healthcare individual sales process manager · • enter simple demographic data such as age and...

Healthcare Individual Sales Process Manager

Business Use Case Guide

2.6

Copyright 2012 Pegasystems Inc., Cambridge, MA

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Although Pegasystems Inc. strives for accuracy in its publications, any publication may contain inaccuracies or typographical errors. This document or Help System could contain technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Pegasystems Inc. may make improvements and/or changes in the information described herein at any time. This document is the property of: Pegasystems Inc. One Rogers Street Cambridge, MA 02142-1590 Phone: (617) 374-9600 Fax: (617) 374-9620 www.pega.com Healthcare Individual Sales Process Manager Document: Business Use Case Guide Software Version: 2.6 Updated: December, 2012

Contents Preface ..................................................................................... 2

Intended Audience .............................................................................. 2

Guide Organization.............................................................................. 2

Chapter 1: Business Application Overview ............................... 3

Chapter 2: Business Use Cases ................................................. 4

Use Case 1: Enrolling in Healthcare Insurance via the Web ...................... 4

Entering Personal Information ...................................................................... 5

Demographic Information Section .............................................................. 5

Your Preference Section ............................................................................ 6

Reviewing Available Products ....................................................................... 7

Enrolling in Healthcare Insurance Products..................................................... 9

Use Case 2: Enrolling a Customer in a Healthcare Insurance Product ...... 15

Use Case 3: Using the Sales Manager Portal ........................................ 16

Chapter 3: Understanding ISPM Calculations and Products .... 18

Calculations...................................................................................... 18

Persona Number ....................................................................................... 18

Persona to Product Match Value .................................................................. 20

Medical Risk ............................................................................................. 21

Sample Products ............................................................................... 25

Product Information Tab ............................................................................ 26

Benefit Groups Tab ................................................................................... 27

How to Access the Product and Benefit Library ..................................... 28

Reviewing Existing Products ....................................................................... 30

Creating New Products .............................................................................. 31

Adding Benefit Groups and Benefits ............................................................ 31

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Preface This guide is designed to provide you with an overview of the Healthcare Individual Sales Process Manager (ISPM) Framework version 2.6 including business use cases to aid:

in the collection of information needed to enroll in individual healthcare products

in using the Sales Manager Portal

in understanding the rules used in ISPM to perform various calculations

in understanding the sample product used in ISPM and how to add new or modify existing products

Intended Audience This guide is intended for business users and gives a conceptual overview of the basic use cases of ISPM Framework.

Guide Organization This guide contains the following chapters:

Chapter 1, Business Application Overview

Provides an overview of ISPM

Chapter 2, Business Use Cases Describes real life business scenarios and the steps needed to enroll in individual healthcare packages.

Chapter 3, Understanding ISPM Calculations and Products

Provides the information needed to understand ISPM calculations, sample products, reviewing and creating products, and adding benefit groups and benefits.

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Chapter 1: Business Application Overview The Healthcare Individual Sales Process Manager Framework 2.6 (ISPM) allows healthcare organizations to streamline and tailor the healthcare insurance enrollment process by providing process automation and decisioning capabilities.

ISPM enables you to: guide a customer through the healthcare insurance enrollment process via the web by

allowing the customer to:

• access an ISPM link located on a health insurance provider’s web site

• enter simple demographic data such as age and gender

• review products, rates and benefits

• initiate the enrollment process by completing an on-line web enrollment application form

enroll a customer, in a health insurance product over the phone by:

• creating new or updating an existing individual sales opportunity

• entering simple demographic data such as age and gender

• reviewing products to compare pricing, benefits and rates

• determining the best possible product for the individual or household

• initiating the enrollment process via the ISPM Sales Representative Portal

automatically adjust the presentation of available products based on customer information by:

• creating and maintaining rules which define Individual or household personas and match them with available products.

automate the underwriting process by:

