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Product templates

Suggest edit Updated on January 26, 2021

In Pega Product Composer for Healthcare, a product template, similar to a container, sets the structure and guidelines for healthcare products in a line of business or jurisdiction. You want to configure a product template to include your definitions for various components of a healthcare insurance product, such as configuration for benefit sets, networks, range of cost shares, coverage rules, and sales guardrails.

During product template configuration, you select one or more networks and assign benefits to each network. This way, you create a structure of provider networks and their benefits where you define coverage levels, eligibility rules, guardrail rules, and the range of values for cost shares. The use of the product template facilitates the efficient building of products because the products inherit the values that are defined in the product template for networks, benefits, and groupers.

Before you begin:

View the and determine if you need to create additional benefit coverage levels.

Ensure that you have configured benefits and groupers, if needed, benefit sets, and networks. For additional information, see Configuring a benefit, Setting up a grouper, Configuring a benefit set, and Configuring a network.

Entering details for a product template

Use a Pega Product Composer for Healthcare product template to define multiple products. Complete the basic information in the product template such as effective date and line of business.

Before you begin: Ensure that you have already configured the required networks and selected benefit sets because you need to select one or more networks in step 2 and one or more benefit sets in step 3 of the wizard.

For more information, see Configuring a network and Configuring a benefit set.

Note: Based on your organization's needs, you can extend the metadata. For additional information, see Extending entity metadata in the Extending the Pega Product Composer for Healthcare application section.
  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the left navigation panel of your workspace, click NewProduct template.
  3. Click New to configure a new product template or Copy from template to copy information from an existing product template.
    If you select Copy from template, select a product template from the Copy from existing template list to reuse the information.
  4. Complete the fields according to your business needs.
  5. To populate the Market segment field, click the Add a row icon to make the field available. Then select an option from the list.
    If you select Medicare in the Market segment field, you must select your rating in the Medicare star rating field.
  6. Expand Other properties to view tabs for other categories of properties that you might want to complete to fit your business needs.
  7. Click Save to complete your product template at a later time or Continue.

Configuring networks and guardrails for a product template

In the product template, you define networks and guardrails that can be inherited from this product template when you configure products and plans later. You reuse existing information and save time during configuration.

Network guardrails are applied when products are configured by using a product template. For example, you can apply a rule that requires that the co-payment for in-network expenses is less than or equal to the co-payment for out-of-network expenses. When you build a product or plan by using the product template, this rule is enforced during the cost share selection process.

Before you begin: Ensure that you entered the details for a product template.
  1. To add a network to your product template, in the Network field, select a network from the list and click Add Network.
  2. Optional: Click the network link to configure a new version or update an existing version of the network. On the Network page, tabs describe the network, provider networks, and notes.
    1. To configure a new version of the product template, click Save as new version, complete the fields, and click Save.
    2. To resume or update the current version, click Resume/update version, complete the fields, and click Save.
  3. Optional: To compare the cost shares of two networks, in the Network guardrails section:
    1. Click the Add a row icon to add a row.
    2. Select your options from the lists.
    3. Repeat these steps for each cost share that you are comparing.
  4. Click Save to complete your product template at a later time or Continue.

Selecting a benefit set for a product template

You can select a benefit set that becomes the foundation for the product template for your networks. A benefit set contains the list of benefits and groupers that will be included for each network that you specified in the previous steps, except for carve-out networks.

Before you begin: Ensure that you configure your networks and guardrails. Carve-out networks cover the providers, including doctor and hospitals, for specialized treatments.
  1. If you are configuring a new product template, in the Benefit set field, select a benefit set.
  2. Optional: If you are copying a product template and you want to select a different benefit set, in the Select benefit set section, click the Edit selection icon and select another benefit from the list.
  3. Optional: If you added a carve-out network, select the category and benefit from the lists and click Add benefit.
  4. In the Product template structure section, based on your configuration, follow the steps in this table:
    OptionSteps
    When you create a new product template (not a copy)Click Generate tree to view the list of all the benefits and groupers within the specified benefit set.
    When you create a product template from an existing product template (copy) or create a new version of an existing product template and you select another benefit set by clicking the Edit iconClick Re-generate tree to view the list of all the benefits and groupers within the specified benefit set.
    When you create a product template from an existing product template (copy) or create a new version of an existing product template and you select another benefit set by clicking the Edit iconClick Re-generate tree and select the Update only check box to retain the values of the previous stand-alone benefits.
    When you create a product template or create a new version of an existing product template and you select another version of the benefit set by clicking the Change benefit set buttonThere is no further action. Do not click the button or select the check box. The values of the benefits in the previous benefit sets and stand- alone benefits are retained.
  5. To view the networks, click Network tree structure to expand the section.
  6. Click Save to complete your product template at a later time or Continue.

