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Pega Foundation for Healthcare '24.1

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Table of Contents
  • Get started
  • Release notes
    • Issues resolved in Pega Foundation for Healthcare 24.1
    • Known issues in Pega Foundation for Healthcare 24.1
    • Updating from prior versions
    • Deprecated and withdrawn rules
      • Deprecated rules
      • Withdrawn rules
  • Product overview
    • Features overview
      • Healthcare object model
      • Healthcare enterprise organization structure
      • Healthcare portals
      • Healthcare sample data
      • Healthcare object search and retrieval
      • Healthcare object layouts
      • Member data masking
      • Member data management
      • Provider data management
      • Healthcare code set management
      • Healthcare code group management
      • Healthcare Appeals and Grievances management
      • HIPAA X12 EDI message support
      • Common integration REST APIs
      • Common integration FHIR REST APIs
      • Integration data pages
      • EDI Eligibility request management
      • Provider directory search and display
      • Document management
      • EDI Claim status request management
      • EDI NCPDP message support
      • HL7 ADT transactions
      • RxNorm drug data search
    • Pega Foundation for Healthcare case types and workflows
      • Example case types
      • Standard case types
      • Associated work case type
    • Roles, portals, and dashboards in Pega Foundation for Healthcare
      • Access Roles
      • Portals and dashboards
    • Primary data entities
    • Further reading
  • Install
    • Completing the prerequisite tasks
    • Backing up your system
    • Installing Pega Foundation for Healthcare
      • Importing the modularized application files
      • Importing full application file
    • Optional: Importing sample data
    • Optional: Importing demo application and sample operators
    • Optional: Enabling sample operator accounts
    • Optional: Configuring a ruleset for your custom code groups
    • Enabling Elasticsearch
    • Search and Reporting Service (SRS) adoption
    • Optional: Configuring a custom local file path for system messaging
  • Update and Hotfixes
    • Pega Foundation for Healthcare 24.1 Update guide
      • Completing the prerequisite tasks
      • Backing up your system
      • Updating Pega Foundation for Healthcare
        • Exporting custom code groups
        • Updating the modularized application files
        • Importing full application file
      • Optional: Importing sample data
      • Optional: Importing demo application and sample operators
      • Optional: Enabling sample operator accounts
      • Optional: Configuring a ruleset for your custom code groups
      • Enabling Elasticsearch
      • Search and Reporting Service (SRS) adoption
      • Optional: Configuring a custom local file path for system messaging
      • Post-update tasks
        • Importing custom code groups
        • Enabling code group versioning on the existing custom code groups
        • Enabling code versioning for CPT, HCPCS, and ICD10 code types
        • Updating existing policy objects
        • Updating existing practitioner, provider, business entity, and provider network objects
        • Updating existing Member objects
        • Updating existing Member's Date of Birth
        • Updating addresses on Practitioner, Provider, and Business entity objects
        • Updating event codes
        • Updating subscribers and policies with Medicare Beneficiary Indicator (MBI)
        • Updating dates on Business entities
        • Updating plans
        • Updating Provider taxonomies
        • Update codeset metadata
        • Setting the version number of your built-on application
        • Appeals and Grievances Manager application only: Updating the LoadAGMSettings data transform
    • Post-update tasks for Pega Cloud services environments 8.x to 24.1
      • Pega Foundation for Healthcare 24.1 Update process
        • Importing custom code groups
        • Enabling code group versioning on the existing custom code groups
        • Enabling code versioning for CPT, HCPCS, and ICD10 code types
        • Updating existing policy objects
        • Updating existing practitioner, provider, business entity, and provider network objects
        • Updating existing Member objects
        • Updating existing Member's Date of Birth
        • Updating addresses on Practitioner, Provider, and Business entity objects
        • Updating event codes
        • Updating subscribers and policies with Medicare Beneficiary Indicator (MBI)
        • Updating dates on Business entities
        • Updating Plans
        • Updating Provider taxonomies
        • Update codeset metadata
        • Setting the version number of your built-on application
        • Appeals and Grievances Manager application only: Updating the LoadAGMSettings data transform
    • Pega Foundation for Healthcare hotfixes
      • Hotfixes for Pega Foundation for Healthcare 8.x
        • Pega Foundation for Healthcare '24.1
        • Pega Foundation for Healthcare 8.8
        • Pega Foundation for Healthcare 8.7
