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Extending union data

Updated on January 26, 2021

Typically, you rely on inheritance when configuring entities in the benefit set tree in Pega Product Composer for Healthcare. When you do not rely on inheritance and you edit cost shares or variations within networks, groupers, and benefits, these values are stored as union data objects (PUnionDataObj). Union data is external to the product template, product, and plan. You can extend union data when you need to customize values to meet your business needs.

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Union data comprises the following types of data:

  • Cost shares, such as copayments and co-insurance
  • Variations or policies, such as limits and authorizations

The following example shows that the value of the copay for the benefit was not inherited from entities in the hierarchy. The benefit copay data is stored as a union object.

PUnionDataObj

Extending union data for cost shares

You can extend union data when you need to customize cost share or variation values to meet your business needs. For example, you might need to add a Max Allowed Amount cost share to restrict the amount of money that is reimbursed for an Ambulance benefit.

Union data has values for cost shares, including accumulators, order of cost shares, and coordination of benefits, as well as variations. These values are external to the product template, product, and plan.
  1. In the navigation panel of Dev Studio, click App.
  2. In the search field, enter Embed-HC-PCS-CostSharesAssembly.
  3. Click Data Model to expand it.
  4. Right-click Property and select Create.
  5. Complete the fields for the new property and save it to your implementation-layer ruleset.
  6. Repeat steps 4 and 5 for each property that you are adding to customize your application.
  7. In the header of Dev Studio, search for and select the CostShareAssemblyDetails_EXT rule in the Embed-HC-PCS-CostSharesAssembly class in the PegaHC-USA-PCS ruleset.
  8. On the CostShareAssemblyDetails_EXT page, click Save AsSpecialize by class or ruleset and save to your implementation-layer ruleset.
  9. Add the properties that you created to this section.
    For additional information, see Harness and Section forms - Adding a section.

    These changes are automatically displayed in the product template, product, and plan, under the network, grouper, and benefit.

    Note: The new properties that you add during this procedure follow the inheritance pattern of the Coordination of benefits (COB) field. Pega Product Composer for Healthcare does not support coordination of benefits in the network layer.

Extending union data for variations

You can configure policy variations for the network, grouper, and benefit. If needed for your business, you can add options for extending variation union data. For example, you might want to exclude a benefit such as disposable medical supplies when they are used in the home.

By default, Pega Product Composer for Healthcare supports these variations:
  • Copayment
  • Coinsurance
  • Deductible
  • Out-of-pocket
  • Limits
  • Authorization
  • Exclusion
  • Eligibility
  1. In the navigation panel of Dev Studio, click App.
  2. In the search field, enter Embed-HC-PCS-VariationsAssembly.
  3. Click Data Model to expand it.
  4. Right-click Property and select Create.
  5. Complete the fields for the property and save it to your implementation-layer ruleset.
  6. Repeat steps 4 and 5 for each property that you are adding to customize your application.
  7. In the header of Dev Studio, search for and select the VariationsAssembly_EXT rule in the Embed-HC-PCS-VariationsAssembly class in the PegaHC-USA-PCS ruleset.
  8. Copy the section to the implementation-layer ruleset.
  9. On the Variations-Assembly_EXT page, click Save As Specialize by class or ruleset and save to your implementation-layer ruleset.
  10. Add the properties that you created to this section.
    For additional information, see Harness and Section forms - Adding a section.

    These changes are automatically visible for the product template, product, and plan in the network, grouper, and benefit.

Extending union data for networks

In Pega Product Composer for Healthcare, you can add options to the network by extending it. For example, you might limit an out-of-pocket cost share for a family and not an individual.

  1. In the navigation panel of Dev Studio, click App.
  2. In the search field, enter Embed-HC-PCS-Network-.
  3. Click Data Model to expand it.
  4. Right-click Property and select Create.
  5. Complete the fields for the property and save it to your implementation-layer ruleset.
  6. Repeat steps 4 and 5 for each property that you are adding to customize your application.
  7. In the header of Dev Studio, search for and select the NetworkAdditionalDetails_EXT rule in the Embed-HC-PCS-Network- class in the PegaHC-USA-PCS ruleset.
  8. Copy the section to the implementation-layer ruleset.
  9. On the NetworkAdditionalDetails_EXT page, click Save AsSpecialize by class or ruleset and save to your implementation-layer ruleset.
  10. Add the properties that you created to this section.
    For additional information, see Harness and Section forms - Adding a section.
Result: These changes are automatically visible for the product template, product, and plan under the network, grouper, and benefit. You can view the changes in the Network additional details section.

Extending union data for groupers

You can extend the union data for groupers, for example, you might want to include a referral to a specialist.

A grouper organizes benefits into common medical areas. For example, all Surgery benefits can be organized under a Surgery grouper. You can also use groupers to accumulate visits, units, and dollars that are assigned to each benefit and configure limits that span the dependent benefits.
  1. In the navigation panel of Dev Studio, click App.
  2. In the search field, enter Embed-HC-PCS-Grouper-.
  3. Click Data Model to expand it.
  4. Right-click Property and select Create.
  5. Complete the fields for the property and save it to your implementation-layer ruleset.
  6. Repeat steps 4 and 5 for each property that you are adding.
  7. In the header of Dev Studio,search for and select the GrouperAdditionalDetails_EXT rule in the Embed-HC-PCS-Grouper- class in the PegaHC-USA-PCS ruleset.
  8. Copy the section to the implementation-layer ruleset.
  9. On the GrouperAdditionalDetails_EXT page, click Save As Specialize by class or ruleset and save to your implementation-layer ruleset.
  10. Add the properties that you created to this section.
    For additional information, see Harness and Section forms - Adding a section.

Extending union data for benefits

You can extend union data for benefits, for example, you might want to add a general Ultrasound benefit with a copayment and an Ultrasound benefit under the Pregnancy benefit that is covered in full.

A benefit is the basic building block of Pega Product Composer for Healthcare. Benefits include sets of code groups that define the benefit, as well as general parameters that describe the benefit such as its name, effective date, and end date. A benefit has mappings that describe the conditions of a benefit. For example, Infertility Treatment Outpatient has conditions that indicate place of service, diagnosis code, and service code. The definition of a benefit is fundamental in benefit determination during the claim adjudication process.
  1. In the navigation panel of Dev Studio, click App.
  2. In the search field, enter Embed-HC-PCS-Benefit-.
  3. Click Data Model to expand it.
  4. Right-click Property and select Create.
  5. Complete the fields for the property and save it to your implementation-layer ruleset.
  6. Repeat steps 4 and 5 for each property that you are adding.
  7. In the header of Dev Studio,search for and select the BenefitAdditionalDetails_EXT rule in the Embed-HC-PCS-Benefit- class in the PegaHC-USA-PCS ruleset.
  8. Copy the section to the implementation-layer ruleset.
  9. On the GrouperAdditionalDetails_EXT page, click Save As Specialize by class or ruleset and save to your implementation-layer ruleset.
  10. Add the properties that you created to this section.
    For additional information, see Harness and Section forms - Adding a section.

Tags

Pega Product Composer for Healthcare 8.5

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