for the customer to repeat to the agent what they just entered into the IVR Ø Fully configurable – can trigger different processes based on the agent and customer profiles for enhanced customer service Ø Transfer customer and work object data with the call Ø Pegasystems 2009 • Voice and Data Transfer • 11 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 • 12 • The CPM 6.1 release (2009) will include pre-configured voice/data transfer capability, so that when a user Pegasystems 2009 Terms you need to know: • Telephony Ø Ø Ø Ø Ø Ø Ø Ø ANI – Automatic Number Identification DNIS – Dialed Number Identification Service ACD – Automatic Call Distributor Skills Based Routing – A feature of many ACD’s that provide the ability to route calls based on call type and agents skill set 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 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 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 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 IVR/VRU – Interactive Voice Response / Voice Response Unit Screen Pop – Screen Population 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 CTILink – Pega component that sits between PRPC and the CTI Server Soft Phone – Software based phone that allows agents to control telephony functions from their computer 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 period 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) 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 Handle Time/AHT – Average Handle Time is the time it takes to handle an interaction. This typically includes wrap and any after call work. 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. Pegasystems 2009 • CTI Ø Ø Ø Ø Ø • Call Center Ø Ø Ø Ø Ø Ø 13 • CPM for Healthcare 14 Pegasystems 2009 Pegasystems – The Healthcare BPM Leader HC Practice Overview 40% of Pega Business Deep domain expertise Market Momentum Results - ROI 75% reduction Claims Backlog 30% increase 1st pass rate 98% reduction in group enrollment costs 20% increase issues handled per contact 20% reduction call handling time 50% reduction in training times 17 new customers in past 18 months 90% licensed our solution frameworks Significant repeat business Enterprise backbone commitments Over 95M covered lives 4 of top 5 payers 55% of BCBS Plans Target Market Large Payers > 2MM Members Top Pharma / LifeScience Cos Healthcare Government Selective Providers/IDNs/PBMs 15 Pegasystems 2009 Marquee Healthcare Clients Transforming Healthcare Across The Globe 16 4 of top 5 Largest U . S . Payers 34 % of Blues Network Blues Members - Pegasystemsmillion covered lives 95 2009 55 % of Execution Gaps Closed by Our Customers New Business Time to Market Customer Relationship Management CSR Desktop Servicing Backbone Enterprise Case & Event Management Risk, Fraud, & Compliance Management Subrogation, Collections & Recovery Tailored Offerings 360 Degree View of the Customer Service Exceptions Processing HIPAA, CMS & Blues Compliance Enrollment Web Self-Service Claims and Adjustments FDA & OIG Compliance Sales Process Management Cross-Sell, Up-sell Internal Servicing Backbone Medical Management 17 Pegasystems 2009 SmartBPM for Healthcare New Business New Business Backbone CRM CPM for Healthcare Servicing Backbone Care Mgmt Backbone *NEW* Claims Backbone Compliance Risk Fraud & Sales Process Manager Membe r Service s Provide r Service s Care Management Claims Repair Claims WS+ Build Risk Fraud & Complia nce Rules In Industry Backbon es HC Product Configuration *NEW* CPM HC Foundation Clinical Foundation Claims Foundation New Member Enrollment Healthcare Common Object Model X12 EDI Message Support Appeals & Grievances Manager Authorization Management Sample Simulated Data Sample Organizational Model Healthcare Industry Foundation PegaRULES Process Commander (PRPC) 18 Pegasystems 2009 Healthcare Industry Foundation Inter action Mana gement Healthcare Common Object & Data Model HC Enterprise Organization Structure HealthCare Object Search & Retrieval EDI Message Support HIPAA X12 Healthcare Portals HealthCare Standard SLAs HIPAA Standard Code Sets Case Mana gement & Contr ol New Business Member Enrollment CRM Authorization Management Servicing Backbone Appeals and Grievances Risk and Fraud Mgmt Authorization Management 19 Pegasystems 2009 HC Industry Framework (Representative Functionality) Member Application & Enrollment Processing Pre-configured Healthcare Components §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 medical underwriting § § § § § § § Work Parties (member, provider, broker, plan sponsor, agency, etc) HIPAA EDI x12 Support Healthcare Common Objects (claims, authorization, premium, benefits, COB,Functionality Pre-built HIPAA policy, etc) Automated file input (batch & real-time) x12 message parsing & mapping HIPAA property validation HIPAA x12 EDI samples Appeals & Grievances Management §Multi-channel guided-intake for web, phone, email and §Comprehensive member composite §Pre-packaged workflows for Appeals, Grievances, fax Requestor Party Information & service/claims information §Concurrent assignments to multiple departments for research & response §Secure one-time link for external parties to provide data and work cases Reusable Work Templates §Member Search & Review §Claim Search & Review §Provider Search & Review §Authorization Search & Review §Policy Search & Review Reporting 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 §Out of the box productivity, quality & aging reports §Drill-down review capabilities §Custom report wizard Correspondence Generation §Reusable standard letter templates - compiled §Automated or on-demand; choose to require review or §Maintained as part of inalterable audit trail for compliance reporting allow edits dynamically when needed 20 Pegasystems 2009 Customer Process Manager for Healthcare Inter action Mana gement Phone Interactions HC Customer ID & Verification Customer Linking Contact Center Portals CTI HC 360 Degree View Customer Alerts Email Response Interaction Driver Customer Profile Management Interaction Analytics Dialog Management Interaction Tracking Knowledge Management Campaign Management Interaction Coaching Customer Surveys Fax & Mail Interactions Web Self-Service InteractionsCC Configuration Wizards Web Contact Center Object & Data Model Healthcare Common Object , Data Model & Policy Structure HC Payer Enterprise Organization Structure CC Queue Management Customer SLAs CC Quality Mgt CC Productivity Analytics Customer Security Member Ser vice Case Mana gement & Contr ol Both Member & Provider Ser vice General Service Requests Materials Fulfillment Complaint / Compliment Send Correspondence Prior Authorization Review Claim Status Review Provider Ser vice Member Healthcare diagnostic Appeal Prior Auth Denial Manage Provider Participation Dispute Claim Payments / Multi-member / Multi – policy inquiry Denial Add Newborn Order ID Cards Add / Update PCP Manage Privacy Settings HealthCare - FAQs Schedule Activities Diagnose Problems Member Eligibility Request Pre-certification / Prior Authorizat Mange Provider Credentialing Manage National Provider ID Manage Group Participation Wor k Automation 21 Pegasystems 2009 CPM-HC (Representative Functionality) Interaction Management § Inbound Customer Call § Automated email receipt & case creation § Manual inbound correspondence case creation § Customer verification * § Interaction DriverTM with suggested customer processes & offers § Smart DialogTM interaction scripting § 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 CTI Facilities Provider § CTI Login & Availability § Screen-pop with data collection from IVR § Desktop telephony controls 22 Customer Management § Smart ViewTM customer data composite (policy, member, provider, facility, claims, authorizations, contact & plan sponsor) § General Information & profile § Multi-channel interaction history § Service history § Benefit Review § Claim search & review § Authorization search & review § Notes § Add a Contact § Quick Contact Add § Update Contact Name & Profile* § Update Contact Address & Profile § General Service Request Processing 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 Member Service Request Processing § 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 Pegasystems 2009 Provider Service Request Processing § Appeal Prior Auth Denial § Enroll in a Provider Network § Manage National Provider ID § Request Prior Authorization § Update Provider Credentials § Update Provider Profile * Facilitates HIPAA Compliance CPM-HC (Representative Functionality) § Random & manual work selection § Employee review, rating & scoring § Coaching sessions & real-time coaching tips Quality Performance Management Knowledge Management § Knowledge content rules and usage statistics § Knowledge inquiry & response § User suggestions for content update § Reporting Access Roles / § Access groups, privileges & user portals for*: ØMember, Provider & Universal CSRs ØMember, Provider & Universal Managers ØSales Representatives ØSales Managers ØSystem Administrators § Operator profile, schedule & skills management § Workbasket assignments § Secure login Correspondence Operator Maintenance Work Assignment & Service Level Management § 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 § System-assigned routing based on case urgency § Service level goals, deadlines & escalation events § User work lists § System workbaskets § Get Most Urgent Work functionality § Work re-assignment § Customer-based service level profiles § Customer-based service level override Offer , Opportunity & Territory