• creating product availability rules and medical risk parameters to ensure only the most appropriate products are offered to individuals interested in healthcare coverage. These rules collect and evaluate medical risk based on a series of defined questions which automate the evaluation and acceptance process for new members whenever allowed by state and federal mandates.

update all back-end systems with accurate enrollment data

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Chapter 2: Business Use Cases This chapter contains business use cases to help you understand:

Enrolling in healthcare insurance products via the web

Enrolling a customer in healthcare insurance products via the ISPM Sales Representative Portal

Using the Sales Manager Portal

Use Case 1: Enrolling in Healthcare Insurance via the Web This use case contains the steps necessary for a user to enroll in individual healthcare insurance products through a website established by a health insurance provider. This website contains a link, when clicked, takes the user to the ISPM framework where they can select health insurance products and enroll.

Task:

Complete the healthcare insurance enrollment process which involves:

Entering Personal Information

Reviewing Available Products

Enrolling in Healthcare Insurance Products

Steps:

1. From the health insurance provider website click to access the ISPM application.

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The Get Quotes screen appears:

Entering Personal Information

Demographic Information Section

1. From the Get Quotes screen, enter the primary covered party’s age and gender including spouse and dependants who will be covered under the health insurance product.

Note: If you enter an age greater than 65, the list of products will be filtered to display only Medicare Supplement products.

2. Enter your Zip code.

Note: Zip Code information helps filter the list of available products based on established business rules. If you wish to see all results it is best to leave the zip code blank.

3. Select, from the drop-down list, the date you wish your health insurance coverage to start.

Note: ISPM is configured to display effective dates starting the first of every month and extending six months. These rules can be modified to fit any Health Product business scenario.

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Your Preference Section

4. Answer questions 1-3 using the slide bar. Your answers help ISPM calculate your persona which determines the appropriate health insurance products to display as well as any informational help you may need. Refer to the following table for additional information:

Question Used to How comfortable are you with

Health Insurance terminology?

manage the level of on screen help available to

you

What is more important to you,

low out of pocket expenses or low

monthly premium?

to determine the best potential product match

based on your request for a low premium/high

cost share product or a high premium/low cost

share product

Do you have a primary physician

or hospital you prefer?

to determine the best potential product match

based on your preference for a network driven

product

Configuration Tip: Additional questions can be created and the existing questions can be changed by modifying the ISPM rules. Refer to, Understanding the Persona Calculation section of this guide for detailed rule information.

5. Click Next to display the Select Products screen.

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Reviewing Available Products

1. Select the health insurance products you want to enroll in. To aid in your health insurance product selection refer to the following table:

To… Click… sort your products list a column header

review product details the product name link to display the Product Benefits Details screen:

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To… Click…

compare multiple

products

Select the checkboxes, in the far right column, of the products you want

to compare and click Compare Product Details:

Note: You can change your answers to the preferences questions on the Select Products screen. This change will alter the list of health insurance products in the bottom portion of the screen.

2. Click Next to display the Enter Application Information screen.

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Enrolling in Healthcare Insurance Products

1. Enter your personal and address information in the fields provided. 2. Select the Cover spouse? checkbox and select the number of other

dependants to cover from the drop-down list. 3. Select the Have other Insurance or Medicare? checkbox.

Note: If your mailing address is the same as your primary address select the Same as Physical Address? checkbox to auto-fill the mailing address.

4. Click Next to display the Enter Other Insurance Information screen.

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5. Select the other insurance type and complete the corresponding sections.

Note: If you didn’t select the Have other Insurance or Medicare? checkbox on the Enter Applicant Information screen, then the Enter Other Insurance Information screen doesn’t display.

6. Click Next to display the Enter Medical History screen.

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7. Select the Check if Yes checkbox on any of the questions that pertain to you.

Configuration Tip: The medical history questions are used to evaluate the risk of insuring an applicant and dependents. ISPM is designed to automatically accept, submit for underwriting, review or reject an enrollment request based on the determined medical risk. Refer to the Medical Risk section of this guide for additional information.