Configuring cost shares and accumulators for a product template

You can define individual cost share ranges for your product template. These values are inherited at the product, plan, benefit, and network levels, which saves you time during configuration. Based on the increment that you select, the cost share ranges are displayed in a list when you select specific cost share values in your product. You can also define the order of which cost shares are applied during claim adjudication.

If you need to customize your cost shares based on your organization's needs, see Extending union data for cost shares in the Extending union data section.

Before you begin: Ensure that you have selected a benefit set.
  1. Optional: In the Product template cost shares and accumulators section, select the N/A check box if a particular cost share does not apply.
    At least one cost share is required and cannot be set to N/A.
  2. Click Set default cost share ranges to set values in the low and high ranges (in US dollars) and set incremental values for the cost shares.

    The value in the Increment field defines how much the value of the cost share increases within the range of low to high.

  3. Optional: Modify the values in the cost share fields, if necessary.
  4. To specify the accumulators to which the copay and coinsurance values contribute, perform these steps:
    1. For each cost share, click the Configure the contributions of icon in the Contributes to column.
    2. In the dialog box, select the check boxes that apply and click Submit.
  5. In the Deductible and out-of-pocket calculation methods list, select an option for your calculation method for deductible and out-of-pocket values.
    OptionDescription
    Policy typeYou enter out-of-pocket maximum amounts (in US dollars) based on the policy-type tiers that are defined by the product template, product, or plan structures.
    Number of family membersYou enter the individual out-of-pocket maximum dollar amount (in US dollars) and the number of family members who are required to meet the individual out-of-pocket maximum amount. The family out-of-pocket maximum amount is automatically calculated when you enter the number of family members.
    EmbeddedYou enter the individual out-of-pocket maximum amount and family out-of-pocket maximum amount (in US dollars).
    Subscriber salaryYou enter out-of-pocket maximum amounts (in US dollars) based on the subscriber's salary. You can define multiple out-of-pocket maximum amounts based on a salary range. You can also define the salary ranges as needed for product template, product, or plan structures.

    If you select this option, . click the Configure subscriber salary ranges link, complete the fields, and click Submit before you perform the next step.

  6. Based on the calculation method that you select:
    1. Optional: In the Deductible and Out-of-pocket sections, select the N/A check box if a line item does not apply.
    2. Enter values in the Low, High, and Increment fields in the Deductible section.
    3. Click the Configure the contributions of individual deductible icon, select the check boxes for deductible contributions, and click Submit.
    4. Enter values in the Low, High, and Increment fields in the Out-of-pocket section as needed.
  7. In the Accumulators section, select options from the available lists to show how deductibles, out-of-pocket, annual maximum, and lifetime maximum expenses accumulate: within the product or across all products.
  8. In the Default order of cost shares section, select a cost share from each list to represent the order in which the cost shares are applied to the benefits during claim adjudication.
    An individual benefit can have its own custom order of cost shares configured within the benefit at the network level in a product template, product, or plan. If an order of cost shares is not specified for an individual benefit, the default order of cost shares that is defined in this step applies.

    A penalty might be calculated for the provider or member if the claim does not meet mandated or contractual authorization requirements.

  9. Click Coordination of benefits (COB) to expand the section.
    1. Select the COB savings eligible check box if the member is eligible to use cost savings from the coordination of benefits toward out-of-pocket expenses.
    2. In the Secondary payment type list, select an option to determine whether the secondary payment is the lesser value of the COB calculation or the remaining patient liability.
    3. In the Cost share exclusions section, select the check boxes to indicate if the cost share is not included in the COB calculation.
  10. Click Authorization to expand the section.
    1. Select the Authorization not applicable? check box if authorizations do not apply.
    2. If authorizations do apply, clear the check box and complete the fields.
    Result: When you enter an authorization, it is inherited by all the benefits for all the networks in the product template. It is also inherited in the product and plan from the product template.
  11. Click Save to complete your product template at a later time or Continue.

Configuring cost shares at the network level

You can view the summary of all the network cost shares and guardrails that you defined in the product template and modify coverage at the network level. For example, you might want to increase the high range of the cost shares to accommodate out-of-network services because the copayment for an out-of-network service might be higher than the cost of the same service within a network.

Additionally, you can add or modify variations and network details that are specific to the selected network. And you can control accumulation across the networks.

The Guardrail summary in the bottom section of the page displays the cost share boundary rules that you previously defined.