Management § Cross-sell, retention, restitution, reward & wellness campaigns § Campaign set-up wizard & script definition § Suggested offer processing § Opportunity creation, assignment & resolution § Named customer & territory assignments Generation § Automatic & manual generation § Create & modify templates § Mail, email, & fax capabilities § Review, editing & verification privileges * Facilitates HIPAA 23 Compliance Pegasystems 2009 The CSR desktop is intent-driven and configured to optimize every customer interaction and overall CSR efficiency Smart Dialog™ Context-sensitive, personalized dialog Smart Scripting™ Dynamic scripting minimizes training and ensures service consistency Interaction Driver™ Context-sensitive, personalized tasks Member Specific Processe s Member Specific Views 24 Pegasystems 2009 Smart Views™ Context-sensitive, summary information enables research & review concurrent with process fulfillment PegaHEALTH™ Member Services The Interaction Driver™ anticipates customer requests, suggests next steps & queues tasks for more effective service Scripting guide user withAnticipates customer intent and guides CSR minimal CSR training Interaction log Customer data available on deman where CSR’s been and going 25 Pegasystems 2009 Grievances & Appeals (Representative Functionality) Multi - Channel Intake Pre - Packaged Workflows § § § § Phone, email, fax or Web Original email/fax stored w/work item Guided data entry §Appeals Management Processes §Grievance Management Processes §Case Creation §Requestor Party Information §Service and/or claims information Multi - Party Processing Historical Composite Member View §Automatic retrieval of relevant legacy data ØMember Benefits ØProvider Contract §User’s access group controls information display Reporting §Concurrent assignments to multiple departments for research & response §Secure one-time link for external parties to provide data and work cases of the box productivity, quality & aging reports §Easily attach supporting documents including medical notes l-down review capabilities om report wizard § Correspondence Generation Compliance Features §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 service levels to ensure compliance and §Comprehensive audit trail documents all human and system generated activities move cases towards timely resolution 26 Pegasystems 2009 Care Management Framework Inter action Mana gement X12 278 STP Medical Claim System Interface Patient 360 Portal Authorization System Interface Patient Event Visualizer Pharmacy Claim System Interface HC Clinical Object and Data Model HealthCare Payer Object and Data Model HC Payer Enterprise Organization Structure ICD-9 Code Lookup CPT Code Lookup HCPCS Code Lookup NDC Code Lookup Correspondence Templates Case Mana gement & Contr ol Goal Management Comprehensive Care Management Assessment Management Alert Management Task Management Care Plan Management Campaign Management Authorization Management Goal Template Wizard Care Plan Template Management Task Template Wizard Alert Template Wizard Code Group Management Wor k Automation 27 Pegasystems 2009 Care Management Wizard - Driven Program Creation (Representative Functionality) Comprehensive Call Management §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 §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 Patient 360 Unified Care Management §Patient 360 degree view provides a complete, up-todate profile of the member’s care and compliance with Care Plans §Comprehensive view of patient demographics including contacts providers, policies, eligibility/benefit information §Single portal for Disease Management, Case §Supports managing participants across the spectrum §Improves the delivery of Care Management programs §Automated straight-through processing of of care by providing a complete view of the patient’s care Management and Utilization Management Automated Case Creation authorizations §Support for creating and routing of authorization requests §Drill down views of medical claims, pharmacy claims, and authorizations §Out of the box support for automated case creation with automatic assignment of Programs and Care Plans Reporting 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 28 §Out of the box productivity, quality & aging reports §Drill-down review capabilities §Custom report wizard Correspondence Generation §Reusable standard letter templates - compiled §Automated or on-demand; choose to require review or §Maintained as part of inalterable audit trail for compliance reporting Pegasystems 2009 dynamically when needed allow edits Healthcare Claims Suite Claims 360 degree Dashboard XML Inbound Claims Inter action Mana gement HIPAA X12 837 Outbound HIPAA X12 837 Inbound Legacy Claim System Connectors Healthcare Portals Image Viewer