        • Pega Foundation for Healthcare 8.6
        • Pega Foundation for Healthcare 8.5
        • Pega Foundation for Healthcare 8.4
        • Pega Foundation for Healthcare 8.3
        • Pega Foundation for Healthcare 8.2
        • Pega Foundation for Healthcare 8.1
      • Hotfixes for Pega Foundation for Healthcare 7.x
        • Pega Foundation for Healthcare 7.4
        • Pega Foundation for Healthcare 7.31
        • Pega Foundation for Healthcare 7.23
        • Pega Foundation for Healthcare 7.22
  • Implement
    • Preparing for implementation
    • Prerequisites
    • Creating new application
      • Creating the baseline application
        • Creating the implementation application only
        • Running new application wizard
        • Creating the framework application and implementation applications
          • Creating a framework application
          • Creating an implementation application on top of a framework application
            • Results of running new application wizard
            • Leveraging optional Healthcare applications
      • Loading sample data
    • Case type configuration
    • Defining the data model
      • Pre-configured data types
      • Pre-configured data pages
      • Pre-configured REST Connector data pages
      • Pre-configured FHIR REST Connector data pages
      • Mapping the application data
    • Connecting system of record
    • Application configurations
      • Defining common codes management requirements
      • Defining code set Elasticsearch requirements
      • Defining code group requirements
      • Enabling Elasticsearch
      • SRS Adoption
    • Updating dynamic class referencing
      • Configuring DCR
    • Integrations
      • Pre-configured REST APIs
      • Pre-configured HL7 FHIR REST APIs
      • Navigating to the pre-configured external data pages
      • Viewing REST API data model schema
      • Pre-configured X12 5010 EDI message services
      • Pre-configured X12 5010 837 claim de-batch process
    • Defining the security model and organization structure
      • Defining your authentication scheme
      • Defining your access groups
      • Defining access roles and privileges
    • Customizing the user experience
      • Designing the portals
    • Features implementation
      • Integrating using REST APIs
        • Key rules in business request API execution
        • Accessing the API data page and connect REST rules
        • Setting the endpoint URL of the source system
        • Extending the mapping
        • Extending mapping using the MapToEntity pattern
      • Defining requirements
        • Defining member PII data masking requirements
        • General Data Protection Regulation (GDPR) support
        • Defining member PII by enabling HIPAA
        • Implementing Elasticsearch on HIPAA security policy
        • Defining reporting requirements
      • Integrating using HL7 FHIR REST APIs
        • Key rules in business request API execution
        • Accessing the FHIR API data page and connect REST rules
        • Setting the endpoint URL of the source system
        • Setup guide to leverage FHIR APIs
        • Error while invoking FHIR APIs
      • Integrating and managing X12 EDI messages
        • HIPAA X12 EDI message support
        • X12 270 - Eligibility request and response message
          • Extending mappings
          • Extending message validation
          • Extending eligibility processing
        • X12 276 - 277 - Claim status request and response message
          • Extending mappings
          • Extending processing
        • Defining the X12 834 outbound file path
      • Comparing two instances (the clipboard structures)- Plan Compare
      • Managing custom code sets
      • Managing code groups
      • Implementing Code Versions (ICD10/HCPCS/CPT)
      • Implementing Elasticsearch on code sets
        • Using Elasticsearch
      • Implementing Elasticsearch on sample data objects
        • Using Elasticsearch
      • Managing member PII data masking
      • Internationalization of Addresses and Phone Numbers for Practitioner, Provider, and Business entities
      • Member keyring
      • HL7 Message Processing
      • RxNorm Drug Data Search capabilities
        • Loading RxNorm data using file listeners
          • Detailed view of a RxNorm file intake process
        • Drug search using RxNorm data model
      • Medical Dictionary for Regulatory Activities (MedDRA) code set
        • Loading MedDRA code set files
          • Detailed view of a MedDRA file intake process
        • Search for MedDRA codes
        • Search from the directory
        • Search for Terms or Codes
        • Multi-source configuration in data pages
      • Modifying the user interface
        • Determining which part of the user interface to modify
      • Document Management portal
      • Provider search
      • Associated work
      • Design Pattern
        • Create a Custom Code Group
          • Usecase example
          • Before you begin
          • Process
          • Results
        • Prescription plan data model
          • Prescription drug plan (PDP) elements
          • Use cases
          • PDP in Pega Foundation for Healthcare