Before you begin: Ensure that you configured your cost shares and accumulators.
  1. In the Network cost shares step of the product template wizard, in the Networks section on the Configure networks page, click a network name link to update coverage at the network level.
  2. To modify covered and required services:
    1. In the expanded Configure network details window, click Edit.
    2. In the Configure or modify coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    3. Based on the specified benefit or grouper, click Covered or Not covered.
      The shaded button shows the current setting.
    4. Click Submit.
    5. If you are not making any other changes to the networks, click Continue.
  3. To modify the requirement for services, follow these steps: For example: Some services are required as part of the plan.
    1. In the expanded Configure network details window, click Edit.
    2. In the Configure or modify coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    3. Based on the specified benefit or grouper, click Required or Not required.
      The shaded button shows the current setting.
    4. Click Mark complete and then click Submit.
  4. To modify the coverage values that you set in the product template:
    1. On the Configure network details page, on the Cost shares and accumulators tab, click Edit.
    2. In the Configure or modify coverage dialog box, select the check boxes for the values that you want to modify, and then click OK.
    3. On the Configure network details page, modify the values as needed in the selected sections, click Save, and then click Submit.
    4. Optional: To restore the original values, click Restore. In the Clear the check boxes to restore values dialog box, clear the check boxes that you previously selected, and click OK.
    5. On the Configured network page, click Save and Mark complete when you are finished editing the coverage values for networks.
    6. For each network whose coverage you are modifying, on the Configure networks page, click the network name link and repeat these steps.
    7. Click Continue if you are not making any other changes to the networks.
  5. To add variations:
    1. On the Configured network details page, click the Variations tab and click Edit.
    2. Click Add variation.
    3. Name the variation, provide the effective and end dates, select the check box for the type of variation, and select a condition type.
    4. Complete the corresponding fields that appear, based on your selections, and click OK.
    5. Repeat steps b through d for each variation that you are adding.
    6. Click Save, then click Mark complete when you are finished adding or editing the variations for the specified network. Click Submit.
    7. For each network to which you are adding variations, on the Configure networks page, click the network name link and repeat these steps.
    8. Click Continue if you are not making any other changes.
  6. To edit network details:
    1. On the Configure network details page, click Edit.
    2. Click the Additional network details tab, and then click Edit.
    3. Complete the fields, click Save to save the changes, click Mark complete, and then click Submit.
    4. For each network to which you are adding details, on the Configure networks page, click the network name link and repeat these steps.
  7. If you have finished making changes, on the Configure networks page, click Mark all as complete, and click Continue.

Configuring benefits for a product template

You can modify the coverage, for example copayment or coinsurance, for a benefit or grouper that was previously included as part of a benefit set for a specific network. During this step, you add the values for the benefit-specific coverage, for example deductible or out-of-pocket amount. You can also add another benefit or grouper that was not included in the benefit set that you previously added. In addition, you can configure the order of cost shares that is used in claim adjudication.

You can assign cost shares for specific conditions or assign limits to a benefit. For example, you can limit physical therapy sessions to 60 visits per year or require an authorization for certain conditions.

Additionally, you can set services that are covered and set services that are required.

