benefit grouper
In the Pega Product Composer System for Healthcare application, a benefit grouper contains benefits. It organizes the benefits into classifications such as Surgery and Mental Health. A grouper accumulates visits, units, and dollars assigned to each benefit, and it lets the insurer configure limits that span the dependent benefits.
A benefit grouper is also used to configure cost shares that are reused for the benefits. A cost share is the portion of the costs, covered by your insurance, that members pay out of their own pocket. This term generally includes deductibles, coinsurance, and copayments, or similar charges. It does not include premiums, balance billing amounts for non-network provider and the cost of non-covered services.