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Plan guardrails API for Pega Sales Automation for Healthcare

Suggest edit Updated on September 10, 2021

Pega Sales Automation for Healthcare has a Plan Guardrails REST API integration with Pega Product Composer for Healthcare. This integration helps to prevent users from entering cost share values that are outside of the standard ranges. During a custom plan request, Pega Sales Automation for Healthcare makes a call to Pega Product Composer for Healthcare to get the standard ranges of cost share values from the matching product template table, and then it populates the custom plan's cost share fields with those values. A user can still enter a value that is outside of the standard range, but a non-standard value must be approved before the custom plan request can be completed.

Note: For Product Composer system version 8.5 and above, you need to create an authentication profile to access data. See the "Creating authentication profile" section below. 

Fetch the plan guardrails that contain the standard ranges

The API sends the plan ID to fetch the plan guardrails from the Pega Product Composer for Healthcare REST service.

When you create a new customer plan request from an existing plan, Pega Sales Automation for Healthcare fetches plan guardrails from Pega Product Composer for Healthcare to check if the plan-level cost shares and network cost shares are within the given range. If the cost shares are out of range, then the plan request is routed to an approval queue so the out of range values can be approved.

Receive and process the standard ranges

If plan guardrails exist for a plan, then Pega Product Composer for Healthcare system sends the plan guardrails in JSON format. The received JSON response is mapped to the clipboard and has the structure that is detailed in the following image:

"plan guardrail api structure"

The following table describes the plan-level cost shares that are available at the product level.

PropertyDescription
AnnualMaximumDataAnnual Max data for Family/Individual
CarryOverDataCarry over data for Family/Individual
CoinsuranceDataCoinsurance data for Family/Individual
CopaymentDataCopay data for Family/Individual
DeductibleDataDeductible data for Family/Individual
LifetimeMaximumDataLifetime maximum data for Family/Individual
OutOfPocketDataOut of pocket data for Family/Individual

The same cost shares are available at the network level, in the NetworkNodes property.

"Plan guardrail API, network level cost shares"

For each type of cost share, the corresponding page property includes the properties that are detailed in the following image:

"Cost share properties for Plan Guardrails API page property"

Plan Guardrails API Rules

Use the following rules to implement the Plan Guardrails API integration:

  • Data page: D_GetPlanGuardrails
  • REST Connector: GetPlanGuardrails
  • Sample REST Service URL to hit: http://10.60.215.7:9080/prweb/PRRestService/healthcarepcsAPI/v1/PlanCostShareRangesService
  • Pre data transform: GetPlanGuardrailsRequestPOST
  • Post data transform: GetPlanGuardrailsResponsePOST
  • Extension points: GetPlanGuardrailsResponsePOST_EXT

Creating authentication profile

For Product Composer system version 8.5 and above, you need to create an authentication profile to access data.

1. In App Studio, create an authentication profile, as in the example image: 

Example authentication profile

2. Use the newly created authentication profile in the REST connector rule, as in the example below:

Authentication profile in REST connector rule

 

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