        • Understanding RxNorm drug database
          • Overview
          • RxNorm structure
          • Use cases
          • RxNorm in PFHC
        • Understanding Medical Dictionary for Regulatory Activities
          • Medical Dictionary Overview
          • MedDRA data hierarchy
          • MedDRA Use cases
          • MedDra in PFHC
        • Extending the Healthcare Foundation Datamodel
          • Extending the data model
          • Adding data classes
          • Usecase: Foundation for healthcare prior authorization data model
          • Adding a property to the data model in Dev Studio
          • Adding a data object to the data model in Dev Studio
          • Best Practices
          • Resolution
          • Appendix
      • Explore Data
        • Pre-built Insights for Pega Foundation for Healthcare
        • Exposing data for Insights
      • Appendix A: Implementing the Appeals and Grievances application
        • Prerequisites
        • Initiate Stage
          • Creating the baseline application
            • Running the New Application wizard
          • Loading sample data
        • Delivery stage
          • Defining requirements
            • Defining the case type modifications and attributes
              • Updating existing case types
            • Defining the data model
              • Pre-configured data types
                • Healthcare object model
                • Healthcare enterprise organization structure
                • Healthcare portals
                • Healthcare sample data
                • Healthcare object search and retrieval
                • Healthcare object layouts
            • Define complaint reasons
            • Mapping the application data
            • Defining integration
              • Pre-configured REST APIs
            • Configuring SLAs
            • Correspondence templates
            • Defining the security model and organization structure
            • Customizing the User Experience
              • Designing the portals
            • Defining reporting requirements
          • Building features
            • Healthcare Appeals and Grievances management
            • Integrating data
              • Integration data pages
            • Implementing the security model
            • Modifying the user interface
              • Determining which part of the user interface to modify
            • Creating reports
            • ODAG and CDAG AGM report set
          • Testing a new application
          • Packaging a new application
          • Production maintenance and monitoring
      • Dynamically Driving Appeals, Grievances, & Organization Determination Sub-Cases from a Complaint Case
        • Overview
        • Dynamically driven complaint sub-cases
        • Create Complaint Workflow
        • Result
      • Create a Post-Service Appeal in Pega Foundation for Healthcare’s Appeals and Grievances Manager Layer
        • Usecase example
        • Demoing the scenario
        • Process or steps to create an appeal
        • Results
  • Technotes
    • Pega Foundation for Healthcare 24.1 Common codes solution business use case guide
      • Healthcare Common Codes Solution
        • Business overview
        • Using and creating code sets and code groups
          • Code sets
          • Code groups
      • Code manager portal
        • Overview
        • Personalized dashboard
        • Dashboard
        • Code Groups
        • Code Sets
      • Code manager portal - Search use cases
        • Code searches
        • Use case 1: Search code sets
        • Use case 2: Search code groups
        • Use case 3: Search ICD mapping
      • Code manager portal - Code sets use cases
        • Use case 1: Search codes in a code set
        • Use case 2: Update metadata
        • Use case 3: Manage code sets
          • Use case 3.1: Managing add code
          • Use case 3.2: Managing edit code
          • Use case 3.3: Managing edit (in Microsoft Excel)
        • Use case 4: Uploading code files
          • Use case 4.1: Upload code set file (except HCPCS, CPT, and ICD10)
          • Use case 4.2: Upload base code set file (HCPCS, CPT, and ICD10)
          • Use case 4.3: Upload base and change code set file (HCPCS, CPT, and ICD10)
          • Scenarios with different change types
            • Adding new code (Change Type: N): New
          • Updating existing code (Change_Type: C and U) : Change or Unrecognized change
          • Deleting the code (Change_Type: D): Delete
        • Use case 5: Accessing audit trail, attachments, and notes
        • Use case 6: Create a custom code set
        • Use case 7: Navigating the Medical Dictionary for Regulatory Activities (MedDRA) code set
          • Use case 7.1: Search from the directory
          • Use case 7.2: Search for Terms/Codes
        • Dynamic Class Referencing in Code Management Layer
          • Configuration
      • Code manager portal - Code group use cases
        • Use case 1: Configure code group ruleset
        • Use case 2: Create code group
          • Use case 2.1: Create code group
          • Use case 2.2 Approve or reject code group
        • Use case 3: Manage code groups
          • Use case 3.1: Update code group metadata
