To successfully create a healthcare insurance plan, you need to configure the Pega Product Composer for Healthcare entity building blocks. By completing the tasks in this tutorial, you configure all the entities that make up a healthcare insurance plan.
Before you begin
- Ensure that you have a test environment available to perform these tasks.
You do not want to create example data in a production environment.
- Ensure that you have administrator credentials for the test environment.
- Ensure that you have configured code sets and code groups, as well as provider networks, in Pega Foundation for Heathcare 8.3.
For additional information, see Pega Foundation for Healthcare Common Codes - Supported File Format and Pega Foundation for Healthcare Sample Data Management Specifications on the Pega Foundation for Healthcare product page.
- Ensure that you have installed Pega Product Composer for Healthcare 8.3.
For additional information, see the product documentation on the Pega Product Composer for Healthcare product page.
- Plan to have a full day available to complete the tasks in this tutorial.
U+Health, an insurance payer, wants to create a small group commercial plan. This addition to their portfolio of plans is a Preferred Provider Organization (PPO) plan. It gives members more flexibility when selecting a doctor or hospital and has fewer restrictions when members visit non-network providers.
Each of the following tasks relates to an entity that you must configure to create the healthcare insurance plan. Ensure that you follow this order of tasks:
- Configuring benefit categories
- Configuring benefits
- Configuring a benefit grouper
- Configuring a benefit set
- Configuring networks
- Configuring a product template for the healthcare insurance plan
- Configuring a new product for the healthcare insurance plan
- Configuring the healthcare insurance plan
- Optional: Configuring a plan bundle
Each topic in this tutorial provides links to ensure that you have completed the prerequisite task and guide you to the next task. You can also use the book outline in the left pane for navigation.
What to do next
Configure benefit categories. See Configuring benefit categories.