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Setting up a grouper

Suggest edit Updated on January 26, 2021

In Pega Product Composer for Healthcare, you can use groupers to accumulate visits, units, and dollars assigned to each healthcare benefit and configure limits that span the dependent benefits. You also use groupers to organize these items across benefit accumulators.

A grouper contains benefits and organizes them in common medical areas. For example, all Surgery benefits can be organized under a Surgery grouper. When there are limits on the benefits, you define the limit in the benefit accumulator. For example, Mental Health group counseling and inpatient Psychiatrist visits are two separate benefits, but they can have a limit of 20 total visits in any combination of the two.

Use a benefit grouper to configure cost shares that are reused for the benefits. For example, if a Physician Services grouper is configured with a $10 copayment, each of the dependent benefits automatically inherits the $10 copayment. To change one of the benefits to a $20 copayment, you must manually configure that benefit.

Based on your organization's needs, you can extend the metadata, as described in Extending entity metadata in the Extending the Pega Product Composer for Healthcare application section.

To extend your grouper, see Extending union data for groupers in the Extending union data section.

Before you begin: Ensure that you have set up your benefits. For additional information, see Configuring a benefit.
  1. In the header of Dev Studio, click Launch portalProduct Development.
  2. In the left navigation panel of your workspace, click NewGroupers.
  3. Enter information to configure a new grouper or copy an existing grouper.
    1. If you select Copy existing, select a grouper from the list.
    2. Optional: To modify the grouper selection, click the Edit icon and select another grouper from the list.
  4. Enter text in the fields, select options from lists, and enter dates to describe your benefit. Ensure that you complete all required fields as you perform the steps in the wizard.
  5. Click Save to complete your grouper at a later date or Continue.
  6. In the Benefit list, select a benefit and then click Add benefit.
  7. Repeat step 6 for each benefit that you are adding.
  8. Click Save and click Finish.
What to do next: Configure a benefit set. For additional information, see Configuring a benefit set.
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