Before you begin: Ensure that you have configured cost shares at the network level.
  1. To add a benefit or grouper, follow these steps:
    1. Click Add benefit/grouper.
    2. Complete the fields in the Add Benefit/Grouper to benefit tree window to add the grouper or benefit and click Submit.Result: The Grouper/Benefit section shows the benefits, groupers, and their cost share values per network.
  2. To modify the coverage of a single benefit, a grouper that contains multiple benefits, or one benefit within a grouper, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon to the right of the benefit or grouper name.
    2. In the Configure details for product template window, click the network for which you are modifying the benefit coverage.
    3. In the expanded Configure details for product template window, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    5. Based on the specified benefit or grouper, click Covered or Not covered.
      The shaded button shows the current setting.
    6. Click Mark complete, and then click Submit.
  3. To modify the requirement for services of a single benefit, a grouper that contains multiple benefits, or one benefit within a grouper, follow these steps: For example: Some services are required as part of the plan.
    1. On the Configure groupers and benefits page, click the Configure item icon to the right of the benefit or grouper name.
    2. In the Configure details for product template window, click the network for which you are modifying the benefit requirement.
    3. In the expanded Configure details for product template window, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, in the To edit, select one or more check boxes for corresponding fields section, select the Covered and required check box and click OK.
    5. Based on the specified benefit or grouper, click Required or Not required.
      The shaded button shows the current setting.
    6. Click Mark complete and then click Submit.
  4. To configure the coverage of a new or an existing item, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon at the right of the benefit or grouper name in the list.
    2. In the Configure details for product template window, on the Coverage tab, click the network name.
    3. In the Configure details for product template expanded window, to update coverage information, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, to update the network coverage values, select the check boxes in the Select the check box to edit the corresponding fields section or the Select the check box to configure the corresponding coverage section that you want to modify and click OK.For example: You might want to increase the values of copayment or coinsurance or change the accumulators. Additionally, you can modify coordination of benefits and authorizations. You also might want to change the values of your deductible or out-of-pocket expenses for the benefit.
    5. In the corresponding sections in the Configure details for product template window, modify the values, and then click Save or Save across networks. If you select Save across networks, select the network name check boxes that appear in the dialog box, and click Submit.
    6. To remove one or all changes that you made in steps c through e and restore the original values, click Restore, clear the check boxes in the dialog box, and click OK.
    7. Repeat step 4 to configure or modify each benefit or grouper.
  5. To configure the values and network contributions of annual maximum and lifetime maximum, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon at the right of the benefit or grouper name in the list.
    2. In the Configure details for product template window, on the Coverage tab, click the network name.
    3. In the Configure details for product template expanded window, to update coverage information, click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, select the Accumulators check box. Then based on your business needs, select either the Annual maximum or Lifetime maximum check box, or both, and click OK.
    5. In the Configure details for product template window, in the Annual maximum and Lifetime maximum fields, select the values.
    6. In each field, click the Cross network for icon, select one or more network name check boxes in the dialog box, and click Submit.
    7. Repeat step 5 as needed for each benefit.
  6. To specify that a benefit limit in a product template applies to multiple networks, follow these steps:
    1. Click the Configure item icon next to the benefit.
    2. On the Configure benefit details page, select a network.
    3. Click Edit.
    4. In the Configure or modify benefit-specific coverage dialog box, select the Accumulators and Limit check boxes and click OK.
    5. In the Accumulators section, clear the Limit not applicable check box.
    6. Enter the limit information in the fields.
    7. Click the Configure the cross-network for limit icon, select the networks that apply, and click Submit.
    8. Click Save.
  7. To create or modify variations of benefits or groupers, follow these steps:
    Note: Use variations sparingly and only when you need to configure an item that is not standard. It is better to configure them at the benefit level whenever possible for better transparency and mass updates.
    1. On the Configure groupers and benefits page, click the Configure item icon next to the benefit or grouper.
    2. In the Configure details for product template window, click the Variations tab.
    3. Click the network link and then click Edit.
    4. Add or edit variations, click Save, and then click Submit.
    5. Repeat these steps for each benefit or grouper variation that you are creating or modifying.
  8. To configure additional details for a benefit or grouper, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon next to the added benefit or grouper.
    2. In the Configure details for product template window, click Additional details.
    3. Click the network link
    4. In the expanded Configure details for product template window, click Edit.
      To meet your business needs, you can configure fields for compliance support, documentation support, and claims instructions.
    5. Click Save and then click Submit.
    6. Repeat these steps for each new benefit or grouper detail that you are creating or modifying.
  9. To review the mapping for a benefit, follow these steps:
    1. On the Configure groupers and benefits page, click the Configure item icon next to the added benefit or grouper.
    2. In the Configure details for product template window, click the Mapping tab.
    3. Review the information that you previously entered. Click Mark Complete and then click Submit.
      If you need to make changes based on your review of the Mapping tab, you must modify the specific benefit. For additional information, see Configuring a benefit.
  10. When you are finished configuring benefits and groupers, click Mark all as complete and then click Continue.

Optional: Changing the default benefit

During product template creation, the system automatically assigns the first benefit as the default benefit in the benefit category. The default benefit best represents the cost share for the benefit category. The cost share, such as copay or coinsurance, on the benefit category displays in a Summary of Benefits and Coverage (SBC) document or in a sales application when using the Plan API. However, you can also change the default benefit for the product template to meet your business needs.

When you use a product template to create a product or plan, the product inherits it from the product template and the plan inherits it from the product. You can also change the default benefit at both the product and plan levels.

In this wizard step, you can also change and add benefit categories. However, if you add a benefit category, there is no default benefit.

Before you begin: Ensure that you have configured the benefits for the product template.
  1. In the Configure benefit categories step of the wizard, in the Benefit category column, click a tab to expand it.
  2. For the benefit that you are setting as default, click the Gear icon and click Set as default display benefit.Result: The default benefit displays Yes. Other benefits within the benefit category display No.
  3. Click Finish.

Changing or adding a benefit category

During product template creation, you can change the benefit category assignments. For example, you might change the benefit category for the Office visit benefit from Inpatient services as defined during benefit creation to Outpatient services. You can also add a benefit category. However, if you add a benefit category, there is no default benefit.

In this wizard step, you might want to change the default benefit.
  1. In the Configure benefit categories step of the wizard, in the Benefit category column, click a tab to expand it.
  2. Click the Gear icon to the right of the benefit that you are modifying.
  3. Click Change benefit categories.
  4. In the Change benefit categories dialog box, click Add benefit category and then enter and click a category from the list.
  5. Click Submit.
  6. When you have completed your changes, click Finish.
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