Integration Healthcare Payer Common Object & Data Model HC Payer Enterprise Organization Structure Automated Work Productivity Analytics Inventory ManagementClaim Edits and Escalation Claim Distribution m Prioritization Case Mana gement & Contr ol Claims Repair Both claims repair & wor kstation + Claims Repair Intent Lead – Desktop Claim Corrections Pre-Adjudication – Duplicate Validation Pre-Adjudication Member Edits / Corrections Claim File Management Edits / Corrections Automated Pended Claim Corrections Pre-Adjudication -Provider Edits / Corrections Pre-Adjudication –Professional Service Pre-Adjudication –Institutional Service Edits / Corrections Edits / Corrections Wor k Automation 29 Pegasystems 2009 Healthcare Claims… Anthem/Wellpoint Pre-Adjudication IBC Pre-Adjudication HealthNow Extended Adjudication XC Rules New New Claim Claim Files Files CLAIMS REPAIR NASCO Adjudication Rules In Data Entry UB04 CareFirst Pre-Adjudication BCBSMN Pre – RX PreProcess PreProcess ing ing CSC Customer Service HealthNow Post-Adjudication, Anthem/Wellpoint BPM BPM CareFirst BPM Adjudication BCBSNC Post-Adjudication Duplicates Anthem/Wellpoint Group-Subgroup Great West Life Service Payment Rules SEPY/BSBS BCBSXX Core Adjudication Rules Adjudicati Adjudicati on on Pend Pend ed ed Claim Claim Files Files NASCO Post Repair CLAIMS REPAIR Anthem/Wellpoint Post-Adjudication CLAIMS WORKSTATION+ MAJOR Payer BPM Finalized 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 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 30 Pegasystems 2009 Claims Repair (Representative Functionality) Pre-Adjudication Business Edits Claims Input & Output Process § § § § § § § § Code Translations Member Provider Timely Filing Duplicate Claim Routing Rules Accident Claims Revenue – CPT Code Validations Surgeries §Chiropractor Services §Podiatry Services §Anesthesia Services §Inpatient Services §Ambulance Services §Lab Tests – Prostate Screening Hemoccult Blood §Routine Eye Exams §Common Eye §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 Post-Adjudication Business Edits §Pending §Pending §Pending §Pending Benefits – Emergency Room Services Benefits – Cardiac Rehab Services Pricing – Home Health Injectable Drugs Potential Duplicate Claim §Claim Repository §Member Eligibility §Provider Data §DRG Agreement Data §ITS Prefix Data §Revenue Code – CPT Code List §Diagnosis & Procedure Code Data Reporting Authorization Data re-adjudication Claim Repair Count Report ost-adjudication Claim Repair Count Report ustom Report Generation Wizard §Referral & Authorization Data Retrieval Correspondence Generation §Critical Error Claims – Member Not Found 31 Pegasystems 2009 Claims Workstation+ (Representative Functionality) Sign-On / Sign-Off & Security Correspondence Generation Claim Prioritization § § § § Secure Login Access Groups: Claims Examiner, Mgr, SysAdmin Custom Portals: Claims Examiner, Mgr, SysAdmin Role-based workflow privileges: Examiner/ Mgr Automated Routing to Workbaskets §Auto-correspondence for rejected claims (Subscriber & Provider) Auto-correspondence option for § requesting additional info (patient/provider/medical) Pre-configured templates for § info requests Service Level Management §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 Claims Adjudication System Integration Tools §Duplicate claim detection §Routing to specified workbasket §Primary routing by line-of§Secondary routing by pend code §Tertiary routing: claim type & total charge amount business §Overall pended claim assignment: Provider Information Request Patient/Subscriber Info Request Medical Info Request §Other Hold Reason §SysAdmin tools for managing desktop w/multiple claim systems §Automatic retrieval of claim from adjudication system §Split-screen desktop display during claim processing Automated Work Assignment Claim File Feed Intake Random Claims Audit §Primary determination by user’s personal worklist assignments §Secondary determination by workbasket assignments on user’s profile §Tertiary determination by thresholds set on workbaskets §Published Claim XML DTD §File-Service-Intake (Listeners) §XML Parser to parse claim §Random selection of completed elements Claim work object creation § §Finalized claim reconciliation (updating & resolving work objects) claims for audit Selected claims transferred to § Audit Review workbasket Auditor review of selected § claims 32 Pegasystems 2009 Managed Desktop “Manage” the core systems Control workflow with Pega Dashboard of the claim work Imaging system Host claims adjudication system object and processing options •Integrate with claims adjudication system and imaging system •Use PegaIMAGE Viewer Pegasystem claim work object or third party tool to view the claim image 33 Pegasystems 2009 Sales Process Manager HIPAA X12 EDI Message