8. Click Next to display the Enter Spouse Information screen.

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Note: If you didn’t select the Cover Spouse? checkbox on the Enter Applicant Information screen, then the Enter Spouse Information screen doesn’t display.

9. Enter your spouse’s information in the fields provided and click Next to display the Enter Medical History screen.

10. Select the Check if Yes checkbox on any of the questions that pertain to your spouse.

11. Click Next to display the Enter Children Information screen.

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Note: If you didn’t select the Number of other dependants to cover? checkbox on the Enter Applicant Information screen, then the Enter Children Information screen doesn’t display.

12. Enter your child’s information in the fields provided and click Next to display the Enter Medical History screen.

13. Select the Check if Yes checkbox on any of the questions that pertain to your child.

Note: If you selected more than one dependant to cover on the Enter Applicant Information screen, the Enter Children Information and Medical History screens will display for each dependant.

14. Click Next to display the Review Enrollment Information:

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15. Review your information in the available tabs as well as collapsible section within each tab. Use the bread crumbs to navigate back to previous screens.

Note: If you chose to cover a spouse and dependants you will see a tab for each containing their specific information.

16. Click Next to display the Confirmation screen containing your confirmation number.

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Use Case 2: Enrolling a Customer in a Healthcare Insurance Product This use case contains the steps necessary for a sales representative to enroll a customer in individual healthcare insurance products. The sales representative can be on the phone with a customer inquiring about individual insurance or could be completing an enrollment request received via paper or fax.

Task:

Complete the healthcare Insurance enrollment process for a customer.

Steps:

1. Log-in to ISPM using salesrep1@myhealthplan as the user name and install as the password to display the Sales Representative Portal.

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2. Select Get Quotes from the New drop-down list. To display the Get Quotes screen.

3. Complete the steps in Use Case 1 to enroll the customer in their health insurance products.

Use Case 3: Using the Sales Manager Portal This use case provides the information needed to use the Sales Manager Portal for:

monitoring activity

processing work

viewing ISPM reports

starting the Get Quotes process

reviewing healthcare products available in ISPM

Note: Log-in to ISPM using ispmmanager as the user name and install as the password to display the Sales Manager Portal.

The following quick reference card outlines the available functionality in the Sales Manager Portal:

Select Get Quotes to initiate the Individual healthcare insurance enrollment process. This process is the same as the process in Use Case 2.

Select Search Object Model to review the healthcare insurance products available in ISPM.

Expand Delegated Rules to access rules you are able to modify. Click on a rule in your list to open the rule for editing.

Expand Monitor Activity to view the standard work reports.

Expand Process Work Rules to view and transfer work in your work group.

Expand Dashboard to access ISPM specific reports. The four reports in this view are provided out-of-the-box.

Healthcare Individual Sales Process Manager Business Use Case Guide

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Chapter 3: Understanding ISPM Calculations and Products This chapter provides the information needed to understand:

ISPM business rules calculations used for:

• Persona Number

• Persona to Product Match Value

• Medical Risk

ISPM out-of-the-box sample products

How to access the Product and Benefit Library to:

• Review existing products

• Create new products

• Add benefits and benefit groups

Calculations ISPM business rules used are used to calculate:

Persona Number

Persona to Product Match Value

Persona Number

Medical Risk

A customer’s persona number is calculated based on their responses to the three questions in the Your Preference section of the Get Quotes and Select Products screens. Each question has an associated ISPM Decision Table which adds to the Persona Number based on the customer’s response.

The following decision table is associated with the first question used in Use Case 1 “How comfortable are you with Health Insurance terminology”?


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The CALCULATEPERSONANUMBER activity rule then pulls the question responses together to calculate the total Persona Number for the individual.

To make modifications to the persona calculation:

1. Create additional questions in the user interface

2. Build the corresponding decision tables for each additional question


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3. Modify the CALCULATEPERSONANUMBER activity

Configuration Tip: The Persona Number does not currently impact ISPM but can be extended to accommodate additional display criteria. For example, the persona calculation can be extended to provide online help specific to the customer’s needs.

