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Pega Care Management case types

The Pega Care Management application provides the case types that are listed in the following table.

CaseDescription
AppealUsed for raising appeals and grievances when an authorization or request for coverage of a service has been denied.
Care managementUsed as the parent case to manage work that is taking place within the care management process. The case type reflects the corresponding program and associated alerts, goals, tasks, and intervention logic.
Utilization managementCovers work that pertains to utilization services, including prior authorization, concurrent review, and discharge planning services.
AdmissionUsed to create a member admission. The case type includes admission details, such as the admission date, length of stay, and admission type. It also captures the diagnosis and procedural details.
Personal health planUsed to create a personal health plan for the member. By using this case type, the care manager can enroll a member for the appropriate program and task.
Case conferenceCreated by a care manger to plan and conduct a conference among caregivers that might or might not include the member. A conference can be a visit follow-up or a utilization review. The purpose of a conference is to capture the member's current issues and caregiver recommendations to overcome those issues.
IncidentCaptures an incident for the member. A user captures the incident details, such as the date, location, and incident type, and the contact details of the person who reported the incident.
Program referralEnrolls a member into a program. After the member consents, a care manager chooses the appropriate program for the member based on the assessment. This is a stage-based case type that is in compliance with the National Committee for Quality Assurance (NCQA) standards.

Tags:

  • Pega Care Management 8.2
  • Pega Care Management 7.4
  • Pega Care Management 8.1
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Published March 23, 2018 — Updated March 22, 2019


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