          • Use case 3.2: SaveAsNewVersion for CodeGroup
          • Use case 3.3: Create a copy from a code group
        • Use case 4: Import Code Groups
        • Use case 5: Accessing audit trail, attachments, and notes
    • Pega Foundation for Healthcare 24.1 common objects API technical specification guide
      • About Pega Healthcare API services
        • Accessing Pega Healthcare APIs
          • Published Healthcare APIs
            • Business service APIs
          • API integration classes
        • Business request APIs
          • Connector rule for API
            • Key rules in business request API execution
            • Connector data page
            • Connect REST rule
            • Dynamic settings end point URL management data page
            • Map request data
            • Map response data
            • Wrapper map rule
            • Resource map rule
        • Business service API
          • Healthcare API - service package rule
          • REST service method
          • Key rules in service execution
          • Service REST rule
          • Resource and query parameters
          • Service activity rule
          • Mapping data transform rule
        • Extending Pega Healthcare APIs
          • MapToEntity extension pattern
          • Inbound mapping
        • HTTP status codes
          • Success codes
          • Error codes
        • Healthcare API - key
          • Business request APIs
            • Authorizations - GET authorization details
              • URL format
              • Parameters
              • Key rules
            • Authorizations - GET authorizations by member policy ID
              • URL format
              • Parameters
              • Key rules
            • Benefit request - POST benefit details
              • URL format
              • Parameters
              • Key rules
            • Business entities - GET business entity
              • URL format
              • Parameters
              • Key rules
            • Business affiliations - GET business entity
              • URL format
              • Parameters
              • Key rules
            • Policy - GET policy details
              • URL format
              • Parameters
              • Key rules
            • Member policies - GET member policies details
              • URL format
              • Parameters
              • Key rules
            • Provider Contracts - GET contract details
              • URL format
              • Parameters
              • Key rules
            • Claims - GET claim history
              • URL format
              • Parameters
              • Key rules
            • Employer group contract - GET employer group contract details
              • URL format
              • Parameters
              • Key rules
            • Member APIs
            • Members - GET member details
              • URL format
              • Parameters
              • Key rules
            • Members - GET members policy networks
              • URL format
              • Parameters
              • Key rules
            • Networks - GET network details
              • URL format
              • Parameters
              • Key rules
            • Payers - GET payer details
              • URL format
              • Parameters
              • Key rules
            • Plan details - GET plan details
              • URL format
              • Parameters
              • Key rules
              • Extensions for plan flattening using REST services
            • Plan networks - GET plan networks
              • URL format
              • Parameters
              • Key rules
            • Providers APIs
            • Providers - GET provider details
              • URL format
              • Parameters
              • Key rules
            • Providers - GET provider networks
              • URL format
              • Parameters
              • Key rules
            • Rate sheets - GET rate sheet details
              • URL format
              • Parameters
              • Key rules
            • Accumulators - GET accumulators
              • URL format
              • Parameters
              • Key rules
            • Plan catalog - GET Plan search results
              • URL format
              • Parameters
              • Request Structure
              • Response structure
              • Key rules
        • Business service API
          • Claims - GET claim
            • URL format
            • Parameters
            • Key rules
    • FHIR API technical specification guide
      • FHIR API overview
      • PFHC FHIR application bundle
        • FHIR API component
        • PegaHC FHIR Module - Healthcare API infrastructure
      • FHIR APIs: key rules
        • Allergy intolerance: GET allergy intolerance details
        • Care Plan: GET CarePlan details
        • Claim: Get claim details
        • Claim: Get Claimresponse details
        • Condition: GET Condition list
        • Coverage: GET Coverage Detail
        • Coverage Eligibility: Get Coverage details
        • Device: GET Device details
        • Diagnostic Report: GET Diagnostic Reports list
        • Encounter: GET Encounter list
        • Explanation of Benefits