Support Inter action Mana gement Healthcare Payer Common Object & Data Model HC Payer Enterprise Organization Structure Product Configuration HealthCare Payer Standard SLAs Healthcare Portals HealthCare Object Search & Retrieval HIPAA Standard Code Sets Case Mana gement & Contr ol Opportunity Management Proposal generation Group and Subgroup Application Generation Company Profile Management Agency And Broker Profile Management Large Group Management Sales Task Management Census Management Small and Large Group Rating Small Group Quote Management Renewal Management Wor k Automation 34 Pegasystems 2009 Sales Process Manager (Representative Functionality) Profile Management Quoting & Proposal Management § § § Company, quote opportunity, agency and broker profile management Automatic and ad hoc correspondence generation leveraging correspondence templates Activity management Rating & Pricing §Manages opportunities for multiple brokers working §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 § Product Configuration with the same company §Employee-based demographic rating for health and §Supports actuarial and underwriting tables dental products (effective- dated for use across multiple rating periods) §Manages rating tables through an Excel interface §Maintains group-specific calculations for later audits Group Enrollment §Manages complex product hierarchies §Assembles data entry screens and validation rules §Packaged enrollment workflows §Electronic submission of group application to for each product based on the included components §Allows easy definition and modification of the product structure through custom-purposed rule forms legacy systems Notifies & assigns tasks to internal & external § parties Manages completion via customizable SLAs § Reporting § Correspondence Generation dynamically when needed allow edits §Reusable standard letter templates - compiled §Automated or on-demand; choose to require review or §Maintained as part of inalterable audit trail for compliance reporting of the box productivity, quality & aging reports l-down review capabilities om report wizard 35 Pegasystems 2009 Product Configuration SmartBPM Healthcare Sales Solutions Driving Membership Growth & Retention Sales Process Manager Identify Market Opportunities RFPs: National Acct Develop Solutions Product Development Manage Sales Opportunities Prospecting Campaign Management Lead Management Quoting & Rating Select Benefits Calculate Rates Generate Quotes Close / Optimize Sale Right Products Right Price Enrollment Collect Enrollment Data Market Segmentation essional Mandate: Medicare Part D Premium Rate Setting Preferred Broker: Large Account Individual: HSA Regulatory Filings Materials Creation Product Load Verify Eligibility & Contract Term Upload Systems w/Group / Subgro Right Effort / Cost Fulfill & Activate Contract Positive Customer Experience Configure Claims System Operationalize Sales Channels Generate Proposals Cross-Sell/ Up-Sell Manage Renewals Verify Inputs Approve Rates and Riders FEATURES Sales §Streamlined Quoting & Rating for Group & Individual §1 Million Medicare Part D Members Captured Duri Initial Open Enrollment BENEFITS §Sales Channel & Broker Management §Automated Proposal Generation §Component-based Product Creation & Maintenance §Group & Prospect Management 36 §98% Quote Delivery Time Reduction §200% Enrollment Processing Improvement §35% Cost of Sale Reduction §42% New Member Service Calls Reduction §75% Manual Steps Eliminated Pegasystems 2009 CPM for Healthcare In Action 37 Pegasystems 2009 CPM Configuration Setup Create a rule set and version 38 Pegasystems 2009 CPM ruleset for new additions 39 Pegasystems 2009 CPM Setup – update application Be sure to add both rulesets 40 Pegasystems 2009 Sample – PRPC Configuration Be sure Profile reflects changes 41 Pegasystems 2009 CPM setup – Work Pools Work Pool update needed 42 Pegasystems 2009 CPM Wizard setup Before After 43 Pegasystems 2009 CPM setup – Wizard is now available 44 Pegasystems 2009 CPM setup – Service Process Accelerator 45 Pegasystems 2009 CPM wizard – Select ruleset and version 46 Pegasystems 2009 CPM Wizard – name the new process 47 Pegasystems 2009 CPM Wizard – When and where would you like it? This will direct where your new process will be placed 48 Pegasystems 2009 CPM Wizard – something special needed? This will make it easy to change screen content later 49 Pegasystems 2009 CPM Wizard – start enhancing You are ready to test & refine!! 50 Pegasystems 2009 Standard PRPC – update the UI 51 Pegasystems 2009 CPM Wizard – Flow Action defaults 52 Pegasystems 2009 CPM Wizard – Flow Action defaults 53 Pegasystems 2009 CPM – New process in action 54 Pegasystems 2009 CPM – add/update dialog defaults 55 Pegasystems 2009 CPM – update new flow 56 Pegasystems 2009