Persona to Product Match Value

ISPM uses the answers to persona questions to match appropriate health insurance products to a customer. The health insurance products are stored in the Healthcare Industry Framework (HCIF) layer and are made available to ISPM. The customer’s answers are used to reorder the display of the health insurance products with the best match at the top of the list.

The persona to product matching is done by comparing the answers to each question with values stored in the health insurance products and calculating a .MATCH property.

The Select Products screen allows the customer to modify their answers, which initiates the recalculation of the .MATCH property and re-orders the list of healthcare insurance products.


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Medical Risk

A medical risk factor is calculated for each covered member during the enrollment process. There are six medical questions that have corresponding decision trees which determine the risk factor for the response to the question. For example, the IMMUNEDISORDER decision tree is associated with question 4 on the Enter Medical History screen:


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The MEDICALRISKFACTORSF flow, shown below, collects the risk factor for each question and calculates a risk factor for each covered member:


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The CALCULATEHOUSEHOLDRISKFACTOR activity rule then calculates the household risk factor by totaling the risk factors for each covered member.

The AUTOMATICAPPROVAL decision table determines the approve/deny/submit for further review outcome for the submitted enrollment request.

To make modifications to the medical risk calculation:

1. Create additional questions in the user interface

2. Build the corresponding decision trees for each additional question

3. Modify the MEDICALRISKFACTORSF flow

4. Modify the CALCULATEPERSONANUMBER activity

Configuration Tip: You could also modify the activity to only calculate a risk factor based on the applicant or modify the AUTOMATICAPPROVAL decision table to account for additional outcomes.


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Sample Products ISPM ships with 11 Medical, 2 Senior and 3 Dental sample products. Each product maintains properties that define parameters such as:

Name

Description

Effective and End Dates

Pricing and associated Benefits.

The TYPE property is used to determine if a product is an ISPM product. When the type is IP – Individual Policy, ISPM picks up the product and display it in the list of Medical, Dental or Senior products.

Internal users such as ISPMManager can create new products using existing products as a template. Benefit groups and benefits can be added or removed and existing products can be updated.

Before extending products, review the properties defined for each. Remove the properties that are not needed or add new properties to support the individual Health Plan needs.

Each product has a review screen that includes two tabs:

Product Information Tab — displays and provides access to product level properties

Benefit Groups Tab — displays the Benefit Groups and Benefits associated with the product. This tab also provides the ability to add, delete or modify benefit groups and benefits as well as the cost share values for each benefit


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Product Information Tab


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Benefit Groups Tab


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How to Access the Product and Benefit Library Access the product and benefits libraries to:

Review existing products

Create new products

Add benefit groups and benefits

To access the product library:

1. Log-in to ISPM as ispmsalesmanager with a password of install.

2. Select Search Object Model from the New drop-down list to display the Select Object Model screen.

3. Select the Plan Benefits Search option and click Submit.


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The Plan Benefits Search screen displays.

To view all products stored in the system, click Submit without entering search parameters.

A complete list of all products displays.

Note: All ISPM products have IP in the Type column.


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Reviewing Existing Products

1. To review an existing product, select one from the Products Search Results list and click Submit , to open the product review screen:


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Creating New Products

1. To create a new product, select Save as New from the available drop-down flow actions. This action makes a copy of the existing product.

2. Change the Product Number (which is a key to the product) and make all desired modifications to the product properties.

Note: Select a Type of IP – Individual Policy to insure this product is classified as an ISPM product.

3. You can also select Add New Product to create a new product and enter the desired properties.

Adding Benefit Groups and Benefits

The Benefit Groups Tab allows you to add benefit groups and benefits as desired.

You can remove a benefit or benefit group using the trash can icon.

healthcare individual sales process manager · • enter simple demographic data such as age and...

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