        • EpisodeOfCare: GET EpisodeOfCare details
        • Family Member History: GET FamilyMemberHistory details
        • Goal: GET Goal details
        • ImagingStudy: GET ImagingStudy details
        • Immunization: GET Immunization details
        • Medication
        • MedicationDispense: GET MedicationDispense details
        • Medication Request: GET MedicationRequest details
        • MedicationStatement - GET MedicationStatement details
        • Observation - GET Observations list
        • Patient: GET Patients list
        • Practitioner: GET Practitioners list
        • Practitoner Role - GET Practitioner role details
        • Procedure - GET Procedure details
        • Questionnaire: Get questionnaireresource details
        • Questionnaire: Get questionnaireresponse details
        • Schedule - GET Schedule details
        • Slot - GET Slot details
      • Testing
      • Configuring a new API for a new FHIR Resource
      • Extending the mapping of an existing FHIR Resource
      • FHIR API services overview
        • Accessing Pega Healthcare FHIR APIs
        • Published Healthcare FHIR API Services
          • Business request APIs
          • API integration classes
      • Business service APIs
        • FHIR API - service package rule
          • REST service method
          • Service REST rule
          • Service activity rule
          • Mapping data transform rule
      • HTTP status codes
        • Success codes
        • Error codes
          • Error while invoking FHIR APIs
      • Healthcare FHIR API key
        • Patient - Read
        • Patient - Search
        • Coverage - Read
        • Coverage - Search
        • Explanation of Benefits - Read
        • Explanation of Benefits - search
        • Allergy Intolerance-Read
        • Allergy Intolerance-Search
        • Condition-Read
        • Condition-Search
        • Document Reference-Read
        • Document Reference-Search
        • Observation-Read
        • Observation-Search
        • Testing the services
          • Patient (read) data page key rules
          • Patient (search) data page key rules
          • Coverage (read) data page key rules
          • Coverage (search) data page key rules
          • Explanation of benefits (read) data page key rules
          • Explanation of benefits (search) data page key rules
          • Allergy Intolerance (read) data page key rules
          • Allergy Intolerance (Search) data page key rules
          • Condition (read) data page key rules
          • Condition (Search) data page key rules
          • Document Reference (read) data page key rules
          • Document Reference (Search) data page key rules
          • Observation (read) data page key rules
          • Observation (Search) data page key rules
        • OAuth authentication
          • OAuth configuration for FHIR/CMS services
          • Test PFHC FHIR services from API landing page with OAuth
          • Test PFHC FHIR services using Data page and Authentication profile
    • Sample Data Management Specifications Member Data Model
      • About Pega Foundation for Healthcare member infrastructure
      • Pega Foundation for Healthcare member record
        • Manually creating a member record
          • Member tab
          • Details tab
          • Contact tab
        • Search and review a member record
        • Updating a member
        • Member class structure
      • Pega Foundation for Healthcare payer record
        • Manually creating a payer record
          • Payer details tab
          • Address tab
        • Search and review a payer record
        • Updating a payer record
        • Payer class structure
      • Pega Foundation for Healthcare company record
        • Manually creating a company record
          • Company tab
          • Address tab
        • Search and review a company record
        • Updating a company record
        • Company class structure
      • Pega Foundation for Healthcare company / group contract record
        • Manually creating a group contract record
          • Contract details tab
          • Contract Information tab
          • Contracted plan tab
        • Search and review a group contract record
        • Updating group contract
        • Contract class structure
      • Pega Foundation for Healthcare policy record
        • Manually creating a policy record
          • Policy overview tab
          • Identify subscriber and group tab
          • Subscriber policy plan details tab
          • Dependent policy plan details tab
        • Search and review a policy record
        • Update a policy record
        • Policy class structure
      • Steps to add membership in Pega Foundation for Healthcare
      • Appendix and Definitions
    • Sample Data Management Specifications Provider Data Management
      • Pega Foundation for Healthcare Practitioner record
        • Manually create a practitioner record
          • Option 1: Contract as solo provider
            • Add practitioner details
            • Add addresses and affiliations
            • Add practitioner pricing information
          • Option 2: Add practitioner to existing group/entity
            • Add practitioner Details
            • Add address and affiliations
        • Search and Review a Practitioner Record
        • Update a Practitioner record
        • Pracitioner class structure
      • Pega Foundation for Healthcare Provider record
        • Manually Create a Provider Record
          • Enter provider details
          • Option 1: Provider is a contracting entity indicates True
            • Enter address and affiliation information
          • Option2: Provider is a contracting entity indicates False
            • Enter Address and Affiliation information
            • Enter pricing information
        • Search and Review a Provider Record
        • Update a Provider record
        • Provider class structure
      • Pega Foundation for Healthcare Business Entity record
        • Manually Create a Business Entity Record
          • Enter Business entity details
          • Enter Contacts
          • Enter Locations
        • Search and Review a Business Entity Record
        • Update a Business Entity Record
        • Business Entity class structure
      • Pega Foundation for Healthcare Contract record
        • Manually Create a Contract Record
          • Enter Metadata
          • Enter contract details
          • Optional: Associate networks to contract
          • Optional: Associate plans to contract
          • Associate rate sheets to contract
        • Search and Review a Contract Record
        • Update a Contract Record
        • Contract Entity class structure
      • Pega Foundation for Healthcare Rate Sheet record
        • Manually Create a Rate Sheet Record
          • Enter Rate sheet metadata
          • Optional: Enter Rate sheet pricing details
        • Search and Review a Rate Sheet Record
        • Update a Rate Sheet Record
        • Rate sheet entity class structure
      • Pega Foundation for Healthcare Pricing Arrangement record
        • Manually Create a Pricing Arrangement Record
          • Enter Pricing arrangement metadata
          • Enter Pricing methodology details
          • Create a Flat Fee pricing methodology
          • Create a Per Diem pricing methodology
        • Search and Review a Pricing Arrangement Record
        • Update a Pricing Arrangement
        • Pricing arrangement sheet entity class structure
      • Pega Foundation for Healthcare Network record
        • Manually Create a Provider Network Record
          • Enter Network details
          • Add the service area
          • Define provider qualifiers
          • Identify provider specialties
          • Identify practitioner types
        • Search and Review a Network Record
        • Update a Network Record
        • Network entity class structure
      • Pega Foundation for Healthcare Service Area record
        • Manually Create a Service Area Record
          • Create a Service area
          • Select geographic attributes
            • Review service areas details
        • Search and Review a Service Area Record
        • Update a Service area
        • Service Area entity class structure
      • Provider 360
    • Pega Foundation for Healthcare24.1 Appeals and Grievances Manager Business Use Case Guide
      • Business overview
        • Complaint - Use-case (UC) 1: Create complaint
        • Complaint - UC 2: Hold case for missing AOR
        • Complaint - UC 3: Follow-up for AOR form
        • Complaint - UC 4: Move case out of PendingAOR workbasket
        • Appeal - UC 5: Review and research appeal information
        • Appeal - UC 6: Clinical review of appeal information
        • Appeal - UC 7: Perform medical review of an appeal
        • Common - UC 8: Communicate appeals resolution
        • Appeal - UC 9: Download appeal case packet
        • Grievance - UC 10: Review and resolve grievance
        • Grievance - UC 11: Request feedback from external users
        • Determination - UC 12: Review and research determination case
        • Determination - UC 13: Medical review of determination
        • Determination - UC 14: Review and research Prescription Drug and Formulary determination case
        • Common - UC 15: Access case details/progress
        • Common - UC 16: Universe and Operational reports
    • Pega Foundation for Healthcare X12 message processing tech note
      • Overview
      • Mapping X12 messages
      • X12 inbound message processing
      • X12 message classes
      • Segments and properties
      • Key X12 mapping rules
      • X12 EDI management
      • Healthcare eligibility request message processing
      • Key rules for eligibility request and response message
      • Healthcare claim status request message processing
      • Key rules for claims status request and response message
      • X12 N834 benefit enrollment - inbound
      • X12 N834 benefit enrollment - outbound
      • X12 message processing: Demo portal
      • Sample X12 scenario maintenance
      • Key rules for X12 Demo-scenarios maintenance
      • X12 message processing: Log file notes
  • Resources
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  • Last UpdatedOct 07, 2022
  • 1 minute read
    • '24.1
    • Pega Foundation for Healthcare
    • Healthcare and Life Sciences
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